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1.
Medicine (Baltimore) ; 98(41): e17404, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593092

RESUMO

Type 2 myocardial infarction (MI) is defined as myocardial necrosis due to imbalance between myocardial oxygen supply and demand. The objective of this study was to assess the features, treatments, and outcomes of patients with type 2 MI in comparison with patients with type 1 MI hospitalized in general medical wards. A retrospective review was performed on patients admitted to general medicine wards diagnosed with MI in Sheba Medical Center between January 1, 2016 and December 31, 2016. Comparative analysis between patients with type 1 and type 2 MI was performed. The study included 349 patients with type 1 MI and 206 patients with type 2 MI. The main provoking factors for type 2 MI were sepsis (38.1%), anemia (29.1%), and hypoxia (23.8%). Patients with type 2 MI were older (79.1 ±â€Š11.9 vs 75.2 ±â€Š11.7, P < .001) and had a lower rate of prior MI (23.3% vs 38.1%, P < .001) and percutaneous coronary intervention (PCI) (34% vs 48.7%, P = .023) compared with patients with type 1 MI. Patients with type 2 MI were significantly less prescribed antiplatelet therapy (79.1% vs 96%, P < .001) and statins (60.7% vs 80.2%, P < .001), and were less referred to coronary angiography (10.7% vs 54.4%, P < .001). Type 2 MI was associated with a significantly higher 1-year mortality rate compared with type 1 MI (38.8% vs 26.6%, P = .004), but after accounting for age and sex differences, this association lacked statistical significance. In conclusion, type 2 MI patients were older and had similar comorbidities compared with those with type 1 MI. These patients were less prescribed medical therapy and coronary intervention, and had a higher 1-year mortality rate. Establishing a clear therapeutic approach for type 2 MI is required.


Assuntos
Angiografia Coronária/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/mortalidade , Quartos de Pacientes/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Prognóstico , Estudos Retrospectivos
2.
Artigo em Japonês | MEDLINE | ID: mdl-31534066

RESUMO

OBJECTIVES: The purpose of this study was to confirm the association of the status of implementation of nonsmoking at eating and drinking establishments with the prevalence of persons with subjective symptoms, the prevalence of persons with diseases under treatment, medical expenses, and mortality rate using prefectural data. METHODS: The prefectural rate of eating and drinking establishments implementing nonsmoking (hereafter, nonsmoking rate) was calculated using the data from "Tabelog®". The variables of interest were the prevalence of persons with subjective symptoms, the prevalence of persons with diseases under treatment, medical expenses (total, hospitalization and nonhospitalization expenses), and the mortality rates of malignant neoplasms (lung cancer, stomach cancer, and colon cancer), heart disease, acute myocardial infarction, cerebrovascular disease, cerebral infarction, and pneumonia in each prefecture. The partial correlation coefficient was estimated between the nonsmoking rate and the variable of interest using the smoking rate by prefectural as the control variable. RESULTS: The nonsmoking rate showed a significantly negative correlation with the medical expenses. When eating and drinking establishments were divided into "restaurant", "café", and "bar", the nonsmoking rate also indicated a significantly negative correlation with the medical expenses in any category. It was negatively related to the mortality rates of cerebrovascular disease, cerebral infarction, and pneumonia. The negative correlation was stronger in females than in males. CONCLUSIONS: These results suggest that the implementation of nonsmoking at eating and drinking establishments may reduce the mortality rates of diseases, such as cerebrovascular disease, cerebral infarction, and pneumonia, and medical expenses. Thus, it is important to implement nonsmoking at eating and drinking establishments in line with the Revised Health Promotion Act.


Assuntos
Transtornos Cerebrovasculares/mortalidade , Gastos em Saúde/estatística & dados numéricos , Promoção da Saúde/estatística & dados numéricos , Cardiopatias/mortalidade , Neoplasias/mortalidade , não Fumantes/estatística & dados numéricos , Restaurantes/estatística & dados numéricos , Prevenção do Hábito de Fumar/estatística & dados numéricos , Humanos , Japão/epidemiologia , Infarto do Miocárdio/mortalidade , Pneumonia/mortalidade , Prevalência
3.
Cochrane Database Syst Rev ; 9: CD013435, 2019 09 23.
Artigo em Inglês | MEDLINE | ID: mdl-31544227

RESUMO

BACKGROUND: Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in unselected patients remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update and assesses the evidence in cardiac surgery only. OBJECTIVES: To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing cardiac surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA: We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing cardiac surgery. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We included 63 studies with 7768 participants; six studies were quasi-randomized and the remaining were RCTs. All participants were undergoing cardiac surgery, and in most studies, at least some of the participants were previously taking beta-blockers. Types of beta-blockers were: propranolol, metoprolol, sotalol, esmolol, landiolol, acebutolol, timolol, carvedilol, nadolol, and atenolol. In twelve studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in nine studies this was before surgery, in 20 studies during surgery, and in the remaining studies beta-blockers were started postoperatively. Overall, we found that most studies did not report sufficient details for us to adequately assess risk of bias. In particular, few studies reported methods used to randomize participants to groups. In some studies, participants in the control group were given beta-blockers as rescue therapy during the study period, and all studies in which the control was standard care were at high risk of performance bias because of the open-label study design. No studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. We judged 68% studies to be at high risk of bias in at least one domain.Study authors reported few deaths (7 per 1000 in both the intervention and control groups), and we found low-certainty evidence that beta-blockers may make little or no difference to all-cause mortality at 30 days (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.47 to 1.90; 29 studies, 4099 participants). For myocardial infarctions, we found no evidence of a difference in events (RR 1.05, 95% CI 0.72 to 1.52; 25 studies, 3946 participants; low-certainty evidence). Few study authors reported cerebrovascular events, and the evidence was uncertain (RR 1.37, 95% CI 0.51 to 3.67; 5 studies, 1471 participants; very low-certainty evidence). Based on a control risk of 54 per 1000, we found low-certainty evidence that beta-blockers may reduce episodes of ventricular arrhythmias by 32 episodes per 1000 (RR 0.40, 95% CI 0.25 to 0.63; 12 studies, 2296 participants). For atrial fibrillation or flutter, there may be 163 fewer incidences with beta-blockers, based on a control risk of 327 incidences per 1000 (RR 0.50, 95% CI 0.42 to 0.59; 40 studies, 5650 participants; low-certainty evidence). However, the evidence for bradycardia and hypotension was less certain. We found that beta-blockers may make little or no difference to bradycardia (RR 1.63, 95% CI 0.92 to 2.91; 12 studies, 1640 participants; low-certainty evidence), or hypotension (RR 1.84, 95% CI 0.89 to 3.80; 10 studies, 1538 participants; low-certainty evidence).We used GRADE to downgrade the certainty of evidence. Owing to studies at high risk of bias in at least one domain, we downgraded each outcome for study limitations. Based on effect size calculations in the previous review, we found an insufficient number of participants in all outcomes (except atrial fibrillation) and, for some outcomes, we noted a wide confidence interval; therefore, we also downgraded outcomes owing to imprecision. The evidence for atrial fibrillation and length of hospital stay had a moderate level of statistical heterogeneity which we could not explain, and we, therefore, downgraded these outcomes for inconsistency. AUTHORS' CONCLUSIONS: We found no evidence of a difference in early all-cause mortality, myocardial infarction, cerebrovascular events, hypotension and bradycardia. However, there may be a reduction in atrial fibrillation and ventricular arrhythmias when beta-blockers are used. A larger sample size is likely to increase the certainty of this evidence. Four studies awaiting classification may alter the conclusions of this review.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Procedimentos Cirúrgicos Cardíacos , Assistência Perioperatória/métodos , Antagonistas Adrenérgicos beta/efeitos adversos , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/prevenção & controle , Bradicardia/induzido quimicamente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Transtornos Cerebrovasculares/mortalidade , Transtornos Cerebrovasculares/prevenção & controle , Humanos , Hipotensão/induzido quimicamente , Hipotensão/mortalidade , Hipotensão/prevenção & controle , Morbidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/prevenção & controle , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto
4.
Cochrane Database Syst Rev ; 9: CD013438, 2019 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-31556094

RESUMO

BACKGROUND: Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES: To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA: We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS: The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Anestesia Geral/efeitos adversos , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/prevenção & controle , Bradicardia/prevenção & controle , Causas de Morte , Humanos , Hipotensão/mortalidade , Hipotensão/prevenção & controle , Morbidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/mortalidade , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Operatórios/mortalidade
5.
Medicine (Baltimore) ; 98(34): e16929, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441880

RESUMO

To examine the characteristics and short-term outcome of perioperative myocardial infarction (PMI), a single-center retrospective study was carried out. The electronic medical records of 278,939 patients aged 45 years or older who underwent non-cardiac surgery at Renji Hospital from January 2003 to December 2015 were screened based on diagnostic codes (ICD121, ICD121.0, ICD121.1, ICD121.2, ICD121.3, ICD121.4, or ICD121.9). The incidence and characteristics of PMI and mortality risk factors were analyzed after non-cardiac surgery. PMI was reported in 45 patients, with an incidence rate of 1.61 per 10,000 and a mortality rate of 75.6% (34/45). The PMI incidence rate increased significantly with age. The PMI incidence rate was the highest for vascular surgery (5.82 per 10,000 cases). PMI occurs mainly within 48 h of surgery, with most cases showing an onset in the general wards. Logistic analysis showed that the use of nitrates is the independent protective factor for the outcomes of patients with PMI. The incidence of PMI in non-cardiac surgery is approximately 2 of 10,000 in patients aged 45 years or older, and increased significantly with age. The use of nitrates might be helpful for their survival.


Assuntos
Infarto do Miocárdio/mortalidade , Período Perioperatório/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , China , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Nitratos/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
6.
Ther Adv Cardiovasc Dis ; 13: 1753944719863641, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31364490

RESUMO

BACKGROUND: This analysis aimed to evaluate the impact of rivaroxaban exposure and patient characteristics on efficacy and safety outcomes in patients with acute coronary syndrome (ACS) and to determine whether therapeutic drug monitoring might provide additional information regarding rivaroxaban dose, beyond what patient characteristics provide. METHODS: A post hoc exposure-response analysis was conducted using data from the phase III ATLAS ACS 2 Thrombolysis in Myocardial Infarction (TIMI) 51 study, in which 15,526 randomized ACS patients received rivaroxaban (2.5 mg or 5 mg twice daily) or placebo for a mean of 13 months (maximum follow up: 31 months). A multivariate Cox model was used to correlate individual predicted rivaroxaban exposures and patient characteristics with time-to-event clinical outcomes. RESULTS: For the incidence of myocardial infarction (MI), ischemic stroke, or nonhemorrhagic cardiovascular death, hazard ratios (HRs) for steady-state maximum plasma concentration (Cmax) in the 5th and 95th percentiles versus the median were statistically significant but close to 1 for both rivaroxaban doses. For TIMI major bleeding events, a statistically significant association was observed with Cmax [HR, 1.08; 95% CI, 1.06-1.11 (95th percentile versus median, 2.5 mg twice daily)], sex [HR, 0.56; 95% CI, 0.38-0.84 (female versus male)], and previous revascularization [HR, 0.62; 95% CI, 0.44-0.87 (no versus yes)]. CONCLUSIONS: The shallow slopes of the exposure-response relationships and the lack of a clear therapeutic window render it unlikely that therapeutic drug monitoring in patients with ACS would provide additional information regarding rivaroxaban dose beyond that provided by patient characteristics.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Modelos Biológicos , Rivaroxabana/administração & dosagem , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Idoso , Isquemia Encefálica/mortalidade , Tomada de Decisão Clínica , Ensaios Clínicos Fase III como Assunto , Relação Dose-Resposta a Droga , Cálculos da Dosagem de Medicamento , Monitoramento de Medicamentos , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/farmacocinética , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Rivaroxabana/farmacocinética , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
7.
BMJ ; 365: l2222, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31253632

RESUMO

OBJECTIVE: To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS: Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS: 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS: In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099519.


Assuntos
Clopidogrel/uso terapêutico , Stents Farmacológicos/normas , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/epidemiologia , Trombose/mortalidade
8.
Lancet ; 393(10190): 2503-2510, 2019 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-31056295

RESUMO

BACKGROUND: New-generation drug-eluting stents (DES) have mostly been investigated in head-to-head non-inferiority trials against early-generation DES and have typically shown similar efficacy and superior safety. How the safety profile of new-generation DES compares with that of bare-metal stents (BMS) is less clear. METHODS: We did an individual patient data meta-analysis of randomised clinical trials to compare outcomes after implantation of new-generation DES or BMS among patients undergoing percutaneous coronary intervention. The primary outcome was the composite of cardiac death or myocardial infarction. Data were pooled in a one-stage random-effects meta-analysis and examined at maximum follow-up and a 1-year landmark. Risk estimates are reported as hazard ratios (HRs) with 95% CIs. This study is registered in PROSPERO, number CRD42017060520. FINDINGS: We obtained individual data for 26 616 patients in 20 randomised trials. Mean follow-up was 3·2 (SD 1·8) years. The risk of the primary outcome was reduced in DES recipients compared with BMS recipients (HR 0·84, 95% CI 0·78-0·90, p<0·001) owing to a reduced risk of myocardial infarction (0·79, 0·71-0·88, p<0·001) and a possible slight but non-significant cardiac mortality benefit (0·89, 0·78-1·01, p=0·075). All-cause death was unaffected (HR with DES 0·96, 95% CI 0·88-1·05, p=0·358), but risk was lowered for definite stent thrombosis (0·63, 0·50-0·80, p<0·001) and target-vessel revascularisation (0·55, 0·50-0·60, p<0·001). We saw a time-dependent treatment effect, with DES being associated with lower risk of the primary outcome than BMS up to 1 year after placement. While the effect was maintained in the longer term, there was no further divergence from BMS after 1 year. INTERPRETATION: The performance of new-generation DES in the first year after implantation means that BMS should no longer be considered the gold standard for safety. Further development of DES technology should target improvements in clinical outcomes beyond 1 year. FUNDING: Bern University Hospital.


Assuntos
Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/instrumentação , Stents/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Stents Farmacológicos/efeitos adversos , Estudos de Equivalência como Asunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Razão de Chances , Intervenção Coronária Percutânea/mortalidade , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Resultado do Tratamento
9.
Medicine (Baltimore) ; 98(21): e15622, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31124941

RESUMO

BACKGROUND: Drug-coated balloon as a novel therapeutic strategy has been used to treat restenosis in cases of bare metal and drug-eluting stents. However, evidence of its safety and efficacy is scarce in de novo small coronary artery vessel disease. This meta-analysis aimed to compare the safety and efficacy of the drug-coated balloon and the drug-eluting stent. METHODS: The PubMed, EMBASE, Web of Science, and Cochrane library databases were searched for studies published up to October 17, 2018. Studies comparing the drug-coated balloon with the drug-eluting stent strategy in patients with de novo small coronary artery vessel disease (reference diameter, <3 mm) were identified. The clinical outcomes were nonfatal myocardial infarction, cardiac death, all-cause death, target lesion revascularization, and target-vessel revascularization. Data were analyzed using the statistical software RevMan (version 5.3). Fixed effects models were performed to calculate the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs). Sensitivity analyses were used to detect potential sources of heterogeneity, while subgroup analyses were implemented to assess the differential effects. RESULTS: Three randomized controlled trials and 3 nonrandomized controlled studies were identified. Six studies including a total of 1800 patients compared the differences between the drug-coated balloon and the drug-eluting stent strategies in patients with de novo small coronary artery vessel disease. The results indicated that the drug-coated balloon strategy was associated with a significant reduction in nonfatal myocardial infarction (OR 0.53, 95% CI 0.31-0.90, P = .02) compared with the drug-eluting stent strategy, while insignificant inter-strategy differences were observed in cardiac death (OR 1.56, 95% CI 0.73-3.33, P = .25), all-cause death (OR 0.56, 95% CI 0.25-1.23, P = .15), target lesion revascularization (OR 1.24, 95% CI 0.73-2.1, P = .43), and target-vessel revascularization (OR 0.95, 95% CI 0.59-1.52, P = .84). CONCLUSIONS: This meta-analysis suggests that the drug-coated balloon strategy is noninferior to the drug-eluting stent strategy, delivering a good outcome in nonfatal myocardial infarction, and can be recommended as an optimal treatment strategy in patients with de novo small coronary artery vessel disease. Larger randomized controlled studies with longer follow-up periods are needed to further confirm the benefits of the drug-coated balloon strategy.


Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/efeitos adversos , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Idoso , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Fármacos Cardiovasculares/administração & dosagem , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/patologia , Vasos Coronários/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
Angiology ; 70(9): 867-877, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31088127

RESUMO

The PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Antiplatelet Therapy (PRECISE-DAPT) score has been validated to predict bleeding complications in patients undergoing stent implantation and dual antiplatelet therapy. This score does not include the platelet count (PC), which has been shown to be an independent marker of mortality in patients with acute coronary syndrome (ACS). We assessed the role of the PRECISE-DAPT score calculated on admission for mortality risk prediction and evaluated whether the predictive accuracy of this score improved by adding the PC. In a retrospective cohort study of 1000 patients with ACS, after adjustment for relevant covariates, a PRECISE-DAPT score ≥25 was independently associated with mortality (hazard ratio [HR]: 7.91; 95% confidence interval [CI]: 4.37-14.30). When this score was combined with PC, compared to patients with PRECISE-DAPT <25 and PC ≥150 × 109/L, the adjusted HR was 7.2 (95% CI 2.4-21.6) for those with PRECISE-DAPT <25 and PC <150 × 109/L; 10.7 (95% CI: 5.2-21.9) for those with PRECISE-DAPT ≥25 and PC ≥150 × 109/L; and 17.9 (95% CI 7.0-45.4) for those with PRECISE-DAPT ≥25 and PC <150 × 109/L. Selecting thresholds for high-risk designation, the PRECISE-DAPT score integrated with PC had a higher prediction value, compared to the PRECISE-DAPT and Global Registry of Acute Coronary Events scores.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Stents Farmacológicos/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Contagem de Plaquetas , Valor Preditivo dos Testes , Síndrome Coronariana Aguda/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/complicações , Quimioterapia Combinada/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Inibidores da Agregação de Plaquetas/uso terapêutico , Contagem de Plaquetas/métodos , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Medição de Risco
11.
Trends Cardiovasc Med ; 29(5): 306-310, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31130187

RESUMO

Consumption of industrially produced trans fatty acids (IP-TFAs) increases LDL cholesterol, either decreases or has no effect on HDL cholesterol, and increases markers of inflammation. Observational studies have shown that consumption of TFA produced by partial hydrogenation of vegetable oils (PHOs) is associated with increased mortality and incidence of MI and stroke rates. Regulatory initiatives to restrict PHOs to less than 2 g per day from food sources, along with concurrent initiatives to reduce tobacco exposure, have been associated with reduction in cardiovascular mortality and MI rates. What remains unknown is whether the consumption of amounts <2 g per day of PHOs is also harmful and whether TFAs present in milk and the meats of ruminant animals is beneficial or harmful.


Assuntos
Gorduras na Dieta/efeitos adversos , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Ácidos Graxos Trans/efeitos adversos , Animais , Medicina Baseada em Evidências , Nível de Saúde , Humanos , Incidência , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Valor Nutritivo , Recomendações Nutricionais , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade
12.
World Neurosurg ; 122: e512-e515, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-31060199

RESUMO

BACKGROUND: Postoperative ileus is not uncommon after spinal surgery. Although previous research has focused on the frequency of ileus formation, little has been done to investigate the clinical sequelae after development. We investigated the effect of postoperative ileus on patients' length of stay and rates of deep vein thrombosis (DVT) formation, myocardial infarction (MI), aspiration pneumonia, sepsis, and death. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample was queried to identify adult patients who underwent any spinal fusion procedure. Patient characteristics and outcomes for discharges involving spinal fusion surgery were compared between patients with and without postoperative ileus. The Rao-Scott χ2 test of association was used for categorical variables, and a t test for equality of means was used for continuous variables. Among discharges with postoperative ileus, a multivariate linear regression model was used to assess how fusion approach and fusion length were associated with length of hospital stay, controlling for sex, age, and race. RESULTS: A total of 250,221 patients were included. The mean length of stay was 3.75 days for patients without postoperative ileus and 9.40 days for patients with postoperative ileus. Patients with postoperative ileus are more likely to have DVT (4.1% vs. 20.8%, P < 0.001), MI (2.5% vs. 7.1%, P < 0.001), aspiration pneumonia (6.6% vs. 34.3%, P < 0.001), sepsis (5.7% vs. 35.7%, P < 0.001), and death (2.6% vs. 11.4%, P < 0.001). CONCLUSIONS: This study demonstrates that patients with postoperative ileus are significantly more likely to have DVT, experience MI, acquire aspiration pneumonia, develop sepsis, and die.


Assuntos
Íleus/etiologia , Fusão Vertebral/efeitos adversos , Adolescente , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Íleus/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Pneumonia Aspirativa/etiologia , Pneumonia Aspirativa/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Sepse/etiologia , Sepse/mortalidade , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/métodos , Fusão Vertebral/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Trombose Venosa/etiologia , Trombose Venosa/mortalidade , Adulto Jovem
13.
BMC Public Health ; 19(1): 505, 2019 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-31053068

RESUMO

BACKGROUND: Identifying disparities in myocardial infarction (MI) burden and assessing its temporal changes are critical for guiding resource allocation and policies geared towards reducing/eliminating health disparities. Our objectives were to: (a) investigate the spatial distribution and clusters of MI mortality risk in Florida; and (b) assess temporal changes in geographic disparities in MI mortality risks in Florida from 2000 to 2014. METHODS: This is a retrospective ecologic study with county as the spatial unit of analysis. We obtained data for MI deaths occurring among Florida residents between 2000 and 2014 from the Florida Department of Health, and calculated county-level age-adjusted MI mortality risks and Spatial Empirical Bayesian smoothed MI mortality risks. We used Kulldorff's circular spatial scan statistics and Tango's flexible spatial scan statistics to identify spatial clusters. RESULTS: There was an overall decline of 48% in MI mortality risks between 2000 and 2014. However, we found substantial, persistent disparities in MI mortality risks, with high-risk clusters occurring primarily in rural northern counties and low-risk clusters occurring exclusively in urban southern counties. MI mortality risks declined in both low- and high-risk clusters, but the latter showed more dramatic decreases during the first nine years of the study period. Consequently, the risk difference between the high- and low-risk clusters was smaller at the end than at the beginning of the study period. However, the rates of decline levelled off during the last six years of the study, and there are signs that the risks may be on an upward trend in parts of North Florida. Moreover, MI mortality risks for high-risk clusters at the end of the study period were on par with or above those for low-risk clusters at the beginning of the study period. Thus, high-risk clusters lagged behind low-risk clusters by at least 1.5 decades. CONCLUSION: Myocardial infarction mortality risks have decreased substantially during the last 15 years, but persistent disparities in MI mortality burden still exist across Florida. Efforts to reduce these disparities will need to target prevention programs to counties in the high-risk clusters.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Características de Residência/estatística & dados numéricos , Adulto , Idoso , Teorema de Bayes , Feminino , Florida , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , População Rural/estatística & dados numéricos , População Urbana/estatística & dados numéricos
14.
Medicine (Baltimore) ; 98(20): e15353, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096434

RESUMO

Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases with golden hour. This study aimed to identify and compare factors that affect in-hospital mortality in patients with stroke and AMI who admitted via the emergency department.This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7693 patients who had an ischemic stroke, 2828 patients who had a hemorrhagic stroke, and 4916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged ≥20 years. This study was analyzed by using Cox's proportional hazards frailty model.Five hundred (6.5%) of 7693 patients with ischemic stroke, 569 (20.1%) of 2828 patients with hemorrhagic stroke, and 399 (8.1%) of 4916 patients with AMI were dead. The clinical factors were associated with in-hospital mortality such as age, CCI, hypertension, and diabetes of patient characteristics. In treatment characteristics, performing PCI and weekday admission was associated with in-hospital mortality (aHR, 0.43; 95% CI, 0.27-0.67; aHR, 1.42; 95% CI, 1.14-1.77, respectively). In hospital characteristics, the volume, the proportion of transferred patient to other hospital and ratio of beds per one nurse was associated with in-hospital mortality.Clinical factors of patient characteristics, intervention such as performing PCI and reducing ICP of treatment characteristics, and the volume, transferred rate, and the number of nurse of hospital characteristics were associated with in-hospital mortality.


Assuntos
Isquemia Encefálica/mortalidade , Mortalidade Hospitalar/tendências , Hemorragias Intracranianas/mortalidade , Infarto do Miocárdio/mortalidade , Qualidade da Assistência à Saúde/estatística & dados numéricos , Acidente Vascular Cerebral/mortalidade , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Transferência de Pacientes , Intervenção Coronária Percutânea/métodos , Qualidade da Assistência à Saúde/tendências , República da Coreia/epidemiologia , Acidente Vascular Cerebral/epidemiologia
15.
Int Heart J ; 60(3): 708-714, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31105140

RESUMO

Multivessel disease (MVD) is an independent risk factor for poor prognosis in acute myocardial infarction patients. Although several global risk scoring systems (RSS) are in use in clinical practice, there is no dedicated RSS for MVD in ST-segment elevation myocardial infarction (STEMI). The primary objective of this study is to develop a novel RSS to estimate the prognosis of patients with MVD in STEMI.We used the Korean Acute Myocardial Infarction Registry (KAMIR) to identify 2,030 STEMI patients with MVD who underwent appropriate percutaneous coronary intervention (PCI). Their data were analyzed to develop a new RSS. The prognostic power of this RSS was validated with 2,556 STEMI patients with MVD in the Korean Working Group on Myocardial Infarction Registry (KORMI).Six prognostic factors related to all-cause death in STEMI patients with MVD were age, serum creatinine, Killip Class, lower body weight, decrease in left ventricular ejection fraction, and history of cerebrovascular disease. The RSS for all-cause death was constructed using these risk factors and their statistical weight. The RSS had appropriate performance (c-index: 0.72) in the KORMI validation cohort.We developed a novel RSS that estimates all-cause death in the year following discharge for patients with MVD in STEMI appropriately treated by PCI. This novel RSS was transformed into a simple linear risk score to yield a simplified estimate prognosis of MVD among STEMI patients.


Assuntos
Doença da Artéria Coronariana/mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Doença Aguda , Idoso , Índice de Massa Corporal , Causas de Morte , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/métodos , Prognóstico , República da Coreia/epidemiologia , Fatores de Risco , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia
16.
Angiology ; 70(8): 765-773, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30995117

RESUMO

With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos , Intervenção Coronária Percutânea , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Humanos , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
17.
BMC Med ; 17(1): 72, 2019 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-30943979

RESUMO

BACKGROUND: Risk prediction for patients with suspected coronary artery disease is complex due to the common occurrence of prior cardiovascular disease and extensive risk modification in primary care. Numerous markers have the potential to predict prognosis and guide management, but we currently lack robust 'real-world' evidence for their use. METHODS: Prospective, multicentre observational study of consecutive patients referred for elective coronary angiography. Clinicians were blinded to all risk assessments, consisting of conventional factors, radial artery pulse wave analysis, 5-minute heart rate variability, high-sensitivity C-reactive protein and B-type natriuretic peptide (BNP). Blinded, independent adjudication was performed for all-cause mortality and the composite of death, myocardial infarction or stroke, analysed with Cox proportional hazards regression. RESULTS: Five hundred twenty-two patients were assessed with median age 66 years and 21% prior revascularization. Median baseline left ventricular ejection fraction was 64%, and 62% had ≥ 50% stenosis on angiography. During 5.0 years median follow-up, 30% underwent percutaneous and 16% surgical revascularization. In multivariate analysis, only age and BNP were independently associated with outcomes. The adjusted hazard ratio per log unit increase in BNP was 2.15 for mortality (95% CI 1.45-3.19; p = 0.0001) and 1.27 for composite events (1.04-1.54; p = 0.018). Patients with baseline BNP > 100 pg/mL had substantially higher mortality and composite events (20.9% and 32.2%) than those with BNP ≤ 100 pg/mL (5.6% and 15.5%). BNP improved both classification and discrimination of outcomes (p ≤ 0.003), regardless of left ventricular systolic function. Conversely, high-sensitivity C-reactive protein, pulse wave analysis and heart rate variability were unrelated to prognosis at 5 years after risk modification and treatment of coronary disease. CONCLUSIONS: Conventional risk factors and other markers of arterial compliance, inflammation and autonomic function have limited value for prediction of outcomes in risk-modified patients assessed for coronary disease. BNP can independently identify patients with subtle impairment of cardiac function that might benefit from more intensive management. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00403351 Registered on 22 November 2006.


Assuntos
Biomarcadores/sangue , Doença da Artéria Coronariana/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Idoso , Austrália/epidemiologia , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Causas de Morte , Angiografia Coronária , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Peptídeo Natriurético Encefálico/análise , Valor Preditivo dos Testes , Prognóstico , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade
18.
Trials ; 20(1): 162, 2019 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-30850023

RESUMO

BACKGROUND: Primary percutaneous coronary intervention (PCI) for patients presenting with acute myocardial infarction (AMI) caused by left main coronary artery occlusion is associated with significantly higher mortality and risks of major adverse cardiovascular events. Deferred stent implantation may improve prognosis of primary PCI by reducing distal embolization and no-reflow phenomenon. There is no randomized clinical trial focusing on the effect and outcome of deferred stent implantation on primary PCI for left main coronary artery occlusion in contrast with conventional strategy. METHODS: The Optimal Strategy of Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction due to Unprotected Left Main Coronary Artery Occlusion (OPTIMAL) study (ClinicalTrials.gov Identifier: NCT03282773) is an open-label, randomized, multicenter clinical trial in which 480 patients presenting with AMI caused by left main coronary artery occlusion recruited from 30 hospitals in mainland China will be randomly assigned 1:1 to immediate stenting or deferred stenting (scheduled 4-10 days after primary angioplasty) groups. The primary endpoint is a composite of all-cause mortality or recurrent myocardial infarction at 30 days after randomization. The secondary outcomes include all-cause mortality, cardiac death, recurrent myocardial infarction, and unplanned target vessel revascularization at 30 days, 6 months, and 12 months. DISCUSSION: The OPTIMAL study is designed to compare the clinical performance of deferred stenting with that of immediate stenting for AMI caused by left main coronary artery occlusion. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03282773 . Registered on 10 September 2017.


Assuntos
Oclusão Coronária/cirurgia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , China , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/mortalidade , Oclusão Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Int. j. cardiovasc. sci. (Impr.) ; 32(2): 118-124, mar.-abr. 2019. tab
Artigo em Inglês | LILACS | ID: biblio-987759

RESUMO

Background: Inflammation is a major component of the response to tissue injury caused by myocardial infarction. High-sensitivity C-reactive protein (hs-CRP) levels might be a simple marker of the severity of this inflammatory response, providing prognostic information. Objective: To associate hs-CRP level on admission and other clinical characteristics with in-hospital mortality of patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: A retrospective cohort study of patients admitted with STEMI was carried out. Patients were analyzed regarding clinical characteristics, reperfusion therapy, hs-CRP on admission and outcomes. Continuous variables were analyzed by non-parametric Mann-Whitney U test and categorical variables by chi-square test. A p value of < 0.05 was considered statistically significant. Results: Of the 118 patients analyzed, 20 died during hospitalization. Higher levels of hs-CRP (p = 0.001) and older ages (p = 0.003) were observed among those patients who died. Logistic regression showed that a one unit increase in hs-CRP increased the risk of death by 15% (p = 0.0017), after adjustment for established risk factors. Similarly, each one-year increase in age increases the risk of death by 6.6% (p = 0.003). Conclusion: Our results demonstrate a strong association between hs-CRP obtained on admission and in-hospital mortality after STEMI. It suggests that hs-CRP can be a marker of inflammatory response to myocardial ischemia, providing prognostic information regarding the risk of death


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Proteína C-Reativa , Biomarcadores , Infarto do Miocárdio/mortalidade , Prognóstico , Doenças Cardiovasculares/mortalidade , Índice de Massa Corporal , Estudos Retrospectivos , Fatores de Risco , Mortalidade Hospitalar , Diabetes Mellitus , Inflamação/fisiopatologia
20.
Int. j. cardiovasc. sci. (Impr.) ; 32(2): 125-133, mar.-abr. 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-988177

RESUMO

Background: Although new studies and guidelines can be considered useful tools, it does not necessarily mean they are put into clinical practice. Objective: The aim of the current analysis was to assess the changes in primary percutaneous coronary intervention (PCI) and mortality in a tertiary university hospital in southern Brazil during a six-year period .Methods: We have included consecutive patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI between March 2011 and February 2017. Previous clinical history, characteristics of the procedure, and reperfusion strategies were collected. In-hospital, short and long-term mortalities were also evaluated. The significance level adopted for all tests was 5%. Results: There was an increase in the use of radial access in patients from 20.0% in 2011 to 62.7% in 2016 (ptrend < 0.0001). Moreover, thrombus aspiration decreased significantly from 66.7% in 2011 to less than 3.0% in 2016 (ptrend < 0.0001). In-hospital, short and long-term mortalities remained reasonably stable from 2011 to 2016 (ptrend > 0.05). However, a lower in-hospital mortality was observed in patients treated through radial access (p < 0.001). Cardiogenic shock occurred in 11.1%, without statistical differences in the period (ptrend = 0.39), while long-term mortality rate decreased from 80.0% in 2011 to 27.3% in 2016 in this patient group (ptrend = 0.29). Conclusions: During a 6-year follow-up period, primary PCI characteristics underwent important modifications. Radial access became widely used, with a decrease in mortality with the use of this route, while aspiration thrombectomy became a rare procedure. The incidence of cardiogenic shock remained stable, but has shown a reduction in its mortality


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Atenção Terciária à Saúde , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio/mortalidade , Choque Cardiogênico , Doença da Artéria Coronariana/mortalidade , Análise Estatística , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Acidente Vascular Cerebral , Diabetes Mellitus , Hipertensão
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