RESUMO
When patients with coronary stents undergo non-cardiac surgery, bridging therapy with low-molecular-weight heparin (LMWH) is not infrequent in clinical practice. However, the efficacy and safety of this approach is poorly understood. This was a retrospective analysis of patients with coronary stent(s) on any antiplatelet therapy undergoing non-cardiac surgery between March 2003 and February 2012. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of cardiac death, myocardial infarction, acute coronary syndrome leading to hospitalisation, or stroke. The primary safety endpoint was the 30-day composite of Bleeding Academic Research Consortium (BARC) bleedings ≥ 2. Among 515 patients qualifying for the analysis, LMWH bridging was used in 251 (49 %). At 30 days, MACCE occurred more frequently in patients who received LMWH (7.2 % vs 1.1 %, p=0.001), driven by a higher rate of myocardial infarction (4.8 % vs 0 %, p< 0.001). This finding was consistent across several instances of statistical adjustment and after the propensity matching of 179 pairs. Patients bridged with LMWH also experienced a significantly higher risk of BARC bleedings ≥ 2 (21.9 % vs 11.7 %, p=0.002) compared to those who were not, which remained significant across different methods of statistical adjustment and propensity matching. In conclusion, LMWH bridging in patients with coronary stents undergoing surgery is a common and possibly harmful practice, resulting in worse ischaemic outcomes at 30 days, and a significant risk of bleeding.
Assuntos
Substituição de Medicamentos/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Cardiopatias/mortalidade , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Pré-Medicação/efeitos adversos , Stents , Acidente Vascular Cerebral/epidemiologia , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/etiologia , Idoso , Aspirina/administração & dosagem , Comorbidade , Doença das Coronárias/complicações , Doença das Coronárias/cirurgia , Reestenose Coronária/epidemiologia , Reestenose Coronária/etiologia , Feminino , Cardiopatias/etiologia , Hemorragia/epidemiologia , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária/administração & dosagem , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/tratamento farmacológico , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Trombofilia/tratamento farmacológico , Trombofilia/etiologia , Resultado do TratamentoRESUMO
The authors report a case of spontaneous dissection of both carotid arteries, followed by spontaneous dissection of the left anterior descending coronary artery after a few days. No major abnormalities of collagen production were found. This case may be underlain by a dysplasia of common precursors of the carotid and coronary walls.
Assuntos
Dissecção Aórtica/etiologia , Dissecação da Artéria Carótida Interna/etiologia , Aneurisma Coronário/etiologia , Túnica Média/anormalidades , Adulto , Dissecção Aórtica/complicações , Dissecação da Artéria Carótida Interna/diagnóstico por imagem , Linhagem da Célula , Colágeno/análise , Anticoncepcionais Orais Combinados/efeitos adversos , Anticoncepcionais Orais Hormonais/efeitos adversos , Aneurisma Coronário/complicações , Angiografia Coronária , Desogestrel/efeitos adversos , Etinilestradiol/efeitos adversos , Matriz Extracelular/química , Feminino , Humanos , Infarto do Miocárdio/etiologia , Crista Neural/patologia , Tomografia Computadorizada EspiralAssuntos
Angioscopia , Doença das Coronárias/patologia , Doença Aguda , Angioscópios , Angioscopia/métodos , Humanos , SíndromeRESUMO
In our centre, during the last five years, emergency operations (within 6 hours) and urgent operations (within 72 hours) have represented 1/4 of all coronary surgery. 295 patients (pts) have been operated on since 1972: of these, 279 with simple revascularization, 5 with combined major surgery, and 11 as a consequence of mechanical complications of acute myocardial infarction. These last were all in cardiogenic shock: the overall 30-day mortality rate was 5.4% (3.6% in those pts with simple revascularization, 20% in those with combined major surgery, and 45.4% in pts with cardiogenic shock). In the subgroup with simple revascularization, the incidence of non fatal perioperative acute myocardial infarction (AMI) was 4.7% in 253 pts with unstable angina, 52.2% in 23 pts with abrupt closure during coronary angioplasty, and obviously 100% in 3 pts surgically treated during evolving AMI. We were able to identify in the univariate analysis as the only 30-day risk mortality factors: 1) a reduced ejection fraction (< 30%) and 2) the combination with endarterectomy. Other factors (female sex, age > 70, severity of angina, diffuse coronary artery disease and more than 3 by pass grafts) have shown a tendency to increase the mortality rate without statistical significance. No deaths occurred in pts revascularized in emergency situations due to coronary angioplasty complications. In recent years emergency and urgent coronary surgical operations have been increasing, with an increase in pts with higher risk factors. In pts with simple revascularization, 30-day mortality and incidence of myocardial infarction are similar to those of elective surgery. In pts with abrupt closure as a consequence of coronary angioplasty the mortality rate seems very low, while the incidence of infarction remains extremely high. These observations have allowed the development of an integrated protocol of intervention in acute unstable coronary syndromes.
Assuntos
Isquemia Miocárdica/cirurgia , Revascularização Miocárdica , Doença Aguda , Adulto , Idoso , Doença das Coronárias/cirurgia , Emergências , Seguimentos , Ruptura Cardíaca Pós-Infarto/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/cirurgia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Fatores de RiscoRESUMO
Femoral vein to artery cardiopulmonary by-pass was used during coronary angioplasty in five high risk patients. In four patients the target vessel supplied more than half of the viable myocardium; in one of these, the ejection fraction of the left ventricle was less than 20%. In one patient the relative contraindications for surgery were the patient's age and the presence of concomitant renal failure. Cardiopulmonary support was established by using cut-down cannulae insertion in three patients and by using the percutaneous system in two. In the latter, the support was stand-by, but the abrupt closure of the artery ten minutes after the end of the successful procedure, required the prompt activation of the support and the patient was treated with emergency saphenous graft. The use of the cardiopulmonary support either as a prophylactic or as a stand-by, enabled coronary angioplasty to be performed on these high-risk patients. The clinical and anatomical data relative to the five patients as well as the possible use of the cardiopulmonary support system either as a prophylactic or standby application during high-risk PTCA are discussed.