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1.
Circ Cardiovasc Interv ; 13(3): e008458, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32151162

RESUMO

BACKGROUND: Financial pressures for reducing hospitalization costs have driven to a move toward same day discharge (SDD) following uncomplicated percutaneous coronary intervention. The UK healthcare system has transitioned to predominantly SDD for elective percutaneous coronary intervention. This study aimed to examine patient's clinical, procedural, and institutional characteristics that are associated with the increased adoption of SDD adoption over time in the United Kingdom and determine whether these vary by region. METHODS: The data were derived from the British Cardiovascular Intervention Society including all the elective percutaneous coronary intervention from 2007 to 2014 in the United Kingdom. We structured 8 meaningful groups of variables, and their relative importance was obtained by decomposing the R2 in each study year. RESULTS: The relative importance of Strategic Health Authorities was substantially higher than all other factors every year, with some reduction over time, from 49.2% (95% CI, 45.4%-52.4%) in 2007 to 43.4% (95% CI, 39.9%-46.6%) in 2014. Center volume followed with 8.95% (95% CI, 7.0%-10.9%) to 19.8% (95% CI, 16.7%-22.4%). Between patients' clinical and procedural characteristics, pharmacology and access site had the highest relative importance values, from 14.3% (95% CI, 12.1%-16.4%) to 7.1% (95% CI, 5.5%-8.8%) and from 3.6% (95% CI, 2.3%-5.1%) to 11.8% (95% CI, 9.4%-14.3%), respectively. Relative importance of different groups varied differently across Strategic Health Authorities. CONCLUSIONS: Growth of SDD was mainly associated with regional characteristics, while subcontributors varied substantially between different regions. Standardized guidelines would provide more homogenous adoption of SDD nationally. This analysis might be of wider interest in healthcare systems slower in SDD adoption.

3.
Am Heart J ; 222: 15-25, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32004796

RESUMO

BACKGROUND: Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. OBJECTIVE: To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. METHODS AND RESULTS: Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CONCLUSIONS: CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. CONDENSED ABSTRACT: Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.


Assuntos
Angina Estável/cirurgia , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros , Medição de Risco/métodos , Carga de Trabalho/estatística & dados numéricos , Idoso , Angina Estável/mortalidade , Bases de Dados Factuais , Inglaterra/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento , País de Gales/epidemiologia
5.
JACC Cardiovasc Interv ; 13(3): 346-357, 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32029252

RESUMO

OBJECTIVES: The authors used the British Cardiovascular Intervention Society (BCIS) national percutaneous coronary intervention (PCI) database to explore temporal changes in the use of intravascular imaging for unprotected left main stem PCI (uLMS PCI), defined the associates of imaging use, and correlate clinical outcomes including survival with imaging use. BACKGROUND: Limited registry data support the use of intravascular imaging during uLMS PCI to improve outcomes. METHODS: Data were analyzed from 11,264 uLMS PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify associates of imaging use. Propensity matching created 5,056 pairs of subjects with and without imaging and logistic regression was performed to quantify the association between imaging and outcomes. Multivariate logistic regression to identify the independent predictors of 12-month mortality was performed. RESULTS: Imaging use increased from 30.2% in 2007 to 50.2% in 2014 (p for trend < 0.001). The factors associated with imaging use included stable angina presentation (odds ratio [OR]: 1.200; 95% confidence interval [CI]: 1.147 to 1.246; p < 0.001), bifurcation LMS disease (OR: 1.220; 95% CI: 1.140 to 1.300; p < 0.001), previous PCI (OR: 1.320; 95% CI: 1.200 to 1.440; p < 0.001), and radial access (OR: 1.266; 95% CI: 1.217 to 1.317; p < 0.001). A lower rate of coronary complications, lower in-hospital major adverse cardiac events (OR: 0.470; 95% CI: 0.37 to 0.590; p < 0.001), and improved 30-day (OR: 0.540; 95% CI: 0.430 to 0.680; p < 0.001) and 12-month (OR: 0.660; 95% CI: 0.570 to 0.770; p < 0.001) mortality were observed with imaging use compared with no imaging use. Greater mortality reductions were observed with higher operator LMS PCI volume. In logistic regression modeling, imaging use was associated with improved 12-month survival. CONCLUSIONS: The observed lower mortality with use of intravascular imaging to guide uLMS PCI justifies the undertaking of a large-scale randomized trial.

6.
Clin Res Cardiol ; 2020 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-31925529

RESUMO

BACKGROUND: Impaired renal function (IRF) is associated with increased risks of both ischemic and bleeding events. Ticagrelor has been shown to provide greater absolute reduction in ischemic risk following acute coronary syndrome (ACS) in those with versus without IRF. METHODS: A pre-specified sub-analysis of the randomized GLOBAL LEADERS trial (n = 15,991) comparing the experimental strategy of 23-month ticagrelor monotherapy (after 1-month ticagrelor and aspirin dual anti-platelet therapy [DAPT]) with 12-month DAPT followed by 12-month aspirin after percutaneous coronary intervention (PCI) in ACS and stable coronary artery disease (CAD) patients stratified according to IRF (glomerular filtration rate < 60 ml/min/1.73 m2). RESULTS: At 2 years, patients with IRF (n = 2171) had a higher rate of the primary endpoint (all-cause mortality or centrally adjudicated, new Q-wave myocardial infarction [MI](hazard ratio [HR] 1.64, 95% confidence interval [CI] 1.35-1.98, padj = 0.001), all-cause death, site-reported MI, all revascularization and BARC 3 or 5 type bleeding, compared with patients without IRF. Among patients with IRF, there were similar rates of the primary endpoint (HR 0.82, 95% CI 0.61-1.11, p = 0.192, pint = 0.680) and BARC 3 or 5 type bleeding (HR 1.10, 95% CI 0.71-1.71, p = 0.656, pint = 0.506) in the experimental versus the reference group. No significant interactions were seen between IRF and treatment effect for any of the secondary outcome variables. Among ACS patients with IRF, there were no between-group differences in the rates of the primary endpoint or BARC 3 or 5 type bleeding; however, the rates of the patient-oriented composite endpoint (POCE) of all-cause death, any stroke, MI, or revascularization (pint = 0.028) and net adverse clinical events (POCE and BARC 3 or 5 type bleeding) (pint = 0.045), were lower in the experimental versus the reference group. No treatment effects were found in stable CAD patients categorized according to presence of IRF. CONCLUSIONS: IRF negatively impacted long-term prognosis after PCI. There were no differential treatment effects found with regard to all-cause death or new Q-wave MI after PCI in patients with IRF treated with ticagrelor monotherapy. CLINICAL TRIAL REGISTRATION: The trial has been registered with ClinicalTrials.gov, number NCT01813435.

7.
Int J Cardiol ; 301: 7-13, 2020 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-31810815

RESUMO

BACKGROUND: International guidelines recommend that for NSTEMI, the timing of invasive strategy (IS) is a function of patient's baseline risk. The extent to which this is delivered across and within healthcare systems is unknown. METHODS: Data were derived from 137,265 patients admitted with an NSTEMI diagnosis between 2010 and 2015 in England and Wales. Patients were stratified into low, intermediate and high-risk in keeping with international guidelines. Time to IS was categorised into early (24 h), intermediate (25-72 h) and late (>72 h). Multivariable logistic regression models were used to identify independent predictors of guidelines recommended receipt of IS. RESULTS: There were 3608 (2.6%) low, 5037 (3.7%) intermediate and 128,621 (93.7%) high-risk patients. Guidelines recommended use of IS was significantly lower in high-risk (16.4%) compared to intermediate (64.7%) and low-risk (62.5%) groups. Both men and women in the low-risk category were almost twice as likely to receive early IS compared to high-risk men (28.9% vs 17%, p < 0.001) and women (26.9% vs 15%, p < 0.001). Women (OR 0.91 95%CI 0.88-0.94), troponin elevation (OR 0.39 95%CI 0.36-0.43) and acute heart failure on admission (OR 0.65 95%CI 0.61-0.70) were strong negative predictors of receiving IS within recommended time in the high-risk group. CONCLUSION: Our study shows that IS for management of NSTEMI is not delivered according to international guidelines recommendations. Specifically, the disconnect between baseline risk and utility of IS increases with increasing risk and women achieve slower access than men to IS.

9.
Int J Cardiol ; 299: 37-42, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31253528

RESUMO

BACKGROUND: The evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear. METHODS AND RESULTS: Using the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08-2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation. CONCLUSIONS: Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.

10.
Oxid Med Cell Longev ; 2019: 6217837, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31827686

RESUMO

Myocardial ischemia/reperfusion-related oxidative stress as a result of cardiopulmonary bypass is thought to contribute to the adverse clinical outcomes following surgical aortic valve replacement (SAVR). Although the acute response following this procedure has been well characterized, much less is known about the nature and extent of oxidative stress induced by the transcatheter aortic valve replacement (TAVR) procedure. We therefore sought to examine and directly compare the oxidative stress response in patients undergoing TAVR and SAVR. A total of 60 patients were prospectively enrolled in this exploratory study, 38 patients undergoing TAVR and 22 patients SAVR. Reduced and oxidized glutathione (GSH, GSSG) in red blood cells as well as the ferric-reducing ability of plasma (FRAP) and plasma concentrations of 8-isoprostanes were measured at baseline (S1), during early reperfusion (S2), and 6-8 hours (S3) following aortic valve replacement (AVR). TAVR and SAVR were successful in all patients. Patients undergoing TAVR were older (79.3 ± 9.5 vs. 74.2 ± 4.1 years; P < 0.01) and had a higher mean STS risk score (6.6 ± 4.8 vs. 3.2 ± 3.0; P < 0.001) than patients undergoing SAVR. At baseline, FRAP and 8-isoprostane plasma concentrations were similar between the two groups, but erythrocytic GSH concentrations were significantly lower in the TAVR group. After AVR, FRAP was markedly higher in the TAVR group, whereas 8-isoprostane concentrations were significantly elevated in the SAVR group. In conclusion, TAVR appears not to cause acute oxidative stress and may even improve the antioxidant capacity in the extracellular compartment.

11.
J Am Coll Cardiol ; 74(25): 3083-3094, 2019 12 24.
Artigo em Inglês | MEDLINE | ID: mdl-31856964

RESUMO

BACKGROUND: Randomized trials have shown that complete revascularization in patients with ST-segment elevation myocardial infarction (MI) with multivessel disease results in lower major adverse cardiovascular events (MACE) (all-cause death, MI, ischemia-driven revascularization, heart failure). OBJECTIVES: The goal of this study was to determine whether the benefits of complete revascularization are sustained long-term and their impact on hard endpoints. METHODS: CvLPRIT (Complete versus Lesion-only Primary PCI Trial) was a randomized trial of complete inpatient revascularization versus infarct-related artery revascularization only at the index admission. Randomized patients have been followed longer-term. The components of the original primary endpoint were collected from physical and electronic patient records, and from local databases for all readmissions. RESULTS: The median follow-up (achieved in >90% patients) from randomization to first event or last follow-up was 5.6 years (0.0 to 7.3 years). The primary MACE endpoint rate at this time point was 24.0% in the complete revascularization group but 37.7% of the infarct-related artery-only group (hazard ratio: 0.57; 95% confidence interval: 0.37 to 0.87; p = 0.0079). The composite endpoint of all-cause death/MI was 10.0% in the complete revascularization group versus 18.5% in the infarct-related artery-only group (hazard ratio: 0.47; 95% confidence interval: 0.25 to 0.89; p = 0.0175). In a landmark analysis (from 12 months to final follow-up), there was no significant difference between MACE, death/MI, and individual components of the primary endpoint. CONCLUSIONS: Long-term follow-up of the CvLPRIT trial shows that the significantly lower rate of MACE in the complete revascularization group, previously seen at 12 months, is sustained to a median of 5.6 years. A significant difference in composite all-cause death/MI favoring the complete revascularization was also observed. (Complete versus Lesion-only Primary PCI Trial; ISRCTN70913605).

12.
JACC Cardiovasc Interv ; 12(22): 2286-2295, 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31753300

RESUMO

OBJECTIVES: The aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society. BACKGROUND: There are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era. METHODS: A longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912). RESULTS: Patients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score-matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p < 0.001). CONCLUSIONS: In this contemporary cohort, EPDs were used more commonly in higher risk patients but were associated with similar clinical outcomes in multivariate analyses. Lower inpatient mortality was observed in the EPD group in univariate and propensity score-matched analyses.

13.
Artigo em Inglês | MEDLINE | ID: mdl-31761641

RESUMO

There is growing awareness that frailty may be an important marker of adverse outcomes in PCI but there is no literature from national cohorts. This study examines a national cohort of patients who underwent percutaneous coronary intervention (PCI) regarding the prevalence of frailty, changes over time, and associated outcomes. The National Inpatients Sample was used to identify adults who underwent PCI procedures between 2004 and 2014. Frailty risk was measured using a validated Hospital Frailty Risk Score (HFRS) using the cutoffs <5, 5-15 and >15 for low, intermediate and high HFRS. From 7,306,007 admissions, a total of 94.58% of admissions were for patients who had a low HFRS(<5), 5.39% had an intermediate HFRS(5-15) and 0.03% had a high HFRS(>15). The prevalence of intermediate or high frailty risk patients has increased over time from 1.9% in 2004 to 11.7% in 2014. The incidence of in-hospital death increased from 1.0% with low HFRS to 13.9% with high HFRS. Mean length of stay also increased from 2.9 days to 17.1 days from low to high HFRS. High frailty risk was independently associated with an OR 9.91 95%CI 7.17-13.71 for in-hospital death, OR 4.99 95%CI 3.82-6.51 for bleeding and OR 3.96 95%CI 3.00-5.23 for vascular injury as compared to patients with low risk of HFRS. While rare in frequency overall, frailty is increasing in prevalence in recent years and intermediate and high HFRS associated with increased odds of mortality compared to low risk of frailty.

14.
Lancet ; 394(10206): 1325-1334, 2019 10 12.
Artigo em Inglês | MEDLINE | ID: mdl-31488373

RESUMO

BACKGROUND: The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was a non-inferiority trial that compared percutaneous coronary intervention (PCI) using first-generation paclitaxel-eluting stents with coronary artery bypass grafting (CABG) in patients with de-novo three-vessel and left main coronary artery disease, and reported results up to 5 years. We now report 10-year all-cause death results. METHODS: The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension of follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to the PCI group or CABG group. Patients with a history of PCI or CABG, acute myocardial infarction, or an indication for concomitant cardiac surgery were excluded. The primary endpoint of the SYNTAXES study was 10-year all-cause death, which was assessed according to the intention-to-treat principle. Prespecified subgroup analyses were performed according to the presence or absence of left main coronary artery disease and diabetes, and according to coronary complexity defined by core laboratory SYNTAX score tertiles. This study is registered with ClinicalTrials.gov, NCT03417050. FINDINGS: From March, 2005, to April, 2007, 1800 patients were randomly assigned to the PCI (n=903) or CABG (n=897) group. Vital status information at 10 years was complete for 841 (93%) patients in the PCI group and 848 (95%) patients in the CABG group. At 10 years, 244 (27%) patients had died after PCI and 211 (24%) after CABG (hazard ratio 1·17 [95% CI 0·97-1·41], p=0·092). Among patients with three-vessel disease, 151 (28%) of 546 had died after PCI versus 113 (21%) of 549 after CABG (hazard ratio 1·41 [95% CI 1·10-1·80]), and among patients with left main coronary artery disease, 93 (26%) of 357 had died after PCI versus 98 (28%) of 348 after CABG (0·90 [0·68-1·20], pinteraction=0·019). There was no treatment-by-subgroup interaction with diabetes (pinteraction=0·66) and no linear trend across SYNTAX score tertiles (ptrend=0·30). INTERPRETATION: At 10 years, no significant difference existed in all-cause death between PCI using first-generation paclitaxel-eluting stents and CABG. However, CABG provided a significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease. FUNDING: German Foundation of Heart Research (SYNTAXES study, 5-10-year follow-up) and Boston Scientific Corporation (SYNTAX study, 0-5-year follow-up).


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea , Idoso , Doença da Artéria Coronariana/patologia , Stents Farmacológicos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do Tratamento
15.
EuroIntervention ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31498113

RESUMO

AIMS: To evaluate the impact of a novel antiplatelet regimen in patients with increasing total stent length (TSL). METHODS AND RESULTS: This is a post-hoc analysis of the Global Leaders trial, a prospective, multi-centre, open-label, randomised trial, investigating the impact of the experimental strategy (one-month dual antiplatelet regimen [DAPT] followed by 23-month ticagrelor monotherapy) versus the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with Biolimus A9-eluting stent (BES). The primary endpoint was the composite of the all-cause death and new Q-wave myocardial infarction (MI), and the secondary endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at two years. To investigate the association between total stent length and outcomes, groups were compared in quartiles according to TSL, and the fourth quartile group was at significantly higher ischemic risk at two years. In that stratum (TSL≥ 46mm), the experimental strategy significantly reduced the risk of the primary endpoint (hazard ratio [HR]:0.67; 95% confidence interval [CI]:0.49-0.90; Pinteraction=0.043), while demonstrating a similar risk of BARC type 3 or 5 bleeding (HR:0.99; 95% CI:0.66-1.49; Pinteraction =0.975). CONCLUSIONS: Ticagrelor monotherapy potentially could balance ischemic and bleeding risks, thereby achieving a net clinical benefit in patients with TSL≥ 46 mm with BES.

16.
J Cardiovasc Transl Res ; 12(6): 608-610, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31367899

RESUMO

Deoxyribonucleic acid (DNA) damage and repair signaling cascades are related to the development of atherosclerosis. Pathological studies have demonstrated that healed coronary plaque rupture (HCPR) contributes to plaque progression and predisposes to sudden ischemic cardiac death. The objective of this study is to investigate the relationship between HCPR detected by optical coherence tomography (OCT) and DNA ligase. Forty-two patients with both OCT and DNA ligase were prospectively enrolled. The population included patients with stable angina pectoris (SA) and non-ST-elevation myocardial infarction (NSTEMI). It was found that the prevalence of HCPR was greater in subjects with higher DNA ligase activity (correlation coefficient 0.36, p = 0.019). The presence of HCPR in patients with NSTEMI was greater than in patients with SA per OCT analysis; however, there was no statistical difference in this limited population (22.53% versus 12.83%, respectively, p = 0.116). DNA repair activity by DNA ligase was associated with HCPR in advanced coronary artery plaque by OCT.

17.
JACC Cardiovasc Interv ; 12(15): 1479-1494, 2019 Aug 12.
Artigo em Inglês | MEDLINE | ID: mdl-31395218

RESUMO

OBJECTIVES: The aim of this study was to evaluate national temporal trends in same-day discharge (SDD) and compare clinical outcomes with those among patients admitted for overnight stay undergoing elective percutaneous coronary intervention (PCI) for stable angina. BACKGROUND: Overnight observation has been the standard of care following PCI, with no previous national analyses around changes in practice or clinical outcomes from health care systems in which SDD is the predominant practice for elective PCI. METHODS: Data from 169,623 patients undergoing elective PCI between 2007 and 2014 were obtained from the British Cardiovascular Intervention Society registry. Multiple logistic regressions and the British Cardiovascular Intervention Society risk model were used to study the association between SDD and 30-day mortality. RESULTS: The rate of SDD increased from 23.5% in 2007 to 57.2% in 2014, with center SDD median prevalence varying from 17% (interquartile range: 6% to 39%) in 2007 to 66% (interquartile range: 45% to 77%) in 2014. The largest independent association with SDD was observed for radial access (odds ratio: 1.69; 95% confidence interval: 1.65 to 1.74; p < 0.001). An increase in 30-day mortality rate over time for the SDD cases was observed, without exceeding the predicted mortality risk. According to the difference-in-differences analysis, observed 30-day mortality temporal changes did not differ between SDD and overnight stay (odds ratio: 1.15; 95% confidence interval: 0.294 to 4.475; p = 0.884). CONCLUSIONS: SDD has become the predominant model of care among elective PCI cases in the United Kingdom, in increasingly complex patients. SDD appears to be safe, with 30-day mortality rates in line with those calculated using the national risk prediction score used for public reporting. Changes toward SDD practice have important economic implications for health care systems worldwide.

18.
Br J Radiol ; 92(1102): 20190344, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31359789

RESUMO

OBJECTIVE: To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI). METHODS: A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant-findings that did not require specific treatment or follow-up; (b) intermediate-findings that did not impact on the decision-making process but required follow-up; (c) significant-findings that either required urgent investigation or meant that TAVI was clinically inappropriate. RESULTS: A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases. CONCLUSION: Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention. ADVANCES IN KNOWLEDGE: This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.


Assuntos
Achados Incidentais , Cuidados Pré-Operatórios , Tomografia Computadorizada por Raios X , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Estudos de Coortes , Feminino , Humanos , Masculino , Neoplasias/diagnóstico por imagem , Prevalência , Estudos Retrospectivos , Risco , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Reino Unido
19.
Cardiovasc Revasc Med ; 20(9): 812-818, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31178349

RESUMO

OBJECTIVE: The aim of this study was to examine DNA ligase activity and expression of DNA damage response pathway (DDR) genes in patients with stable angina (SA) and non-ST elevation myocardial infarction (NSTEMI) and determine whether they correlate with plaque morphology. BACKGROUND: Patients with coronary artery disease (CAD) have evidence of deoxyribonucleic acid (DNA) damage in peripheral blood mononuclear cells (PBMCs). It is unclear whether this represents excess damage or defective DNA repair activity. METHODS: DNA ligase activity and the expression of 22 DDR genes were measured in PBMCs of patients (both SA (n = 47) and NSTEMI (n = 42)) and in age and gender-matched controls (n = 35). Target lesion anatomical assessment was undertaken with frequency domain optical coherent tomography. RESULTS: DNA ligase activity was different across the three groups of patients (control = 119 ±â€¯53, NSTEMI = 115.6 ±â€¯85.1, SA = 81 ±â€¯55.7 units/g of nuclear protein; ANOVA p = 0.023). Pair wise comparison demonstrated that this significance is due to differences between the control and SA patients (p = 0.046). Genes involved in double strand break repair and nucleotide excision repair pathways were differentially expressed in patients with SA and NSTEMI. In SA patients, fibrocalcific plaques were strongly associated with GTSE1, DDB1, MLH3 and ERCC1 expression. By contrast, in NSTEMI patients the strongest association was observed between fibrous plaques and ATM and XPA expression. CONCLUSION: PBMCs from patients with CAD exhibit differences in DNA ligase activity and expression of DDR genes. Expression levels of certain DDR genes are strongly associated with plaque morphology and may play a role in plaque development and progression. Trial Registration Number URL: www.Clinicaltrials.gov; NCT02335086.

20.
Int J Cardiol Heart Vasc ; 22: 160-162, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30828601

RESUMO

Fractional flow reserve (FFR) is a physiologic measurement of coronary artery perfusion. Studies have demonstrated its benefit in lowering cost and improving outcomes in patients undergoing elective coronary angiography, though follow-up surveys have demonstrated low usage nationwide. We sought to investigate the actual usage in elderly patients undergoing elective coronary angiography. Overall utilization of FFR for elective coronary angiography was 6.3%. Age, sex, race, prior stress testing and region of the country were all statistically significant predictors for FFR use. There still exist many barriers to widespread adoption of this modality, which require further exploration.

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