RESUMO
Background The Heart Team ( HT ) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease ( CAD ). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion. Methods and Results This observational study was conducted at St Thomas' Hospital (London, UK). Case mixture included unprotected left main, 2-vessel (including proximal left anterior descending artery) CAD , 3-vessel CAD , or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy ( OMT ) alone, OMT +percutaneous coronary intervention ( PCI ), or OMT +coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23-39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3-vessel CAD . Three-year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT + PCI cohort, and 90.2% in the OMT +coronary artery bypass grafting cohort (92 of 102). Conclusions In our experience, the HT approach involved a careful selection process resulting in appropriate patient-specific decision making and good long-term outcomes in patients with complex CAD .
Assuntos
Cardiologia , Fármacos Cardiovasculares/uso terapêutico , Tomada de Decisão Clínica/métodos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Equipe de Assistência ao Paciente , Intervenção Coronária Percutânea , Cirurgia Torácica , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comportamento Cooperativo , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Choque Cardiogênico/epidemiologia , Taxa de Sobrevida , Reino Unido , Disfunção Ventricular Esquerda/epidemiologiaAssuntos
Ponte de Artéria Coronária , Vasos Coronários , Infarto do Miocárdio , Intervenção Coronária Percutânea , Complicações Pós-Operatórias , Medição de Risco/métodos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Humanos , Multimorbidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Administração dos Cuidados ao Paciente/métodos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/mortalidade , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Projetos de Pesquisa , Fatores de Risco , Função Ventricular EsquerdaRESUMO
A 57-year-old hypertensive and dyslipidaemic man with a history of coronary artery bypass graft 19â years previously, presented with severe exertional angina and dyspnoea despite optimal anti-ischaemic pharmacological therapy and previous percutaneous coronary intervention to the left circumflex artery. CT revealed an aneurysm of the saphenous vein graft to the posterior left ventricular branch of the right coronary artery. The aneurysm had formed a fistulous connection with the right atrium. Initially, luminal reconstruction with serial stents was deemed the most appropriate treatment strategy. However, the procedure was abandoned due to the inability to visualise the graft distal to the aneurysm and the significant shunt to the right atrium. Surgical correction of the right atrial wall defect and replacement of the diseased grafts led to complete resolution of the patient's symptoms.
Assuntos
Aneurisma Coronário/diagnóstico por imagem , Ponte de Artéria Coronária , Átrios do Coração/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Veia Safena/transplante , Fístula Vascular/diagnóstico por imagem , Angina Pectoris/etiologia , Aneurisma Coronário/complicações , Aneurisma Coronário/cirurgia , Angiografia Coronária , Dispneia/etiologia , Átrios do Coração/cirurgia , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Tomografia Computadorizada por Raios X , Fístula Vascular/complicações , Fístula Vascular/cirurgiaRESUMO
BACKGROUND: High on treatment platelet reactivity (HTPR) is common in patients receiving clopidogrel following an acute coronary syndrome (ACS); it's also associated with increased morbidity and mortality. More potent and predictable antiplatelet drugs have addressed this issue at the expense of increased bleeding. Identification of HTPR and the targeted use of more potent antiplatelet drugs has, so far, broadly failed. We investigate this approach in terms of the timing of platelet function testing and how this can impact on the ability of these bedside tests to predict HTPR around the time of coronary intervention. METHODS: High risk ACS patients treated with 5 days of clopidogrel had platelet function assessed using the multiple electrode aggregometry system (MEA) pre, post and 24 h following percutaneous coronary intervention (PCI). Simultaneous detailed analysis of platelet status was undertaken with quantification of platelet bound and soluble p-selectin and mass spectrometry quantification of the eicosanoid 12-HETE. RESULTS: As assessed by MEA 40.5% of patients had HTPR pre-PCI; mean aggregation units (AU) in response to ADP were 499.1 ± 46.3 pre-PCI, 407.6 ± 37.7 post-PCI and 269.1 ± 24.6 AU 24 h post-PCI (pre to post PCI p > 0.05, pre to 24 h post-PCI p = 0.0002). This highly significant drop in platelet reactivity was contrasted with on-going expression of platelet bound p-selectin, increased soluble p-selectin and rising 12-HETE concentrations. CONCLUSIONS: This study outlines significant changes in ex-vivo platelet aggregation that occur within 24 h of PCI in high risk NSTEMI patients using bedside PFT. Whilst there were no changes in antiplatelet therapy during the study period its clear that timing is crucial when assessing high on treatment residual platelet activity.