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1.
Br J Anaesth ; 123(2): 118-125, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31101323

RESUMO

BACKGROUND: Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. METHODS: We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin-angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. RESULTS: Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05-3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09-3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17-0.75) and thiazides (aOR: 0.28; 95% CI: 0.10-0.78) were associated with lower mortality in patients with systolic hypertension. CONCLUSIONS: These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Pressão Sanguínea/fisiologia , Hipertensão/tratamento farmacológico , Complicações Pós-Operatórias/mortalidade , Cuidados Pré-Operatórios/métodos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Hipertensão/complicações , Masculino , Fatores de Risco , Reino Unido/epidemiologia
3.
Open Heart ; 5(1): e000767, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29765614

RESUMO

Background: The evidence for benefits of bivalirudin over heparin has recently been challenged. We aimed to analyse the safety and cost-effectiveness following reintroduction of heparin instead of bivalirudin as the standard anticoagulation for primary percutaneous coronary intervention (PPCI) in a high-volume centre. Methods and results: This analysis was an open-label, prospective registry including all patients admitted to our centre for PPCI from April 2014 to April 2016. Heparin was reintroduced as standard anticoagulant in April 2015. During the 2 years, 1291 patients underwent a PPCI, 662 in the Bivalirudin protocol period (Cohort B) and 629 in the Heparin protocol period (Cohort H). Baseline and procedural characteristics were not significantly different, except for a higher use of thromboaspiration and femoral access in the earlier Cohort B. Glycoprotein 2b3a (Gp2b3a) antagonists were used in 24% of the patients in Cohort B versus 28% in Cohort H (P<0.01). We did not observe any differences in death at 180 days (11.03% in Cohort B vs 11.29% in Cohort H)(HR 95% CI 0.98 (0.72 to 1.33), P=0.88). The incidence of any bleeding complications at 30 days did not differ between the two periods (21.9% vs 21.9%, P=0.99). The cost related to the anticoagulants amounted to £246 236 in Cohort B versus £4483 in Cohort H (£324 406 vs £102 347 when adding Gp2b3a antagonists). Conclusion: We did not find clinically relevant changes in patient outcomes, including bleeding complications with reintroduction of heparin in our PPCI protocol. However, the use of heparin was associated with a major reduction in treatment costs.

4.
Eur J Heart Fail ; 19(11): 1545-1550, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28948706

RESUMO

Over the past 13 years bone marrow-derived mononuclear cells (BM-MNCs) have been widely investigated for clinical efficacy in patients following acute myocardial infarction (AMI). These early phase II trials have used various surrogate markers to judge efficacy and, although promising, the results have been inconsistent. The phase III BAMI trial has therefore been designed to demonstrate that intracoronary infusion of BM-MNCs is safe and will significantly reduce the time to first occurrence of all-cause death in patients with reduced left ventricular ejection fraction after successful reperfusion for ST-elevation AMI (powered with the aim of detecting a 25% reduction in all-cause mortality). This is a multinational, multicentre, randomized, open-label, controlled, parallel-group phase III study aiming to enrol approximately 3000 patients in 11 European countries with at least 17 sites. Eligible patients who have impaired left ventricular ejection (≤45%) following successful reperfusion for AMI will be randomized to treatment or control group in a 1:1 ratio. The treatment group will receive intracoronary infusion of BM-MNCs 2-8 days after successful reperfusion for AMI added on top of optimal standard of care. The control group will receive optimal standard of care. The primary endpoint is time from randomization to all-cause death. The BAMI trial is pivotal and the largest trial to date of BM-MNCs in patients with impaired left ventricular function following AMI. The aim of the trial is to provide a definitive answer as to whether BM-MNCs reduce all-cause mortality in this group of patients.


Assuntos
Transplante de Medula Óssea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Função Ventricular Esquerda/fisiologia , Causas de Morte/tendências , Ecocardiografia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Taxa de Sobrevida/tendências , Resultado do Tratamento
5.
Expert Rev Med Devices ; 14(7): 577-582, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28621162

RESUMO

BACKGROUND: The second generation STENTYS Xposition S self-expanding stent with a novel balloon delivery system was launched in May 2015. The stents unique properties are well suited for the treatment of left main stem disease where large diameters, coverage of diameter differences and precise positioning are required. We report the first consecutive experience of using this device in the treatment of left main stem lesions. METHODS: 20 consecutive patients with a mean age of 73.9±10.1 years were treated over a period of 8 months at our institution and were assessed on the parameters of technical, angiographic and procedural success. RESULTS: Technical success was achieved in 95% of cases and angiographic success in 80% of cases. There was no incidence of geographical miss. Side branch access was straightforward, with no failure to recross stent struts, dilate or deploy a second stent if required. In this unselected clinical cohort, 2 critically ill patients with cardiogenic shock on presentation died despite successful revascularisation. There was no incidence of early stent related complications up to 30-day follow up. CONCLUSION: This first consecutive series of left main lesions treated with STENTYS Xposition S documents high acute technical and procedural success rates.


Assuntos
Doença da Artéria Coronariana/terapia , Stents Metálicos Autoexpansíveis , Idoso , Angioplastia Coronária com Balão , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Humanos , Masculino , Resultado do Tratamento
6.
Catheter Cardiovasc Interv ; 90(2): 251-256, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28185396

RESUMO

Primary percutaneous coronary intervention (PCI) is the treatment modality of choice in patients presenting with ST elevation myocardial infarction (STEMI). Clinical outcomes have dramatically improved with the wide adoption of primary PCI in patients with STEMI because of acute thrombotic native coronary artery occlusion. However, patients with prior coronary artery bypass graft (CABG) surgery who present with STEMI because of acute saphenous vein graft (SVG) occlusion continue to have worse outcomes because of poor acute and long-term results of SVG stenting. Therefore, it may be preferable to treat the native coronary artery supplied by the occluded graft although this can be challenging if the native vessel is a chronic total occlusion (CTO). Recent advances in technology and techniques in CTO PCI have significantly improved the success rate and efficiency of CTO procedures. At our institution we have developed a high volume CTO programme with high success rates. We present three cases of acute inferior STEMI because of SVG occlusion which were treated with successful retrograde PCI of the native vessel CTO, utilising the occluded graft as a retrograde channel in two cases and native septal collaterals in the other. Thrombolysis In Myocardial Infarction (TIMI) 3 flow in the native coronary artery was achieved in all three cases with good acute outcomes. Our case series highlights the benefits of a high volume CTO programme. With recent advances in CTO techniques, acute PCI to native vessel CTO is feasible and may be the treatment of choice in selected cases of acute SVG failure. © 2017 Wiley Periodicals, Inc.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Oclusão Coronária/terapia , Oclusão de Enxerto Vascular/terapia , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Doença Aguda , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/complicações , Oclusão Coronária/diagnóstico por imagem , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Resultado do Tratamento
7.
Eur J Heart Fail ; 19(1): 138-147, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27790824

RESUMO

AIMS: The effect of combined cytokine and cell therapy in ischaemic cardiomyopathy is unknown. Meta-analyses suggest improved cardiac function with cell therapy. The optimal cell delivery route remains unclear. We investigated whether granulocyte colony-stimulating factor (G-CSF) alone or in combination with intracoronary (i.c.) or intramyocardial (i.m.) injection of autologous bone marrow-derived cells (BMCs) improves cardiac function. METHODS AND RESULTS: Ninety patients with symptomatic ischaemic cardiomyopathy and no further treatment options were enrolled in the randomized, placebo-controlled, single-centre REGENERATE-IHD study. Randomization was to one of three arms: peripheral, i.c., or i.m. In each arm, patients were randomized to active treatment or placebo. All patients, apart from the peripheral placebo group (saline only) received G-CSF for 5 days. The i.c. and i.m. arms received either BMCs or serum (placebo). The primary endpoint was change in LVEF at 1 year assessed by cardiac magnetic resonance imaging/computed tomography. The i.m. BMC group showed a significant improvement in LVEF of 4.99% (95% confidence interval 0.33-9.6%; P = 0.038) at 1 year. This group also showed a reduction in NYHA class at 1 year and NT-proBNP at 6 months. No other group showed a significant change in LVEF. This finding is supported by post-hoc between-group comparisons. CONCLUSION: We have shown that G-CSF combined with autologous i.m. BMCs has a beneficial effect on cardiac function and symptoms. However, this result should be considered preliminary in support of a clinical benefit of i.m. stem cell infusion in 'no option' patients and needs further exploration in a larger study.


Assuntos
Transplante de Medula Óssea/métodos , Cardiomiopatias/terapia , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Transplante de Células-Tronco/métodos , Idoso , Cardiomiopatias/sangue , Cardiomiopatias/etiologia , Cardiomiopatias/fisiopatologia , Vasos Coronários , Feminino , Humanos , Injeções Intra-Arteriais , Injeções Intramusculares , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Miocárdio , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Volume Sistólico , Tomografia Computadorizada por Raios X , Transplante Autólogo , Reino Unido
8.
Eur J Anaesthesiol ; 33(1): 49-57, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26565957

RESUMO

BACKGROUND: Statins reduce risk from coronary artery bypass graft (CABG) surgery, but the influence of angiotensin-converting enzyme inhibitors, alpha-2 adrenergic agonists, calcium channel blockers and beta-blockers is less clear. OBJECTIVES: We investigated the association of each of these drugs with perioperative risk, accounting for different confounders, and evaluated the class, dose-response and long-term protective effect of statins. DESIGN: A retrospective analysis of observational data. SETTING: United Kingdom. PATIENTS: Sixteen thousand one hundred and ninety-two patients who underwent CABG surgery during the period 01 January 2004 to 31 December 2013 and contributed data to Primary Care Clinical Practice Research Datalink. EXPOSURE VARIABLES: Cardiovascular drugs. OUTCOME MEASURE: Perioperative mortality within 30 days of surgery. STATISTICAL ANALYSIS: Five multivariable logistic regression models and a further Cox regression model were used to account for preexisting cardiovascular and other comorbidities along with lifestyle factors such as BMI, smoking and alcohol use. RESULTS: Exposure to statins was most prevalent (85.1% of patients), followed by beta-blockers (72.8%), angiotensin-converting enzyme inhibitors (60.5%), calcium channel blockers (42.8%) and alpha-2 adrenergic agonists (1.2%). The mortality rate was 0.8% in patients not prescribed statins and 0.4% in those on statins. Statins were associated with a statistically significant reduced perioperative mortality in all five logistic regression models with adjusted odds ratios (OR) (95% confidence interval, 95% CI) ranging from 0.26 (0.13 to 0.54) to 0.35 (0.18 to 0.67). Cox regression for perioperative mortality [adjusted hazard ratio (95% CI) 0.40 (0.20 to 0.80)] and 6-month mortality [adjusted hazard ratio (95% CI) 0.63 (0.42 to 0.92)] produced similar results. Of the statin doses tested, only simvastatin 40 mg exerted protective effects. The other cardiovascular drugs lacked consistent effects across models. CONCLUSION: Statins appear consistently protective against perioperative mortality from CABG surgery in multiple models, an effect not shared by the other cardiovascular drugs. Further data are needed on whether statins exert class and dose-response effects.


Assuntos
Fármacos Cardiovasculares/administração & dosagem , Ponte de Artéria Coronária/métodos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Cuidados Pré-Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Fármacos Cardiovasculares/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Relação Dose-Resposta a Droga , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Estilo de Vida , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos
9.
Eur Heart J ; 36(44): 3061-9, 2015 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-26333366

RESUMO

AIMS: The REGENERATE-DCM trial is the first phase II randomized, placebo-controlled trial aiming to assess if granulocyte colony-stimulating factor (G-CSF) administration with or without adjunctive intracoronary (IC) delivery of autologous bone marrow-derived cells (BMCs) improves global left ventricular (LV) function in patients with dilated cardiomyopathy (DCM) and significant cardiac dysfunction. METHODS AND RESULTS: Sixty patients with DCM and left ventricular ejection fraction (LVEF) at referral of ≤45%, New York Heart Association (NYHA) classification ≥2 and no secondary cause for the cardiomyopathy were randomized equally into four groups: peripheral placebo (saline), peripheral G-CSF, peripheral G-CSF and IC serum, and peripheral G-CSF and IC BMC. All patients, except the peripheral placebo group, received 5 days of G-CSF. In the IC groups, this was followed by bone marrow harvest and IC infusion of cells or serum on Day 6. The primary endpoint was LVEF change from baseline to 3 months, determined by advanced cardiac imaging. At 3 months, peripheral G-CSF combined with IC BMC therapy was associated with a 5.37% point increase in LVEF (38.30% ± 12.97 from 32.93% ± 16.46 P = 0.0138), which was maintained to 1 year. This was associated with a decrease in NYHA classification, reduced NT-pro BNP, and improved exercise capacity and quality of life. No significant change in LVEF was seen in the remaining treatment groups. CONCLUSION: This is the first randomized, placebo-controlled trial with a novel combination of G-CSF and IC cell therapy that demonstrates an improvement in cardiac function, symptoms, and biochemical parameters in patients with DCM.


Assuntos
Células-Tronco Adultas/transplante , Transplante de Medula Óssea/métodos , Cardiomiopatia Dilatada/terapia , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Transplante de Células-Tronco/métodos , Cardiomiopatia Dilatada/fisiopatologia , Terapia Combinada/métodos , Tolerância ao Exercício/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/metabolismo , Fragmentos de Peptídeos/metabolismo , Qualidade de Vida , Volume Sistólico/fisiologia , Resultado do Tratamento
10.
Regen Med ; 10(4): 403-10, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-26022762

RESUMO

AIM: Tß4 is an integral factor in repair of myocardium in animal models. To investigate whether Tß4 is important in human cardiac disease and has a role in mediating the beneficial cardiac effects of bone-marrow-derived stem cell (BMSC) therapy, we measured serial plasma Tß4 levels in patients enrolled on the REGENERATE-IHD cell therapy trial. PATIENTS & METHODS: Plasma Tß4 concentrations were measured in 13 patients who received BMSCs and 14 controls. RESULTS: There was a significant increase in plasma Tß4 in the BMSC group 24 h after intracardiac injection. Increases in Tß4 levels were associated with improvement in New York Heart Association symptom class. CONCLUSION: This exploratory study highlights the need for further study of Tß4 in human cardiovascular disease.


Assuntos
Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/terapia , Isquemia Miocárdica/sangue , Isquemia Miocárdica/terapia , Miocárdio/patologia , Transplante de Células-Tronco , Timosina/sangue , Idoso , Células da Medula Óssea/citologia , Contagem de Células , Doença Crônica , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Testes de Função Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/fisiopatologia , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Resultado do Tratamento
11.
Coron Artery Dis ; 26(1): 17-21, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25076359

RESUMO

AIMS: Recent studies have suggested that a low proportion of patients presenting with left bundle branch block (LBBB) require emergency intervention. In this study, we have compared baseline clinical characteristics, angiographic findings and subsequent outcomes in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: A large retrospective observational study was performed involving 1875 consecutive patients presenting to our single tertiary cardiac centre for primary PCI over a 27-month period. Patients presenting with LBBB (n=155, 8.3%) were significantly older (P<0.0001) and were more likely to be female (P<0.0001) and have a prior history of myocardial infarction (P<0.0001) or coronary artery bypass graft surgery (P=0.005). Rates of acute occlusion (12.2 vs. 63%; P<0.0001) and PCI (26 vs. 83%; P<0.0001) were significantly lower in LBBB patients compared with STEMI patients. Although the 30-day mortality was similar, overall mortality during the 2 years of follow-up was significantly higher in the LBBB group compared with the STEMI group (27.8 vs. 13.9%; P=0.023). CONCLUSION: The incidence of an acutely occluded vessel is low in LBBB when compared with STEMI, but the long-term outcome is significantly worse. Patients with LBBB referred for primary PCI need better risk stratification, and further work is needed to identify potential diagnostic and management strategies.


Assuntos
Síndrome Coronariana Aguda/terapia , Bloqueio de Ramo/terapia , Oclusão Coronária/terapia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Adolescente , Idoso , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/mortalidade , Criança , Pré-Escolar , Angiografia Coronária , Oclusão Coronária/diagnóstico , Oclusão Coronária/mortalidade , Eletrocardiografia , Inglaterra , Feminino , Humanos , Lactente , Recém-Nascido , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Atenção Terciária à Saúde , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
12.
Regen Med ; 9(3): 269-78, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24935040

RESUMO

AIM: This study presents an interim safety and feasibility analysis of the REGENERATE-IHD randomized controlled trial, which is examining the safety and efficacy of three different delivery routes of bone marrow-derived stem cells (BMSCs) in patients with ischemic heart failure. METHODS & RESULTS: The first 58 patients recruited to the REGENERATE-IHD study are included in this interim analysis (pilot). Symptomatic patients with ischemic heart failure were randomized to receive subcutaneous granulocyte colony-stimulating factor or saline injections only; or subcutaneous granulocyte colony-stimulating factor injections followed by intracoronary or intramyocardial injections of BMSCs or serum (control). No significant differences were found in terms of safety and feasibility between the different delivery routes, with no significant difference in procedural complications or major adverse cardiac events. There was a signal towards improved heart failure symptoms in the patients treated with intramyocardial injection of mobilized BMSCs. CONCLUSION: Peripheral mobilization of BMSCs with or without subsequent direct myocardial delivery appears safe and feasible in patients with chronic ischemic heart failure.


Assuntos
Transplante de Medula Óssea/métodos , Vias de Administração de Medicamentos , Insuficiência Cardíaca/terapia , Coração , Miocárdio , Fator Estimulador de Colônias de Granulócitos/administração & dosagem , Fator Estimulador de Colônias de Granulócitos/farmacologia , Humanos , Peptídeo Natriurético Encefálico/administração & dosagem , Peptídeo Natriurético Encefálico/farmacologia , Fragmentos de Peptídeos/administração & dosagem , Fragmentos de Peptídeos/farmacologia , Projetos Piloto , Transplante Autólogo
13.
Nucl Med Commun ; 35(8): 839-48, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24769888

RESUMO

BACKGROUND: Bone marrow stem cell (BMSC) therapy for cardiovascular disease has shown considerable preclinical and clinical promise, but there remains a need for mechanistic studies to help bridge the transition from bench to bedside. We have designed a substudy to our REGENERATE-IHD trial (ClinicalTrial.gov Identifier: NCT00747708) to assess the feasibility of a novel imaging technique to detect angiogenesis following BMSC therapy. METHODS AND RESULTS: Nine patients who had been randomized to receive intracoronary injection of G-CSF-mobilized BMSCs or control (serum) were included in this substudy. Patients underwent SPECT imaging using a novel radiolabelled peptide (Tc-NC100692), which has a high affinity for the αvß3 integrin, an angiogenesis-related integrin. This was repeated 4 days after intracoronary injection of BMSCs/control to assess for neoangiogenesis. The imaging study was well tolerated with no adverse effects. Myocardial tracer uptake was detectable at baseline in all nine patients, with no myocardial uptake seen in two control patients used for comparison. Baseline uptake appeared to correlate with baseline ejection fraction but changes with therapy did not reach statistical significance. CONCLUSION: SPECT imaging with a Tc-NC100692 is feasible in patients with heart failure, with baseline activity suggesting persistent angiogenesis in patients with remote myocardial infarction.


Assuntos
Células da Medula Óssea/citologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Isquemia Miocárdica/complicações , Neovascularização Fisiológica , Transplante de Células-Tronco , Doença Crônica , Estudos de Viabilidade , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Humanos , Pessoa de Meia-Idade , Compostos de Organotecnécio , Peptídeos Cíclicos , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X
14.
J Invasive Cardiol ; 26(1): 13-6, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24402805

RESUMO

AIMS: We aimed to assess the impact of a non-infarct related artery (IRA) chronic total occlusion (CTO) on clinical outcomes following primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) in a real-world cohort of patients. METHODS AND RESULTS: This is a retrospective observational study of 1435 patients treated at a large single tertiary cardiac center providing a high-volume PPCI service. Patients with coexisting CTO (4.7%) were significantly more likely to have presented in cardiogenic shock and less likely to achieve TIMI 2/3 flow in the IRA post procedure resulting in lower ejection fraction and higher peak troponin-T levels. A concurrent CTO in a non-IRA was associated with higher in-hospital mortality (16.4% vs 3.1%; P<.001), 30-day mortality (19.4% vs 5.9%; P<.001) and long-term mortality (23.9% vs 12.2%; P=.01). Binary logistic regression analysis showed that the presence of a non-IRA CTO was independently predictive of mortality at 30 days (odds ratio, 3.2; 95% confidence interval, 1.2-8.1) but not for long-term mortality. CONCLUSION: The presence of a coexisting CTO in patients undergoing PPCI for STEMI is associated with adverse clinical outcomes; further work is required to improve prognosis in these patients, which may include early staged revascularization of the non-IRA CTO.


Assuntos
Oclusão Coronária/complicações , Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Idoso , Doença Crônica , Estudos de Coortes , Comorbidade , Oclusão Coronária/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Reino Unido
15.
Catheter Cardiovasc Interv ; 83(6): 929-32, 2014 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-24089343

RESUMO

The hybrid approach to percutaneous treatment of chronic total occlusion (CTO) of coronary arteries requires both antegrade and retrograde skillsets. In the retrograde approach, wire externalization through the antegrade guide catheter often requires the use of a short donor guide catheter and a long (>150 cm) micro-catheter. Despite this there are occasions where the micro-catheter is unable to reach the anterograde guide catheter because of long collateral channels particularly when the retrograde limb involves a bypass graft. We report such a case where retrograde intervention was used to treat a right coronary artery (RCA) CTO in a patient with stable angina. The retrograde limb involved a saphenous vein graft to the native circumflex artery, which in turn provided collateral channels to the distal RCA. After performing reverse controlled anterograde and retrograde sub-intimal tracking (CART), the retrograde micro-catheter was only able to reach the mid RCA. To solve this, a Guideliner™ catheter was passed on the antegrade wire and successfully advanced over and "captured" the retrograde micro-catheter. Wire externalization was then completed and the RCA was subsequently stented with a good final angiographic result. This case illustrates a novel approach to completing wire externalization and provides a further indication for the role of the Guideliner™ catheter in treating CTOs.


Assuntos
Cateteres Cardíacos , Oclusão Coronária/terapia , Intervenção Coronária Percutânea/instrumentação , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Desenho de Equipamento , Humanos , Masculino , Intervenção Coronária Percutânea/métodos , Resultado do Tratamento
16.
BMJ Case Rep ; 20132013 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-24114603

RESUMO

A 33-year-old lady in the second trimester of pregnancy presented to the emergency department having suffered a cardiac arrest at home. An emergency caesarean section was performed in the resuscitation area. On return of spontaneous circulation, a 12-lead ECG showed anterior ST elevation myocardial infarction. She was transferred to our tertiary centre for an emergency coronary angiography and was successfully treated, making a full recovery. This case report examines the relatively rare entity of myocardial infarction in pregnancy and looks at the mechanisms underlying this.


Assuntos
Infarto do Miocárdio/complicações , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Reanimação Cardiopulmonar , Cesárea , Angiografia Coronária , Feminino , Humanos , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Parada Cardíaca Extra-Hospitalar/complicações , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico
17.
Anesthesiology ; 118(4): 885-93, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23303488

RESUMO

BACKGROUND: Data are lacking on the optimal scheduling of coronary artery bypass grafting (CABG) surgery after stroke. The authors investigated the preoperative predictors of adverse outcomes in patients undergoing CABG, with a focus on the importance of the time interval between prior stroke and CABG. METHODS: The Hospital Episode Statistics database (April 2006-March 2010) was analyzed for elective admissions for CABG. Independent preoperative patient factors influencing length of stay, postoperative stroke, and mortality, were identified by logistic regression and presented as adjusted odds ratios (OR). RESULTS: In all, 62,104 patients underwent CABG (1.8% mortality). Prior stroke influenced mortality (OR 2.20 [95% CI 1.47-3.29]), postoperative stroke (OR 1.99 [1.39-2.85]), and prolonged length of stay (OR 1.31 [1.11-1.56]). The time interval between stroke and CABG did not influence mortality or prolonged length of stay. However, a longer time interval between stroke and CABG surgery was associated with a small increase in risk of postoperative stroke (OR per month elapsed 1.02 [1.00-1.04]; P = 0.047). An interaction was evident between prior stroke and myocardial infarction for death (OR 5.50 [2.84-10.8], indicating the importance of the combination of comorbidities. Prominent effects on mortality were also exerted by liver disease (OR 20.8 [15.18-28.51]) and renal failure (OR 4.59 [3.85-5.46]). CONCLUSIONS: The authors found no evidence that more recent preoperative stroke predisposed patients undergoing CABG surgery to suffer postoperative stroke, death, or prolonged length of stay. The combination of prior stroke and myocardial infarction substantially increased perioperative risk.


Assuntos
Ponte de Artéria Coronária/métodos , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Acidente Vascular Cerebral/complicações , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Razão de Chances , Período Pré-Operatório , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
18.
Int J Cardiol ; 168(1): 338-43, 2013 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-23063211

RESUMO

BACKGROUND: Administrative data have been used to construct risk-adjustment models for provider profiling to benchmark hospital performance for acute myocardial infarction (AMI), but much less for acute coronary syndrome (ACS). We assess the impact on risk model performance and hospital-level mortality rate ratios (SMRs) of three key issues: comorbidity measurement methods, inter-hospital transfers and post-discharge deaths. METHODS: Logistic regression models for 30-day total mortality used three years of national public hospital emergency (unplanned) admissions data for England for ACS (n=329,369) linked to death registrations. We compared using the Charlson comorbidity index with modelling previous admissions. RESULTS: Prior admission for various conditions such as cancer and renal failure was associated with higher post-ACS mortality, whereas previous AMIs, PCI and unstable angina admissions were associated with lower mortality. The Charlson comorbidity index performed better than one- and five-year admission histories. Discrimination (c=0.81) was comparable with that from clinical databases. Adjusted 30-day total mortality rates ranged between hospitals from 6.3% to 13.3%. Median differences in SMRs between the comorbidity-adjustment methods were small. Although SMRs and outlier status could change, a hospital's 'qualitative' mortality rating (low, average or high) was not affected. In contrast, a sizeable minority of SMRs changed by ≥ 10 points if transfers were excluded or post-discharge deaths ignored. Model choice occasionally affected funnel plot outlier status. CONCLUSIONS: Models for comparing hospitals' ACS mortality can be constructed with good discrimination using English administrative hospital data. Adjusting for transfers in and capturing post-discharge deaths are more important than the choice of comorbidity adjustment.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Bases de Dados Factuais , Administração Hospitalar , Mortalidade Hospitalar/tendências , Classificação Internacional de Doenças , Síndrome Coronariana Aguda/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais/estatística & dados numéricos , Bases de Dados Factuais/tendências , Inglaterra/epidemiologia , Feminino , Administração Hospitalar/estatística & dados numéricos , Administração Hospitalar/tendências , Hospitais Públicos/estatística & dados numéricos , Hospitais Públicos/tendências , Humanos , Classificação Internacional de Doenças/estatística & dados numéricos , Classificação Internacional de Doenças/tendências , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
19.
Stem Cells Dev ; 22(2): 216-23, 2013 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-22834565

RESUMO

The potential of autologous bone marrow (BM)-derived progenitor/stem cell (BMSC) therapy for cardiac repair maybe limited by patient-related factors, such as age and the disease process itself. In this exploratory analysis, we assessed the impact of age, different disease states, and granulocyte colony-stimulating factor (G-CSF) therapy on progenitor cell concentration and function in patients recruited to our clinical trials of BMSC therapy for ischaemic heart failure (IHD), dilated cardiomyopathy (DCM), and acute myocardial infarction (AMI). The concentrations of CD34+ cells and endothelial progenitor cells (EPCs) were measured in the peripheral blood (PB) and BM of 201 patients. Additionally, cell mobilization following G-CSF and the functional capability of CD34+ cells (using a colony-forming unit assay) were assessed. We found that older age was associated with a lower PB CD34+ cell concentration in the whole study group as well as blunting the effect of G-CSF on BMSC mobilization in IHD patients. Nonischaemic heart failure (DCM) was associated with a significantly higher baseline PB CD34+ and EPC concentration compared to IHD. Following G-CSF treatment, the CD34+ cell concentration was greater in the BM compared to PB, however, the PB CD34+ cells appeared to have a greater and improved (compared to baseline) functional potential. Our results suggest treatment with G-CSF improves the functional potential of mobilized circulating progenitor cells compared to those in the BM. Further work is required to determine which source of cells is best for the purposes of cardiac repair following G-CSF therapy.


Assuntos
Medula Óssea/metabolismo , Fator Estimulador de Colônias de Granulócitos/farmacologia , Insuficiência Cardíaca/terapia , Células-Tronco/efeitos dos fármacos , Adulto , Fatores Etários , Idoso , Antígenos CD34/metabolismo , Medula Óssea/efeitos dos fármacos , Medula Óssea/patologia , Cardiomiopatia Dilatada/metabolismo , Cardiomiopatia Dilatada/patologia , Cardiomiopatia Dilatada/terapia , Estudos de Casos e Controles , Contagem de Células , Movimento Celular/efeitos dos fármacos , Ensaio de Unidades Formadoras de Colônias , Feminino , Insuficiência Cardíaca/metabolismo , Insuficiência Cardíaca/patologia , Transplante de Células-Tronco Hematopoéticas , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Proteínas Recombinantes/farmacologia , Células-Tronco/citologia , Células-Tronco/metabolismo , Fatores de Tempo
20.
Ann Surg ; 255(5): 901-7, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22504189

RESUMO

OBJECTIVE: To identify independent preoperative predictors of outcome for total hip or knee replacement (THKR) and abdominal aortic aneurysm (AAA) repair, including the importance of the time interval between an acute coronary syndrome (ACS) or stroke and surgery. BACKGROUND: Present guidelines do not advocate a prolonged delay after ACS though recent data suggest delaying operations by 8 weeks. There is a lack of data on when to schedule surgery following stroke. METHODS: The Hospital Episode Statistics database was analyzed for elective admissions for THKR and AAA surgery between 2006-2007 and 2009-2010. Patient factors influencing mortality, length of stay, and readmission rates were identified by logistic regression. RESULTS: A total of 414,985 THKRs (mortality: 0.2%) and 14,524 AAA repairs (mortality: 3.5%) were included. Heart failure, renal failure, liver disease, peripheral vascular disease, and non-atrial fibrillation arrhythmia increased the odds of mortality for both surgeries. Among other factors, previous ACS and stroke predicted mortality after THKR but not AAA surgery. Compared with more delayed surgery, THKR surgery performed within 6 months of an ACS (odds ratio [OR]: 3.81; 95% confidence interval [CI]: 1.55-9.34), but not stroke, increased the odds of mortality. The effect of ACS persisted up to 12 months (OR: 1.99; 95% CI: 1.02-3.88) and was not altered by exclusion of patients who received percutaneous coronary intervention or coronary artery bypass grafting for treatment of their ACS. CONCLUSIONS: Previous stroke and ACS increased the odds of perioperative mortality from THKR but not AAA surgery; THKR surgery conducted up to 12 months after an ACS was associated with increased mortality.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Artroplastia de Quadril , Artroplastia do Joelho , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/cirurgia , Avaliação de Resultados (Cuidados de Saúde) , Acidente Vascular Cerebral/epidemiologia , Síndrome Coronariana Aguda/cirurgia , Síndrome Coronariana Aguda/terapia , Angioplastia Coronária com Balão , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Ponte de Artéria Coronária , Procedimentos Cirúrgicos Eletivos , Humanos , Tempo de Internação , Modelos Logísticos , Osteoartrite do Quadril/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Período Pré-Operatório , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/terapia , Tempo
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