RESUMO
Background The choice of optimal drug-eluting stent therapy for patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention remains uncertain. We aimed to assess the long-term clinical outcomes after percutaneous coronary intervention with biodegradable polymer sirolimus-eluting stents (BP-SES) versus durable polymer everolimus-eluting stents (DP-EES) in patients with DM. Methods and Results In a prespecified subgroup analysis of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization) trial (NCT01443104), patients randomly assigned to ultrathin-strut BP-SES or thin-strut DP-EES were stratified according to diabetic status. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, at 5 years. Among 2119 patients, 486 (22.9%) presented with DM. Compared with individuals without DM, patients with DM were older and had a greater baseline cardiac risk profile. In patients with DM, target lesion failure at 5 years occurred in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (risk ratio, 1.23; 95% CI, 0.87-1.73 [P=0.24]). In individuals without DM, target lesion failure at 5 years occurred in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (risk ratio, 0.98; 95% CI, 0.77-1.26 [P=0.90; P for interaction=0.31]). Cumulative 5-year incidence rates of cardiac death, target vessel myocardial infarction, clinically indicated target lesion revascularization, and definite stent thrombosis were similar among patients with DM treated with BP-SES or DP-EES. There was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES. Conclusions In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout 5 years between patients with DM treated with ultrathin-strut BP-SES or thin-strut DP-EES. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01443104.
Assuntos
Implantes Absorvíveis , Antineoplásicos/administração & dosagem , Estenose Coronária/cirurgia , Complicações do Diabetes/cirurgia , Diabetes Mellitus/terapia , Stents Farmacológicos , Everolimo/administração & dosagem , Sirolimo/administração & dosagem , Idoso , Angina Estável/etiologia , Angina Estável/cirurgia , Angina Instável/etiologia , Angina Instável/cirurgia , Estudos de Casos e Controles , Estenose Coronária/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea , Poliésteres , Polímeros , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Minimal lipoprotein(a) [Lp(a)] target values are advocated for high-risk cardiovascular patients. We investigated the prognostic value of Lp(a) in the acute setting of patients with acute coronary syndromes (ACS). MATERIALS AND METHODS: Plasma levels of Lp(a) were collected at time of angiography from 1711 patients hospitalized for ACS in a multicentre Swiss prospective cohort. Associations between elevated Lp(a) ≥30 mg/dL (cut-off corresponding to the 75th percentile of the assay) or Lp(a) tertiles at baseline, and major adverse cardiovascular events (MACE) at 1 year, defined as a composite of cardiac death, myocardial infarction or stroke, were assessed using hazard ratios (HR) and 95% confidence intervals (CI) adjusting for traditional cardiovascular risk factors (age, sex, smoking, diabetes, hypertension, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C] and triglycerides. RESULTS: Lp(a) levels range between 2.5 and 132 mg/dL with a median value of 6 mg/dL and a mean value of 14.2 mg/dL. A total of 276 patients (23.0%) had Lp(a) plasma levels ≥30 mg/dL. Patients with elevated Lp(a) were more likely to be of female gender and to have higher levels of total cholesterol, LDL-C, HDL-C and triglycerides. Higher Lp(a) was associated with failure to reach the LDL-C target <1.8 mmol/L at 1 year (HR 1.71, 95% CI 1.13-2.58, P = 0.01). No association was found between elevated Lp(a) and MACE at 1 year (HR 1.05, 95% CI 0.64-1.73), nor for Lp(a) tertiles (HR 0.82, 95% CI 0.52-1.28, P > 0.20) or standardized continuous variables (0.98, 95% CI 0.82-1.19 for each increase of standard deviation). CONCLUSIONS: Our real-world data suggest high Lp(a) levels at time of angiography are not predictive for cardiovascular outcomes in patients otherwise medically well controlled, but might be useful to identify patients who would not be on LDL-C targets 1 year after ACS.
Assuntos
Síndrome Coronariana Aguda/sangue , Lipoproteína(a)/metabolismo , Biomarcadores/metabolismo , HDL-Colesterol/metabolismo , LDL-Colesterol/metabolismo , Morte Súbita Cardíaca/etiologia , Feminino , Humanos , Hiperlipoproteinemia Tipo II , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Prognóstico , Estudos Prospectivos , Acidente Vascular Cerebral/etiologia , Triglicerídeos/metabolismoRESUMO
PURPOSE OF REVIEW: Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. RECENT FINDINGS: Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.
Assuntos
Oclusão Coronária/cirurgia , Complicações do Diabetes , Diabetes Mellitus , Intervenção Coronária Percutânea , Doença Crônica , Angiografia Coronária , Humanos , Masculino , Sistema de Registros , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Several chemotherapy molecules, monoclonal antibodies and tyrosine kinase inhibitors, have been linked to Takotsubo cardiomyopathy (TC). CASE PRESENTATION: In this article, we describe the case of a 45-year-old woman who developed TC after receiving an intra-arterial and intra-venous polychemotherapy for locally advanced epidermoid carcinoma of the anal canal. This is the first described case of TC associated with intra-arterial chemotherapy. CONCLUSIONS: A review of the literature points to 5-fluorouracil as the most common molecule associated with TC and highlights the potential risk associated with rechallenging patient with the same drug.
Assuntos
Neoplasias do Ânus/tratamento farmacológico , Carcinoma de Células Escamosas/tratamento farmacológico , Recidiva Local de Neoplasia/tratamento farmacológico , Cardiomiopatia de Takotsubo/fisiopatologia , Neoplasias do Ânus/complicações , Neoplasias do Ânus/patologia , Carcinoma de Células Escamosas/complicações , Carcinoma de Células Escamosas/patologia , Feminino , Fluoruracila/efeitos adversos , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/complicações , Recidiva Local de Neoplasia/patologia , Cardiomiopatia de Takotsubo/induzido quimicamenteRESUMO
Long-term clinical outcomes of new-generation drug-eluting stents in complex anatomic and clinical settings are not well defined. This study assessed the impact of patient and lesion complexity on 2-year outcomes after coronary revascularization with ultrathin strut biodegradable-polymer (BP) sirolimus-eluting stents (SES) versus durable-polymer (DP) everolimus-eluting stents (EES). In a prespecified analysis of the BIOSCIENCE randomized trial (NCT01443104), complex patients (911 of 2,119; 43%) were defined by the presence of acute ST-elevation myocardial infarction (MI); left ventricular ejection fraction ≤30%; renal dysfunction; insulin-treated diabetes; treatment of ostial lesion, bypass graft, unprotected left main lesion; or 3-vessel intervention. The primary end point was target lesion failure (TLF), a composite of cardiac death, target vessel MI, and clinically indicated target lesion revascularization. At 2 years, complex compared with simple patients had a greater risk of TLF (14.5% vs 7.4%, risk ratio 2.05, 95% confidence interval 1.56 to 2.69; p <0.001). The difference was sustained beyond 1 year on landmark analysis. Complex patients had higher rates of the patient-oriented composite end point of death, any MI, or any revascularization (23% vs 14.4%; p <0.001) as well as definite stent thrombosis (1.6% vs 0.4%, p = 0.006). There were no differences in TLF and patient-oriented composite end point between the BP-SES versus DP-EES, consistently among simple and complex patients. In conclusion, patient and lesion complexity had a durable adverse impact on clinical outcomes throughout 2 years of follow-up in this all-comers randomized trial. Safety and efficacy of new-generation BP-SES and DP-EES were comparable, irrespective of complexity status.
Assuntos
Implantes Absorvíveis , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos , Intervenção Coronária Percutânea , Polímeros , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Idoso , Antibióticos Antineoplásicos/administração & dosagem , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal Crônica/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Índice de Gravidade de Doença , Sirolimo/administração & dosagem , Volume Sistólico , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/fisiopatologiaAssuntos
Insuficiência da Valva Aórtica/cirurgia , Migração de Corpo Estranho/diagnóstico por imagem , Próteses Valvulares Cardíacas/efeitos adversos , Artéria Ilíaca/diagnóstico por imagem , Falha de Prótese , Adulto , Angiografia por Tomografia Computadorizada , Ecocardiografia , Auscultação Cardíaca , Sopros Cardíacos/etiologia , Humanos , Masculino , Prolapso da Valva Mitral/cirurgia , ReoperaçãoRESUMO
Churg-Strauss syndrome (CSS) is a rare multisystemic disorder of unknown origin and cardiac involvement is one of the most serious manifestations of the disease, accounting for approximately one-half of deaths attributable to CSS. Cardiac manifestation can be acute and mimic acute coronary syndrome (ACS). In this setting checking the blood leucocyte count can reveal hypereosinophilia and lead to a diagnosis of CSS.
Assuntos
Síndrome Coronariana Aguda/diagnóstico , Síndrome de Churg-Strauss/diagnóstico , Eosinofilia/etiologia , Miocardite/etiologia , Miocárdio/patologia , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Biópsia , Angiografia Coronária , Diagnóstico Diferencial , Ecocardiografia , Eletrocardiografia , Eosinofilia/diagnóstico , Eosinofilia/tratamento farmacológico , Feminino , Seguimentos , Glucocorticoides/administração & dosagem , Humanos , Injeções Intravenosas , Contagem de Leucócitos , Imagem Cinética por Ressonância Magnética , Miocardite/diagnóstico , Miocardite/tratamento farmacológico , Prednisolona/administração & dosagemRESUMO
We present the case of a 52-year-old man with a 2-month history of dyspnea, bilateral pleural effusion and cardiomegaly of rapid onset. A cardiac ultrasound showed pericardial effusion with infiltration of the infero-lateral cardiac wall, right auricle and aortic arch by a mass of unknown origin. Despite 1% blast cells in the peripheral blood, 2 bone marrow biopsies were negative for malignancy. Flow cytometry analysis of the blood and immunohistochemistry study of the pleural liquid showed a blast population of CD34+, CD33+, CD13+ and HLA-DR+ cells; a percutaneous cardiac biopsy showed CD34+ cells in the pericardium which led to the diagnosis of extramedullary acute myeloid leukemia (AML). The patient was treated with induction chemotherapy allowing remission, but unfortunately died of septic shock of fungal origin. This case illustrates a rare presentation of cardiac extramedullary AML.