The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial.

Aims: Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results: The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion: A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

[Effect of transmyocardial laser revascularization on the myocardium in the early postoperative period]. / Ocena wplywu przezmiesniowej rewaskularyzacji laserowej na stan miesnia sercowego we wczesnym okresie pooperacyjnym.

BACKGROUND: Transmyocardial laser revascularization (TMLR) is a modem approach in the management of coronary artery disease. It can be considered as a method of choice in some cases unsuitable for coronary angioplasty or bypass grafting. Transmyocardial laser revascularization is expected to relieve angina and to improve patient quality of life and survival. The aim of the study was to determine whether the laser energy released during TMLR induces any myocardial deterioration, which could affect the heart status and function in early postoperative period. METHODS: A group of 80 patients with CAD (37 TMLR/CABG, 43 CABG) was evaluated within 24 hours after the procedure for CK-MB and cTnT concentrations to determine myocardial injury. Elective hemodynamic indexes were used to determine the heart function. The cardiac rhythm disturbances were recorded by Holter monitoring. Homeostatic disturbances and postoperative complications were also recorded. RESULTS: The postoperative CK-MB and cTnT levels were significantly higher in the TMLR g roup (ANOVA: p < 0.001 and p = 0.013), with significantly high correlation of laser energy and number of channels with CK-MB(max) concentration (Pearson coefficient of correlation 0.614 and 0.561, p < 0.0001) and non significant correlation with cTnT(max) concentration. No significant differences between the TMLR and the CABG group regardinghemodynamic indexes were observed. Significantly more patients in the TMLR group had ventricular events (VE) within 24 postoperative hours (27 vs 10, chi 2: p < 0.0001), reguiring antyarrhythmic drugs administration (13 vs 2, chi2: p < 0.0008). The number of channels created in a group of patients with VE was significantly higher (21.8+/- 7.66 vs 15.7 +/- 7.63; p = 0.0255). No significant difference in postoperative blood loss was observed. Significantly more patients from the TMLR group received blood (37/37 vs 36/43 in CABG group, chi2: p = 0.029), but no significant difference in number of blood units used was observed (3.22 +/- 1.8 U. in TMLR group vs 2.92 +/- 1.52 U. in CABG group: p = 0.445). Significantly more patients needed postoperatively inotropic support in the TMLR group (10 vs 2, chi2; p = 0.019). One patient from the TMLR group had low output syndrome (IAB support) and one from the CABG group had postoperative myocardial infarction. CONCLUSION: The laser energy released during TMLR injures th e myocardium (CK-MB, cTnT, VE) but does notaffect the heart function (hemodynamic status, postoperative course).