Coronary artery bypass vs percutaneous coronary intervention in under 50s.

BACKGROUND: Young patients with coronary artery disease are undergoing percutaneous coronary intervention (PCI) primarily, with a view to deferring coronary artery bypass grafting (CABG). We investigated the validity of this approach, by comparing outcomes in patients ≤50 years undergoing CABG or PCI. METHODS: One hundred consecutive patients undergoing PCI and 100 undergoing CABG in 2004 were retrospectively studied to allow for 5 and 12 years follow-up. The two groups were compared for the primary endpoints of major adverse cardiac or cerebrovascular event (MACCE). RESULTS: Diabetes, peripheral vascular disease, and left ventricular ejection fraction <50% were higher in the CABG group. At 5 years, rates of myocardial infarction (MI) (9% vs 1%, P = .02), repeat revascularization (31% vs 7%, P < .01), and MACCE (34 vs 12, P < .01) were greater in the PCI vs the CABG group. Similarly, at 12 years, rates of MI (27.4% vs 19.4%, P = .19), repeat revascularization (41.1% vs 20.4%, P < .01), and MACCE (51 vs 40, P = .07) were greater in the PCI group. There were no differences in major outcomes in patients with 1 or 2VD, at 5 or 12 years. Rates of MI, revascularization, and MACCE were higher in patients with 3VD undergoing PCI (n = 21; MI, 47.6%; revascularization, 66.7%; and MACCE, 19 events) vs CABG (n = 78; MI, 19.2%; revascularization, 20.5%; and MACCE, 31 events); P < .01, for all end points. CONCLUSIONS: MACCE was lower in young patients undergoing CABG vs PCI at both 5 and 12 years follow-up, primarily as a consequence of patients with 3VD undergoing PCI having more MI and repeat revascularization. CABG should remain the preferred method of revascularization in young patients with 3VD.

Spontaneous combined lung and bowel hernia following an episode of acute bronchitis.

Spontaneous lung hernias are unusual conditions which usually follow attacks of excessive straining. Spontaneous bowel hernias are even rarer. Here, we present the first reported case of a combined spontaneous herniation of both the lung and bowel following an attack of acute bronchitis and coughing together with a description of surgical approach and repair.

Antiplatelet actions of statins and fibrates are mediated by PPARs.

OBJECTIVES: Statins and fibrates are hypolipidemic drugs which decrease cardiac events in individuals without raised levels of cholesterol. These drugs inhibit platelet function, but the mechanisms by which this pleiotropic effect is exerted are not known. METHODS AND RESULTS: We used a range of approaches to show statins inhibit human platelet activation in vitro while engaging PPARalpha and PPARgamma. The effects of simvastatin were prevented by the PPARgamma antagonist GW9662 or the PPARalpha antagonist GW6471. In a small-scale human study fluvastatin activated PPARalpha and PPARgamma in platelets and reduced aggregation in response to arachidonic acid ex vivo. The effects of fenofibrate were prevented by PPARalpha antagonism with GW6471. Fenofibrate increased bleeding time in wild-type, but not in PPARalpha-/- mice. The inhibitory effect of fenofibrate, but not simvastatin, on aggregation was prevented by deletion of PPARalpha in murine platelets. PKCalpha, which influences platelet activation, associated and immune-precipitated with PPARgamma in platelets stimulated with statins and with PPARalpha in platelets stimulated with fenofibrate. CONCLUSIONS: This study is the first to provide a unifying explanation of how fibrates and statins reduce thrombotic and cardiovascular risk. Our findings that PPARs associate with PKCalpha in platelets also provide a mechanism by which these effects are mediated.