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1.
Can J Cardiol ; 40(2): 275-289, 2024 02.
Artigo em Inglês | MEDLINE | ID: mdl-38181974

RESUMO

The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.


Assuntos
Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Humanos , Feminino , Doença da Artéria Coronariana/cirurgia , Ponte de Artéria Coronária/métodos , Resultado do Tratamento
2.
J Am Coll Cardiol ; 80(22): 2119-2134, 2022 11 29.
Artigo em Inglês | MEDLINE | ID: mdl-36423996

RESUMO

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Recent clinical practice guidelines provide clinicians with guidance; however, decisions regarding treatment for individual patients can still be difficult. The American College of Cardiology's Cardiac Surgery Team and Interventional Council joined together to develop a practical approach to the treatment of LM CAD, taking into account randomized clinical trial, meta-analyses, and clinical practice guidelines. The various presentations of LM CAD based on anatomy and physiology are presented. Recognizing the complexity of LM CAD, which rarely presents isolated and is often in combination with multivessel disease, a treatment algorithm with medical therapy alone or in conjunction with percutaneous coronary intervention or coronary artery bypass grafting is proposed. A heart team approach is recommended that accounts for clinical, procedural, operator, and institutional factors, and features shared decision-making that meets the needs and preferences of each patient and their specific clinical situation.


Assuntos
Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Humanos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Guias de Prática Clínica como Assunto
3.
JACC Case Rep ; 4(7): 377-384, 2022 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-35693904

RESUMO

The 2021 Coronary Artery Disease revascularization guidelines of the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) provide recommendations for managing nonculprit arteries in ST-segment elevation myocardial infarction (STEMI). Although staged revascularization is preferred, at times same-setting intervention, coronary artery bypass surgery, or medical therapy may be preferable. These cases exemplify clinical scenarios for treating nonculprit arteries in STEMI. (Level of Difficulty: Intermediate.).

5.
JACC Case Rep ; 4(3): 115-120, 2022 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-35199000

RESUMO

The 2021 ACC/AHA/SCAI coronary artery disease revascularization guideline highlights the importance of the multidisciplinary heart team in making patient-centered, evidence-based clinical decisions for patients considered for coronary revascularization. We present 2 cases highlighting aspects of heart team decision making for complex patients with coronary artery disease. (Level of Difficulty: Intermediate.).

6.
JACC Case Rep ; 4(1): 31-35, 2022 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-35036940

RESUMO

This case series shows how the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization can be used to decide between revascularization or optimal medical therapy to reduce mortality or cardiovascular events in selected subsets of patients with stable ischemic heart disease and complex coronary disease with or without left ventricular dysfunction. (Level of Difficulty: Advanced.).

7.
Circulation ; 145(3): e4-e17, 2022 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-34882436

RESUMO

AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.


Assuntos
Cardiologia/normas , Ponte de Artéria Coronária/normas , Revascularização Miocárdica/normas , Intervenção Coronária Percutânea/normas , Procedimentos Cirúrgicos Vasculares/normas , American Heart Association/organização & administração , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Vasos Coronários/cirurgia , Humanos , Estados Unidos , Procedimentos Cirúrgicos Vasculares/métodos
9.
J Am Coll Cardiol ; 79(2): e21-e129, 2022 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-34895950

RESUMO

AIM: The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.


Assuntos
Cardiologia/normas , Doença da Artéria Coronariana/terapia , Revascularização Miocárdica/normas , American Heart Association , Humanos , Revascularização Miocárdica/métodos , Estados Unidos
10.
J Am Coll Cardiol ; 79(2): 197-215, 2022 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-34895951

RESUMO

AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.


Assuntos
Doença da Artéria Coronariana/terapia , Revascularização Miocárdica/normas , Algoritmos , American Heart Association , Tomada de Decisão Compartilhada , Diabetes Mellitus , Terapia Antiplaquetária Dupla , Humanos , Revascularização Miocárdica/métodos , Equipe de Assistência ao Paciente , Medição de Risco , Estados Unidos
12.
Int J Cardiol Heart Vasc ; 30: 100634, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32995474

RESUMO

Although most prevalent in elderly, myocardial infarction (MI) also affects younger adults. We sought to investigate baseline characteristics in young patients (<55 years) with MI using the National Inpatient Sample (NIS) database between 2004 and 2015. Multivariable logistic regression models were used to assess factors associated with acute myocardial infarction (AMI) in young patients. After multivariable analyses adjusted for age, sex, race, family history of atherosclerosis, body mass index (BMI), diabetes, hypertension, hyperlipidemia, chronic kidney disease, and current cigarette smoking; novel risk factors such as human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) were associated with a higher risk of developing an AMI in the young (adjusted OR for HIV 4.06; 95 CI 3.48-4.71, p < 0.001), (adjusted OR for SLE 2.12; 95 CI 1.89-2.39, p 0.04), and (adjusted OR for OSA 1.16; 95 CI 1.12-1.20, p < 0.001), respectively. Rheumatoid arthritis was associated with a lower risk of AMI (adjusted OR 0.83; 95 CI 0.76-0.89, p < 0.001). After multivariable analyses, cigarette smoking (adjusted OR 1.98; 95 CI 1.95-2.02, p < 0.001), obesity (adjusted OR 1.37; 95 CI 1.33-1.41, p = 0.003), hyperlipidemia (adjusted OR 1.07; 95 CI 1.04-1.08, p < 0.001) and a family history of CAD (adjusted OR 1.35; 95 CI 1.3-1.4, p < 0.001) were also associated with a higher risk of developing an AMI in the young. In conclusion, young patients with AMI have both traditional risk factors and non-traditional risk factors. In addition to traditional risk factors, close attention should be paid to emerging risk factors such as SLE, HIV and OSA.

13.
Am Heart J ; 227: 9-10, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32640370

RESUMO

We aimed to investigate long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) using a meta-analysis from updated published randomized trials. Our data showed that the risk of all-cause death as well as cardiovascular death, myocardial infarction, and stroke was similar between PCI and CABG, whereas PCI had significantly higher rates of repeat revascularization compared to CABG. Decisions for PCI versus CABG for LMCAD should be based on weighing the upfront morbidity and mortality risk of CABG with late risk of repeat revascularization with PCI and taking into consideration patient preference.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento
14.
Am J Med ; 133(11): 1293-1301.e1, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32417118

RESUMO

BACKGROUND: Women are undertreated and have worse clinical outcomes than men after acute myocardial infarction. It remains uncertain whether the sex disparities in treatments and outcomes persist in the contemporary era and whether they affect all age groups equally. METHODS: Using the National Inpatient Sample (NIS) registry, we evaluated 1,260,200 hospitalizations for ST-elevation myocardial infarction (STEMI) between 2010 and 2016, of which 32% were for women. The age-stratified sex differences in care measures and mortality were examined. Stepwise multivariable adjustment models, including baseline comorbidities, hospital characteristics, and reperfusion and revascularization therapies, were used to compare measures and outcomes between women and men across different age subgroups. RESULTS: Overall, women with STEMI were older than men and had more comorbidities. Women were less likely to receive fibrinolytic therapy, percutaneous coronary intervention (PCI), and coronary artery bypass surgery across all age subgroups. Women with STEMI overall experienced higher unadjusted in-hospital mortality (11.1% vs 6.8%; adjusted odds ratio [OR] = 1.039, 95% confidence interval [CI]: 1.003-1.077), which persisted after multivariable adjustments. However, when stratified by age, the difference in mortality became non-significant in most age groups after stepwise multivariable adjustment, except among the youngest patients 19-49 years of age with STEMI (women vs men: 3.9% vs 2.6%; adjusted odds ratio = 1.259, 95% confidence interval: 1.083-1.464). CONCLUSIONS: Women with STEMI were less likely to receive reperfusion and revascularization therapies and had higher in-hospital mortality and complications compared with men. Younger women with STEMI (19-49 years of age) experienced higher in-hospital mortality that persisted after multivariable adjustment.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Intervenção Coronária Percutânea/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica/estatística & dados numéricos , Injúria Renal Aguda/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Feminino , Parada Cardíaca/epidemiologia , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais Rurais , Hospitais de Ensino , Hospitais Urbanos , Humanos , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/epidemiologia , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto Jovem
16.
J Am Coll Cardiol ; 61(17): 1767-76, 2013 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-23500245

RESUMO

OBJECTIVES: This study evaluated differences in outcome among women and men enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. BACKGROUND: Women and men with coronary artery disease have different clinical presentations and outcomes that might be due to differences in management. METHODS: We compared baseline variables, study interventions, and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization. RESULTS: At enrollment, women were more likely than men to have angina (67% vs. 58%, p < 0.01) despite less disease on angiography (Myocardial Jeopardy Index 41 ± 24 vs. 46 ± 24, p < 0.01; number of significant lesions 2.3 ± 1.7 vs. 2.8 ± 1.8, p < 0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables (death/myocardial infarction/cerebrovascular accident: hazard ratio: 1.11, 99% confidence interval [CI]: 0.85 to 1.44). However, women reported more angina than men (adjusted odds ratio: 1.51, 99% CI: 1.21 to 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (adjusted beta coefficient: -1.58, 99% CI: -2.84 to -0.32, p < 0.01). CONCLUSIONS: There were no sex differences in death, myocardial infarction, or cerebrovascular accident among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores after 5 years of medical therapy with or without prompt revascularization. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).


Assuntos
Angina Pectoris/epidemiologia , Angioplastia Coronária com Balão , Fármacos Cardiovasculares/uso terapêutico , Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Diabetes Mellitus Tipo 2/complicações , Comportamento de Redução do Risco , Antagonistas Adrenérgicos beta/administração & dosagem , Adulto , Idoso , Angina Pectoris/etiologia , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Bloqueadores dos Canais de Cálcio/administração & dosagem , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Complicações do Diabetes/terapia , Dieta , Diuréticos/administração & dosagem , Exercício Físico , Feminino , Seguimentos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Prevalência , Qualidade de Vida , Índice de Gravidade de Doença , Distribuição por Sexo , Fatores Sexuais , Abandono do Hábito de Fumar , Apoio Social , Resultado do Tratamento
17.
Catheter Cardiovasc Interv ; 82(1): E1-27, 2013 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-23299937
18.
J Am Coll Cardiol ; 61(4): e78-e140, 2013 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-23256914
19.
Am J Cardiol ; 107(7): 980-5, 2011 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-21276585

RESUMO

Previous studies have reported differences in presenting symptoms and angiographic characteristics between women and men undergoing evaluation for suspected coronary artery disease (CAD). We examined the relation between symptoms and extent of CAD in patients with type 2 diabetes mellitus and known CAD enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Of 1,775 patients (533 women, 30%, and 1,242 men, 70%), women were more likely than men to have angina (65% vs 56%, p <0.001) or an atypical angina/anginal equivalent (71% vs 58%, p <0.001). More women reported unstable angina (17% vs 13%, p = 0.047) or were in a higher Canadian Cardiology Society class compared to men (Canadian Cardiology Society classes II to IV 78% vs 68%, p = 0.002). Fewer women than men had no symptoms (14% vs 22%, p <0.001). Women had a lower mean myocardial jeopardy index (42.5 ± 24.3 vs 47.9 ± 24.3, p <0.001), smaller number of total significant lesions (2.3 ± 1.7 vs 2.7 ± 1.8, p <0.001), and fewer jeopardized left ventricular regions (p <0.001 for distribution) or long-term occlusions (29% vs 42%, p <0.001). After adjustment for relevant covariates, the odds of having CAD symptoms were still higher in women than men (odds ratio for angina 1.31, 95% confidence interval 1.02 to 1.69; odds ratio for atypical angina 1.52, 95% confidence interval 1.17 to 1.96). In conclusion, in a high-risk group of patients with known CAD and diabetes mellitus, women were more symptomatic than men but had less obstructive CAD. These data suggest that factors other than epicardial CAD severity influence symptom presentation in women in this population.


Assuntos
Angina Instável/diagnóstico , Angioplastia Coronária com Balão , Angiografia Coronária , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/terapia , Angiopatias Diabéticas/diagnóstico , Angiopatias Diabéticas/terapia , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/terapia , Angina Instável/terapia , Comorbidade , Estenose Coronária/diagnóstico , Estenose Coronária/terapia , Comparação Transcultural , Feminino , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores Sexuais
20.
Ann Noninvasive Electrocardiol ; 11(2): 139-44, 2006 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-16630088

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia occurring in patients after coronary artery bypass surgery (CABG). The purpose of this study was to determine whether AF characteristics were independently associated with postoperative length of stay (LOS). METHODS: Two hundred ninety consecutive post-CABG patients were examined through a detailed chart review. Baseline, intraoperative, and postoperative variables and the characteristics of AF were recorded. AF episodes were divided into single episodes lasting less than 24 hours (short-lived AF) and recurrent or prolonged >or=24 hours of AF (recurrent/prolonged AF). RESULTS: AF occurred in 94 (32.4%) patients. Twenty-six (27.7%) of AF patients had short-lived AF, and 68 (72.3%) of AF patients had recurrent/prolonged AF. Patients with recurrent/prolonged AF were older (P < 0.001) and more likely to have a history of prior AF (P < 0.001) relative to the other groups. Short-lived AF did not prolong LOS (7.2 +/- 2.1 days) relative to patients without AF (7.5 +/- 3.9 days), whereas recurrent/prolonged AF significantly prolonged LOS (10.4 +/- 6.1 days, P < 0.001). Multivariate analysis identified postoperative complications, recurrent/prolonged AF, age, and digoxin use as independent predictors of LOS. Recurrent/prolonged AF contributed an additional 1.1 days to LOS after adjusting for baseline clinical differences. CONCLUSIONS: There are heterogenous patterns of AF after cardiac surgery. A substantial minority of AF is short-lived and isolated with no impact on LOS; however, recurrent or prolonged AF significantly affects LOS.


Assuntos
Fibrilação Atrial/fisiopatologia , Ponte de Artéria Coronária , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/fisiopatologia , Fatores Etários , Idoso , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco
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