RESUMO
Chest pain (CP) has been reported in 20% to 40% of patients 1 year after percutaneous coronary intervention (PCI), though rates of post-PCI health-care utilization (HCU) for CP in nonclinical trial populations are unknown. Furthermore, the contribution of noncardiac factors - such as pulmonary, gastrointestinal, and psychological - to post-PCI CP HCU is unclear. Accordingly, the objectives of this study were to describe long-term trajectories and identify predictors of post-PCI CP-related HCU in real-world patients undergoing PCI for any indication. This retrospective cohort study included patients receiving PCI for any indication from 2003 to 2017 through a single integrated health-care system. Post-PCI CP-related HCU tracked through electronic medical records included (1) office visits, (2) emergency department (ED) visits, and (3) hospital admissions with CP or angina as the primary diagnosis. The strongest predictors of CP-related HCU were identified from >100 candidate variables. Among 6386 patients followed an average of 6.7 years after PCI, 73% received PCI for acute coronary syndrome (ACS), 19% for stable angina, and 8% for other indications. Post-PCI CP-related HCU was common with 26%, 16%, and 5% of patients having ≥1 office visits, ED visits, and hospital admissions for CP within 2 years of PCI. The following factors were significant predictors of all 3 CP outcomes: ACS presentation, documented CP >7 days prior to the index PCI, anxiety, depression, and syncope. In conclusion, CP-related HCU following PCI was common, especially within the first 2 years. The strongest predictors of CP-related HCU included coronary disease attributes and psychological factors.
Assuntos
Dor no Peito/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Visita a Consultório Médico/estatística & dados numéricos , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/cirurgia , Idoso , Idoso de 80 Anos ou mais , Angina Pectoris , Angina Estável/cirurgia , Angina Instável/cirurgia , Ansiedade/epidemiologia , Estudos de Coortes , Depressão/epidemiologia , Feminino , Serviços de Saúde/estatística & dados numéricos , Humanos , AVC Isquêmico/epidemiologia , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Fatores SexuaisRESUMO
OBJECTIVE: To investigate the effects of atorvastatin combined with trimetazidine on periprocedural myocardial injury and serum inflammatory mediators in unstable angina pectoris (UAP) patients following percutaneous coronary intervention (PCI) treatment. PATIENTS AND METHODS: 90 patients with UAP treated with conventional medications and PCI were recruited and were randomly divided into the control group and the experimental group. The control group had 42 patients were treated with atorvastatin alone, while the experimental group had 48 cases treated with atorvastatin combined with trimetazidine. All the patients were checked the preoperative 24h and postoperative 24h PCI concentrations of cardiac troponin I (cTnI), hypersensitive C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), serum interferon-γ (IFN-γ) and interlukin-10 (IL-10). RESULTS: At the pre-PCI stage, every serum factors was no significant difference. 24 hours after the PCI intervention, the occurence of abnormal cTnI level in the experimental group was remarkable reduced than the control group. In the experimental group, the serum levels of TNF-α and IFN-γ significantly decreased (p < 0.05); while IL-10 was increased. In the control group, all the mediators were increased significantly except the hs-CRP (p < 0.05). CONCLUSIONS: No unexpected symptom was found in patients with large dose atorvastatin combined with large dose trimetazidine. The administration of conventional medications together with the atorvastatin plus trimetazidine were able to reduce the prevalence of postoperative myocardial injury.
Assuntos
Angina Instável/tratamento farmacológico , Angina Instável/cirurgia , Atorvastatina/administração & dosagem , Traumatismos Cardíacos/epidemiologia , Mediadores da Inflamação/sangue , Intervenção Coronária Percutânea/métodos , Trimetazidina/administração & dosagem , Idoso , Angina Instável/sangue , Angina Instável/epidemiologia , Atorvastatina/efeitos adversos , Proteína C-Reativa/metabolismo , Terapia Combinada , Quimioterapia Combinada , Feminino , Traumatismos Cardíacos/sangue , Humanos , Interferon gama/sangue , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Trimetazidina/efeitos adversos , Troponina I/sangue , Fator de Necrose Tumoral alfa/sangueRESUMO
BACKGROUND: The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real-world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has used this strategy, with strict quality oversight, since 2005, and can provide insight into this question. METHODS AND RESULTS: Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient drive time (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction, and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction/unstable angina versus elective) and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median drive time for patients treated at those facilities decreased by 90.8 minutes (P<0.001). Procedural need for emergent coronary artery bypass graft and mortality rates were low and similar between facilities. Adjusted 1-year mortality and myocardial infarction rates were similar between facilities (hazard ratio in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval, 0.87-1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (hazard ratio, 1.21; 95% confidence interval, 1.03-1.42). CONCLUSIONS: This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without compromising procedural or 1-year outcomes.
Assuntos
Ponte de Artéria Coronária/mortalidade , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/mortalidade , Sistema de Registros/estatística & dados numéricos , United States Department of Veterans Affairs/estatística & dados numéricos , Idoso , Angina Instável/mortalidade , Angina Instável/cirurgia , Angina Instável/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/cirurgia , Infarto do Miocárdio/terapia , Sistemas de Identificação de Pacientes/estatística & dados numéricos , Stents/estatística & dados numéricos , Estados UnidosRESUMO
In Part 1 of this review, we discussed how plaque rupture is the most common underlying cause of most cases of unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI) and how early risk stratification is vital for the timely diagnosis and treatment of acute coronary syndromes (ACS). Now, in Part 2, we focus on the medical therapies and treatment strategies (early conservative vs early invasive) used for UA/NSTEMI. We also discuss results from various large randomized controlled trials that have led to the contemporary standards of practice for, and reduced morbidity and death from, UA/NSTEMI. In summary, ACS involving UA/NSTEMI is associated with high rates of adverse cardiovascular events, despite recent therapeutic advances. Plaque composition and inflammation are more important in the pathogenesis of ACS than is the actual degree of arterial stenosis. As results from new trials challenge our current practices and help us develop the optimal treatment strategy for UA/NSTEMI patients, the cornerstones of contemporary treatment remain early risk stratification and aggressive medical therapy, supplemented by coronary angiography in appropriately selected patients. An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients. Adjunctive medical therapy with acetylsalicylic acid, clopidogrel or another adenosine diphosphate antagonist, glycoprotein IIb/IIIa inhibitors, and either low-molecular-weight heparin or unfractionated heparin, in the appropriate setting, further reduces the risk of ischemic events secondary to thrombosis. Short- and long-term inhibition of platelet aggregation should be achieved by appropriately evaluating the risk of bleeding complications in these patients.
Assuntos
Síndrome Coronariana Aguda/terapia , Angina Instável/terapia , Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Infarto do Miocárdio/terapia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/cirurgia , Angina Instável/diagnóstico por imagem , Angina Instável/mortalidade , Angina Instável/cirurgia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/mortalidade , Anticoagulantes/efeitos adversos , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Medicina Baseada em Evidências , Hemorragia/induzido quimicamente , Humanos , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Seleção de Pacientes , Inibidores da Agregação Plaquetária/efeitos adversos , Guias de Prática Clínica como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The administration of insulin has been shown to exert cardioprotective and immunomodulatory properties. Ischemia and inflammation are typical features of acute coronary syndrome, thus it was hypothesized that high-dose glucose-insulin-potassium (GIK) treatment could suppress the systemic inflammatory reaction and attenuate myocardial ischemia-reperfusion injury in patients with unstable angina pectoris after urgent coronary artery bypass surgery. METHODS: Forty patients with unstable angina pectoris scheduled for urgent coronary artery bypass surgery and cardiopulmonary bypass were randomly assigned to receive either high-dose insulin treatment (short-acting insulin 1 IU/kg/h with 30% glucose 1.5 ml/kg/h administered separately) or control treatment (saline). Blood glucose levels were targeted to 6.0-8.0 mmol/l in both groups by adjusting the rate of glucose infusion in the GIK group and by additional insulin in the control group as needed. RESULTS: High-dose insulin treatment was associated with significantly lower average C-reactive protein (23.8 vs. 40.1 mg/l, P= 0.008) and free fatty acid levels (0.22 vs. 0.41 mmol/l, P= < 0.001) post-operatively. Average blood glucose levels were comparable during the intensive care unit (ICU) stay (7.1 vs. 6.9 mmol/l, P= 0.5) and 95% of the control patients received supplemental insulin. The pro-inflammatory cytokine response [interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha)] did not differ between the groups and beneficial effects on myocardial injury were not detected. CONCLUSIONS: High-dose insulin treatment has potential anti-inflammatory properties independent of its ability to lower blood glucose levels. Even profound suppression of free fatty acid levels, the attenuation of myocardial ischemia-reperfusion injury was not detected.
Assuntos
Angina Instável/cirurgia , Glucose/administração & dosagem , Inflamação/prevenção & controle , Insulina/administração & dosagem , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Revascularização Miocárdica , Idoso , Biomarcadores/metabolismo , Glicemia/metabolismo , Proteína C-Reativa/efeitos dos fármacos , Soluções Cardioplégicas/administração & dosagem , Tratamento de Emergência , Ácidos Graxos não Esterificados/metabolismo , Feminino , Humanos , Interleucina-10/metabolismo , Interleucina-6/metabolismo , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Potássio/administração & dosagem , Estudos Prospectivos , Resultado do TratamentoRESUMO
During the last decades, the prognosis of non-ST-elevation acute coronary syndromes has greatly improved. This improvement mainly depends on a better understanding of their pathophysiological background that allowed a remarkable evolution of their diagnostic and therapeutic management. Likewise, invasive strategies have evolved accordingly. Initially, patients with non-ST-elevation acute coronary syndromes had a very conservative approach and coronary revascularization was strongly discouraged during the acute phase. Afterward, as pharmacological therapies and revascularization techniques improved, interventional strategies gradually switched to a careful "delayed invasive approach". Recently, several studies, taking full advantage from the most effective treatments, have demonstrated that an early aggressive strategy (coronary revascularization within 48 hours of symptom onset) could reduce the incidence of cardiac events in patients with non-ST-elevation acute coronary syndromes at medium-to-high risk. These findings made this "early aggressive" strategy very attractive. However, in the real world such a strategy is rarely an option due to several logistical constraints and very often the selection of the therapeutic strategy depends more on resource availability than on patients' risk profile. Therefore, Italian cardiologists should pursue integrated healthcare models in order to overcome such limitations. They should develop critical pathways able to target adequately the patient risk and improve interventional networks where even subjects admitted to peripheral hospitals could benefit from a timely revascularization procedure according to their risk profile. This could reduce treatment disparities and could counteract the vicious circle that tends to privilege interventions in low-risk subjects instead of high-risk patients, like the elderly, women or diabetics.
Assuntos
Angina Instável/cirurgia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica , Doença Aguda , Humanos , Revascularização Miocárdica/métodos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , SíndromeRESUMO
Of 35 acetylsalicylic acid (ASA)-treated patients undergoing coronary artery bypass surgery, 10 received a high dose of aprotinin (mean 5.2 x 10(6) KIU) during cardiopulmonary bypass (CPB); in 15 cases low-dose aprotinin (2 x 10(6) KIU) was added to the CPB priming solution, and 10 patients made up a control group without aprotinin. Median total blood loss was 52% less in aprotinin-treated patients, irrespective of dose, than in the controls. Fibrin-D dimer levels remained low in patients treated with high-dose aprotinin, but increased significantly in the control group. Platelet adhesion and platelet adenosine triphosphate secretion were reduced after CPB in all patients. Whole-blood aggregation after bypass was enhanced in aprotinin-treated patients. Aprotinin inhibited fibrinolysis and seemingly preserved platelet function despite ASA treatment. In view of the possible risks and relatively high cost of aprotinin, use of a high dose seems unnecessary, since a low dose was equally effective in reducing blood loss in ASA-treated patients.
Assuntos
Aprotinina/administração & dosagem , Perda Sanguínea Cirúrgica/prevenção & controle , Ponte Cardiopulmonar , Hemostáticos/administração & dosagem , Trifosfato de Adenosina/metabolismo , Adulto , Idoso , Angina Instável/tratamento farmacológico , Angina Instável/cirurgia , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Transfusão de Sangue , Intervalos de Confiança , Relação Dose-Resposta a Droga , Feminino , Fibrina/análise , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Adesividade Plaquetária/efeitos dos fármacos , Contagem de Plaquetas/efeitos dos fármacos , Cuidados Pré-Operatórios , Valores de Referência , Resultado do TratamentoRESUMO
Creemos haber demostrado que en la actualidad no es razonable hablar de la evolución natural de la cardioapatía isquémica en su conjunto. Es posible identificar una serie de cuadros clínicos con diferentes modalidades evolutivas que confirmen características determinadas a cada uno de los grupos. Lo antedicho avala la propuesta de nuestra clasificación de la cardiapatía isquémica sintomática en base al angor, esta división es sin duda perfectible pero, hemos comenzado a aplicarla hace cuatro años y hasta ahora funciona a entera satisfacción. Todavía hoy se lee y se escucha en los congresos nacionales e internacionales que muy poco se conoce de la evolución natural de la ateroesclerosis coronaria en la angina de pecho estable. Es indudable que mucho se ha progresado en el conocimiento de la misma desde los trabajos iniciales analizados aquí y basados solamente en la clasificación clínica de los pacientes, con todos los errores que ello llevaba involucrado. No obstante dieron una idea general del panorama a abarcar y en nuestros días la introducción de la cine coronario angiografía por Sones abrió todo un camino para conocer la base anatómica precisa de la enfermedad... (TRUNCADO)
Assuntos
Masculino , Feminino , Humanos , Angina Instável/cirurgia , Angina Instável/terapia , Angina Pectoris Variante/cirurgia , Angina Pectoris Variante/etiologia , Angina Pectoris Variante/fisiopatologia , Angina Pectoris Variante/terapia , Angina Pectoris/cirurgia , Angina Pectoris/classificação , Angina Pectoris/diagnóstico , Angina Pectoris/terapia , Angiografia Coronária , Avaliação Nutricional , Cineangiografia , Diagnóstico Diferencial , Doença da Artéria Coronariana/complicações , Eletrocardiografia , Ergometria , Evolução Clínica , Hemodinâmica , História Natural das Doenças , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Isquemia Miocárdica/classificação , Isquemia Miocárdica/etiologia , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/prevenção & controle , Isquemia Miocárdica/terapia , Morte Súbita , Prognóstico , Seguimentos , Sinais e SintomasRESUMO
Creemos haber demostrado que en la actualidad no es razonable hablar de la evolución natural de la cardioapatía isquémica en su conjunto. Es posible identificar una serie de cuadros clínicos con diferentes modalidades evolutivas que confirmen características determinadas a cada uno de los grupos. Lo antedicho avala la propuesta de nuestra clasificación de la cardiapatía isquémica sintomática en base al angor, esta división es sin duda perfectible pero, hemos comenzado a aplicarla hace cuatro años y hasta ahora funciona a entera satisfacción. Todavía hoy se lee y se escucha en los congresos nacionales e internacionales que muy poco se conoce de la evolución natural de la ateroesclerosis coronaria en la angina de pecho estable. Es indudable que mucho se ha progresado en el conocimiento de la misma desde los trabajos iniciales analizados aquí y basados solamente en la clasificación clínica de los pacientes, con todos los errores que ello llevaba involucrado. No obstante dieron una idea general del panorama a abarcar y en nuestros días la introducción de la cine coronario angiografía por Sones abrió todo un camino para conocer la base anatómica precisa de la enfermedad... (TRUNCADO)(AU)