Risk factors for acute myocardial infarction during the postoperative period of myocardial revascularization.

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p = 0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1% vs. 1.1%; p < 0.001 and 15.7 days vs. 10.6 days; p < 0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis.

Drug-eluting stents in the elderly: long-term (> one year) clinical outcomes of octogenarians in the DESIRE (Drug-Eluting Stents In the REal world) registry.

BACKGROUND: Despite the increasing number of elderly people, this high-complexity subset of patients is often excluded from randomized trials of percutaneous coronary intervention (PCI) and, therefore, limited data are available about their outcomes after drug-eluting stent (DES) implantation. We sought to compare the very long-term (> 1 year) clinical follow up of octogenarians treated with DES compared to younger individuals. METHODS: The DESIRE registry is a prospective, nonrandomized, single-center registry with consecutive patients treated solely with DES between May 2002 and May 2007. The only exclusion criteria were the treatment of patients in the setting of acute myocardial infarction (MI) (< 72 hours) and lesions located in non-native coronary arteries. The primary endpoint was the occurrence of combined major adverse cardiac events (MACE) (cardiac death, non-fatal MI and target vessel revascularization) in-hospital and in very long term (> 1 year) follow up. Patients were clinically evaluated at 1, 3 and 6 months and then annually up to 5 years. Stent thrombosis was classified according to the ARC definition. RESULTS: A total of 1,364 patients matched the inclusion/exclusion criteria and were sorted into 3 groups according to their ages: Group I = patients < 70 years of age (n = 914); Group II = patients greater than or equal to 70 and < 80 years of age (n = 334); and Group III = patients greater than or equal to 80 years old (n = 116). As expected, octogenarians had significantly more comorbid and complex anatomic lesion presentation. Nevertheless, in-hospital success was comparable among the 3 groups. Long-term (2.6 +/- 1.2 years) follow up was obtained from 97% of the total population and showed equivalent cumulative MACE in all age ranges (7.6% for < 70 years old vs. 5.4% for septuagenarians and 6.0% for octogenarians, p = 0.7). However, octogenarians had markedly more cardiac death, reflecting the severity of their comorbidity and the natural evolution of coronary disease. Of note, very few cases of stent thrombosis were noticed in the overall population (20 patients, 1.5%), with no difference among the groups. CONCLUSIONS: PCI with DES represents an efficient and safe approach to treat coronary artery disease in the elderly, with low rates of combined MACE comparable to other age ranges.

Impacto de stents farmacológicos em pacientes com doença arterial coronária estável submetidos a intervenção coronária percutânea na prática diária do mundo real / Impact of drug eluting stents in patients with stable coronary artery disease undergoing percutaneous coronary intervention in real world clinical practice

INTRODUÇÃO: Estudos recentes incluindo pacientes portadores de doença coronária estável sugerem ausência de benefício clínico da estratégia inicial de intervenção coronária percutânea com stents não-farmacológicos associada a terapia medicamentosa otimizada vs. terapia medicamentosa otimizada isolada. No entanto, o tratamento ideal para pacientes com doença coronária estável no mundo real permanece controverso. Reportamos o impacto dos stents farmacológicos (SF) em pacientes portadores de doença coronária estável tratados na prática clínica diária. Método: Entre maio de 2002 e novembro de 2009, 1814 pacientes portadores de doença coronária estável (angina estável ou isquemia silenciosa) foram prospectivamente incluídos no Registro DESIRE, e o seguimento clínico de até 8 anos (média de 3,9 +- 2 anos) foi realizado em 98 por cento desses pacientes. Resultados: A média das idades era de 64,2 +- 10,8 anos, 28 por cento tinham diabetes melito, 21 por cento tinham infarto do miocárdio prévio e 51,7 por cento, revascularização prévia. A artéria descendente anterior foi o vaso-alvo mais tratado (42 por cento) e, considerando-se o total de lesões (n= 2.701), 66,3 por cento delas eram de elevada complexidade (tipos B2/C). Ao final do procedimento, o sucesso angiográfico...

BACKGROUND: Recent studies in patients with stable coronary artery disease suggest there is no clinical benefit of the initial strategy of percutaneous coronary intervention with bare metal stents associated to optimal medical therapy (OMT) vs OMT alone. However, the best therapeutic option for patients with stable coronary artery disease in the real world remains controversial. We report the impact of drug eluting stents (DES) in patients with stable coronary artery disease treated in the daily clinical practice. METHOD: From May 2002 to November 2009, 1,814 patients with stable coronary artery disease (stable angina or silent ischemia) were prospectively included in the DESIRE Registry and 98% of the patients were followed up to 8 years (mean 3.9 ± 2 years). RESULTS: Mean age was 64.2 ± 10.8 years, 28% had diabetes mellitus, 21% had a prior myocardial infarction and 51.7% had a prior revascularization. Left anterior descending artery was treated in 42% of the patients. When all of the lesions (n = 2,701) were taken into consideration, 66.3% were classified as complex B2/C lesions. Angiographic success was 99%. The cumulative rate of adverse events in the late clinical follow-up was: cardiac death, 3.4%; myocardial infarction, 5.5%; target-lesion revascularization (TLR), 4.8%; and stent thrombosis, 0.8%. CONCLUSION: The use of DES in stable coronary artery disease was associated to excellent late clinical follow-up including a cumulative TLR rate < 5% and stent thrombosis < 1%. When compared to historical data, such findings show a great benefit of DES in this population, suggesting that percutaneous coronary intervention with DES is a safe and effective initial strategy in patients with stable coronary artery disease.

Reoperaçäo em pacientes revascularizados / Reoperation in patients for myocardial revascularization

Um grupo de pacientes submetidos a cirurgia de revascularizaçäo do miocárdio pode vir a necessitar uma reoperaçäo tardia. Neste trabalho, discute-se quais os possíveis fatores determinantes deste evento, bem como o prognóstico imediato destes indivíduos. Foram analisados 261 (10,5%) pacientes, submetidos a reoperaçäo para revascularizaçäo isolada do miocárdio entre janeiro de 1984 e junho de 1986. Havia 109 (41%) hipertensos e 145 (55%) portdores de infarto do miocárdio prévio. A reoperaçäo foi indicada pela presença de lesöes no leito nativo das artérias em 66 (25%), por lesöes nos enxertos em 88 (33%) e por lesöes nos leitos nativos e nos enxertos em 107 (42%). O tempo de reoperaçäo foi de 7,1 ñ 3,3 anos, sendo 75% dos pacientes reoperados num intervalo superior a 6 anos. O número global de artérias mamárias obstruídas foi de 5 (20%) enquanto que 171 (75%) das pontes de veia safena apresentavam lesöes. A mortalidade hospitalar foi de 23 (9%). Os autores discutem as relaçöes destes achados com a incidência da reoperaçäo bem como as possíveis causas da mortalidade elevada

Fatores preditivos de risco de infarto agudo do miocárdio no pós-operatório de operações de revascularizaçäo miocárdica / Risk factors for acute myocardial infarction during the postoperative period of myocardial revascularization

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p=0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1 percent vs. 1.1 percent; p<0.001 and 15.7 days vs. 10.6 days; p<0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis