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1.
Khirurgiia (Mosk) ; (9): 109-115, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33030011

RESUMO

Complete revascularization in patients with multiple-vessel coronary artery disease and partial or complete absence of the grafts is still actual problem for cardiac surgeons. The main causes of the absence of conduits for coronary artery bypass surgery are aging of population, increased incidence of repeated coronary artery bypass surgery and prevalence of varicose vein disease of the lower extremities. The most perspective approaches characterized by acceptable early and long-term postoperative outcomes are bilateral internal mammary artery grafting, sequential bypass including autoarterial grafts, as well as hybrid revascularization methods. However, treatment strategy is individualized in each patient.


Assuntos
Doença da Artéria Coronariana , Artéria Torácica Interna , Revascularização Miocárdica , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Humanos
3.
Int Heart J ; 61(5): 865-871, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921667

RESUMO

Bleeding complication has been considered as a serious problem in current percutaneous coronary interventions (PCI). Fortunately, several groups have already reported the effectiveness of protamine use just after PCI to immediately remove any arterial sheath. However, there is a concern that protamine reversal may increase non-occlusive thrombus and, in turn, lead to mid-term cardiovascular events such as target vessel revascularization (TVR) or stent thrombosis. Thus, the purpose of this study was to evaluate whether protamine use following elective PCI was associated with mid-term clinical outcomes. In total, 472 patients were included in this study; subsequently, they were divided into protamine group (n = 142) and non-protamine group (n = 330). The primary endpoint was the composite of ischemia-driven TVR and stent thrombosis. The median follow-up period was determined to be at 562 days. In total, 32 primary endpoints were observed during the study period, and the incidence of primary endpoints tended to be greater in the protamine group than in the non-protamine group (P = 0.056). However, the lesion length, the degree of calcification, and the prevalence of hemodialysis were significantly determined greater in the protamine group than in the non-protamine group. In the multivariate Cox proportional hazards model, the use of protamine (versus non-protamine: hazard ratio 0.542 and 95% confidence interval 0.217-1.355, P = 0.191) was deemed not to be associated with the primary endpoint after controlling legion length, calcification, and hemodialysis. In conclusion, immediate protamine use following elective PCI did not increase mid-term ischemia-driven TVR or stent thrombosis. However, immediate protamine use after PCI should be discussed further for the safety of the patient.


Assuntos
Estenose Coronária/cirurgia , Antagonistas de Heparina/uso terapêutico , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/prevenção & controle , Protaminas/uso terapêutico , Trombose/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Estudos de Casos e Controles , Estenose Coronária/epidemiologia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Heparina/efeitos adversos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/estatística & dados numéricos , Complicações Pós-Operatórias/induzido quimicamente , Hemorragia Pós-Operatória/induzido quimicamente , Modelos de Riscos Proporcionais , Diálise Renal , Estudos Retrospectivos , Stents , Trombose/induzido quimicamente , Calcificação Vascular/epidemiologia
4.
Int Heart J ; 61(5): 888-895, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921675

RESUMO

Although B-type natriuretic peptide (BNP) has gradually gained recognition as an indicator in risk stratification for patients with acute myocardial infarction (AMI), the prognostic impact on long-term clinical outcomes in patients with non-ST-segment elevation acute myocardial infarction (NSTEMI) without creatine kinase (CK) elevation remains unclear.This prospective multicenter study assessed 3,283 consecutive patients with AMI admitted to 28 institutions in Japan between 2012 and 2014. We analyzed 218 patients with NSTEMI without CK elevation (NSTEMI-CK) for whom BNP was available. In the NSTEMI-CK group, patients were assigned to high- and low-BNP groups according to BNP values (cut-off BNP, 100 pg/mL). The primary endpoint was defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. Primary endpoints were observed in 60 (33.3%) events among patients with NSTEMI-CK. Kaplan-Meier analysis revealed a significantly higher event rate for primary endpoints among patients with high BNP (log-rank P < 0.001). After adjusting for covariates, a higher BNP level was significantly associated with long-term clinical outcomes in NSTEMI-CK (adjusted hazard ratio, 4.86; 95% confidence interval, 2.18-12.44; P < 0.001).The BNP concentration is associated with adverse long-term clinical outcomes among patients with NSTEMI-CK who are considered low risk. Careful clinical management may be warranted for secondary prevention in patients with NSTEMI-CK with high BNP levels.


Assuntos
Angina Instável/epidemiologia , Creatina Quinase/sangue , Insuficiência Cardíaca/epidemiologia , Mortalidade , Infarto do Miocárdio/epidemiologia , Peptídeo Natriurético Encefálico/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/cirurgia , Causas de Morte , Feminino , Humanos , Japão/epidemiologia , Masculino , Revascularização Miocárdica/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Prognóstico , Modelos de Riscos Proporcionais
5.
Medicine (Baltimore) ; 99(31): e21554, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756213

RESUMO

BACKGROUND: Bioresorbable vascular scaffolds (BVS) completely resorb within 3 years after placement into the coronary artery. The safety and effectiveness of bioabsorbable scaffolds are of critical importance during this 3-year period. OBJECTIVE: We performed a meta-analysis to compare the safety and efficacy of BVS and second-generation drug-eluting stents (DES) at 3 years after implantation. METHODS: Published randomized trials comparing BVS to second-generation DES for the treatment of coronary artery disease were identified within PubMed, EMBASE, Cochrane Library, Web of Science, and relevant Web sites with publication dates through June 2019. The primary efficacy endpoint was target lesion failure. The primary safety endpoint was definite/probable stent/scaffold thrombosis. Secondary outcomes were cardiac death, target vessel myocardial infarction, ischemia-driven target lesion revascularization, and a patient-oriented composite end point. RESULTS: Six randomized controlled trials, with a total of 5,412 patients (BVS n = 3,177; DES n = 2,235), were included. At 3 years, BVS was associated with higher rates of target lesion failure (OR = 1.33, 95%CI: 1.10-1.60, P = 0.003) and definite/probable stent/scaffold thrombosis (OR = 3.75, 95% CI: 2.22-6.35, P < .00001)compared with DES. The incidence of target vessel myocardial infarction (OR = 1.68, 95% CI: 1.30-2.17, P < .0001), ischemia-driven target lesion revascularization (OR = 1.46, 95% CI: 1.14-1.86, P = .003), and the patient-oriented composite end point(OR = 1.20, 95% CI: 1.04-1.39, P = .01) were higher for those treated with BVS compared with DES. However, there was no significant difference in risk of cardiac death (OR = 0.94, 95%CI: 0.61-1.45, P = .79) between treatment groups. CONCLUSIONS: At the 3-year follow-up, BVS was inferior to second-generation DES in both safety and efficacy.


Assuntos
Implantes Absorvíveis/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/efeitos adversos , Morte , Humanos , Infarto do Miocárdio/etiologia , Revascularização Miocárdica/estatística & dados numéricos , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/etiologia
6.
Wiad Lek ; 73(4): 728-732, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32731705

RESUMO

OBJECTIVE: The aim: To estimate the dynamics of echocardiographic parameters in patients with CAD within 5 years after revascularization. PATIENTS AND METHODS: Material and methods: 50 persons (males/females 39/11; mean age 59.9±9.3 years; STEMI 76%, non-STEMI 24%) were divided into two groups: n=38 after PCI with stenting (PCIwS); n=12 after CABG. Observation included regular echocardiography with LV myocardial mass (LVMM) and geometry estimation. RESULTS: Results: Groups were comparable by age, co-morbidity, BP, heart rate and BMI. Significantly severe baseline LV hypertrophy (LVH) and left atrial enlargement (LAE) in group 2 explained by spread coronary atherosclerosis. Later progressive LAE (4.37±0.22 cm, P0-60<0.05) in group 1, and aortic/LV dilatation (+0.4/+1.0 cm, respectively, both P0-60<0.05) in group 2 developed. In two years LVMM index increased by 13.4/17.5% in groups 1/2, respectively. Normal geometry and concentric remodeling completely disappeared in 3/1.5 years after PCIwS/CABG, respectively. CONCLUSION: Conclusions: Within the 1st year after revascularization, patients with CABG had more severe LVH. In 5 years after PCIwS the ratio between concentric/eccentric LVH was 2:1, whereas after CABG - 1:2.


Assuntos
Doença da Artéria Coronariana , Idoso , Ponte de Artéria Coronária , Ecocardiografia , Feminino , Humanos , Hipertrofia Ventricular Esquerda , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica
7.
JAMA ; 324(3): 279-290, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692391

RESUMO

Importance: Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. Observations: Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose ß-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without ß-blocker use; P = .005) and mortality (3.1% vs 2.3% without ß-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. Conclusions and Relevance: Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.


Assuntos
Doenças Cardiovasculares/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Biomarcadores/sangue , Angiografia Coronária , Ecocardiografia Transesofagiana , Eletrocardiografia/métodos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Isquemia Miocárdica/diagnóstico , Revascularização Miocárdica , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Stents/efeitos adversos , Acidente Vascular Cerebral/induzido quimicamente , Fatores de Tempo , Estados Unidos/epidemiologia
8.
Biomed Environ Sci ; 33(6): 431-443, 2020 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-32641206

RESUMO

Objective: To analyze factors associated with unplanned revascularization (UR) risk in patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI). Methods: A total of 10,640 cases with CAD who underwent PCI were analyzed. Multivariate COX regressions and competing risk regressions were applied. Results: The patients who underwent UR following PCI in 30 days, 1, and 2 years accounted for 0.3%, 6.5%, and 8.7%, respectively. After multivariate adjustment, the number of target lesions [hazard ratio ( HR) = 2.320; 95% confidence interval ( CI): 1.643-3.277; P < 0.001], time of procedure ( HR= 1.006; 95% CI: 1.001-1.010; P = 0.014), body mass index ( HR= 1.104; 95% CI: 1.006-1.210; P = 0.036), incomplete revascularization (ICR) ( HR= 2.476; 95% CI: 1.030-5.952; P = 0.043), and age ( HR = 1.037; 95% CI: 1.000-1.075; P = 0.048) were determined as independent risk factors of 30-day UR. Factors, including low-molecular-weight heparin or fondaparinux ( HR= 0.618; 95% CI: 0.531-0.719; P < 0.001), second-generation durable polymer drug-eluting stent ( HR = 0.713; 95% CI: 0.624-0.814; P < 0.001), left anterior descending artery involvement ( HR= 0.654; 95% CI: 0.530-0.807; P < 0.001), and age ( HR= 0.992; 95% CI: 0.985-0.998; P = 0.014), were independently associated with decreased two-year UR risk. While, Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score ( HR= 1.024; 95% CI: 1.014-1.033; P < 0.001) and ICR ( HR= 1.549; 95% CI: 1.290-1.860; P < 0.001) were negatively associated with two-year UR risk. Conclusion: Specific factors were positively or negatively associated with short- and medium-long-term UR following PCI.


Assuntos
Doença da Artéria Coronariana/cirurgia , Revascularização Miocárdica/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Adulto , Idoso , China , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
11.
Lancet ; 396(10248): 381-389, 2020 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-32679111

RESUMO

BACKGROUND: Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. METHODS: We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. FINDINGS: Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37-43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13-20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38-46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12-29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29-45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2-9) in 2019 to 3 days (1-5) by the end of March, 2020. INTERPRETATION: Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses. FUNDING: UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.


Assuntos
Síndrome Coronariana Aguda/terapia , Infecções por Coronavirus/epidemiologia , Hospitalização/estatística & dados numéricos , Pandemias , Pneumonia Viral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/terapia , Betacoronavirus , Inglaterra/epidemiologia , Utilização de Instalações e Serviços , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia
12.
Arq Bras Cardiol ; 114(6): 995-1003, 2020 06.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32638905

RESUMO

Background There is lack of prospective data on evolution within one year of acute coronary syndromes (ACS) in a representative population of Brazilian patients. Objectives To assess the prescription of evidence-based therapies, the incidence of severe outcomes and the predictors for these outcomes in a multicenter Brazilian registry of ACS patients. Methods The ACCEPT is a prospective observational study, which included patients hospitalized with a diagnostic of ACS in 47 Brazilian hospitals. The patients were followed for a 1 year and data were collected on the medical prescription and the occurrence of major cardiovascular events (cardiovascular mortality, reinfarction and cerebrovascular accident - CVA). Values of p < 0.05 were considered statistically significant. Results A total of 5,047 patients were included in this registry from August 2010 to April 2014. The diagnosis of ACS was confirmed in 4,782 patients (94.7%) and, among those, the most frequent diagnosis was ACS with ST segment elevation (35.8%). The rate of major cardiovascular events was 13.6 % within 1 year. Adherence to prescription of evidence-based therapy at admission was of 62.1%. Age, public service, acute myocardial infarction, CVA, renal failure, diabetes and quality of therapy were associated independently with the occurrence of major cardiovascular events. Conclusions During the one-year follow-up of the ACCEPT registry, more than 10% of the patients had major cardiovascular events and this rate ranged according with the quality of therapy. Strategies must be elaborated to improve the use of evidence-based therapies to minimize the cardiovascular events among the Brazilian population. (Arq Bras Cardiol. 2020; 114(6):995-1003).


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Sistema de Registros/estatística & dados numéricos , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Brasil/epidemiologia , Seguimentos , Humanos , Revascularização Miocárdica/estatística & dados numéricos , Estudos Prospectivos , Resultado do Tratamento
13.
Diab Vasc Dis Res ; 17(4): 1479164120941809, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32722933

RESUMO

BACKGROUND: Diabetes is considered a risk factor for myocardial infarction. However, we have previously found that diabetes was not a short-term risk factor for myocardial infarction in the absence of obstructive coronary artery disease. METHODS: We conducted a cohort study of patients undergoing coronary angiography from 2003 to 2012 and followed them by cross-linking Danish health registries. Patients were stratified according to coronary artery disease and diabetes. Endpoints included myocardial infarction, cardiac death, all-cause death and coronary revascularization. RESULTS: 86,202 patients were included in total (diabetes: n = 12,652). Median follow-up was 8.8 years. Using patients with neither coronary artery disease nor diabetes as reference (cumulative myocardial infarction incidence 2.6%), the risk of myocardial infarction was low and not substantially increased for patients with diabetes alone (3.2%; hazard ratio 1.202, 95% confidence interval 0.996-1.451), was increased for patients with coronary artery disease alone (9.3%; hazard ratio 2.75, 95% confidence interval 2.52-3.01) and was highest for patients with both coronary artery disease and diabetes (12.3%; hazard ratio 3.79, 95% confidence interval 3.43-4.20). Similar associations were observed for cardiac death and coronary revascularization. CONCLUSION: Diabetes patients without coronary artery disease by coronary angiography have a low risk of myocardial infarction, not substantially increased compared to patients with neither coronary artery disease nor diabetes. In the presence of coronary artery disease, however, diabetes increases the risk of myocardial infarction.


Assuntos
Doença da Artéria Coronariana/epidemiologia , Diabetes Mellitus/epidemiologia , Infarto do Miocárdio/epidemiologia , Idoso , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Dinamarca/epidemiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidade , Diabetes Mellitus/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Prognóstico , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo
14.
Am J Cardiol ; 128: 28-34, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650921

RESUMO

Involvement of atherosclerosis in extracardiac vascular territories may identify coronary artery disease (CAD) patients at higher risk for adverse events. We investigated the long-term prognostic implications of polyvascular disease in patients with CAD, and further analyzed lipid goal attainment and its relation to patient outcomes. The study was a retrospective analysis of 10,297 patients who underwent coronary revascularization, categorized as having CAD alone (83.1%) or with multisite artery disease (MSAD) (16.9%) including cerebrovascular disease (CBVD) and/or peripheral artery disease (PAD). Incidence rates and hazard ratios (HR) for major adverse cardiovascular events (MACE) (myocardial infarction, ischemic stroke, or all-cause death) according to vascular territories involved, and in relation to most-recent lipid levels attained, were analyzed. Patients with MSAD were older with higher burden of co-morbidities. The rate of MACE (myocardial infarction, ischemic stroke, or all-cause death) and its individual components increased with the number of affected vascular beds. Adjusted HR (95% confidence interval) for MACE was 1.41 (1.24 to 1.59) in patients with CAD and CBVD, 1.46 (1.33 to 1.62) in CAD and PAD, and 1.69 (1.49 to 1.92) in those with CAD and CBVD and PAD, compared with CAD alone. Most-recent low-density lipoprotein cholesterol (LDL-C) levels <55 mg/dl and <70 mg/dl were attained by 21.8% and 44.6% of patients with CAD alone, in comparison to 22.7% and 43.3% in MSAD. Compared with patients with most-recent LDL-C > 100 mg/dl, attaining LDL-C < 70 mg/dl had an adjusted HR for MACE of 0.52 (0.47 to 0.57) in CAD only patients and 0.66 (0.57 to 0.78) in MSAD patients. In conclusion, the presence of CBVD and/or PAD in patients with CAD is associated with higher burden of co-morbidities and progressive increase in long-term MACE. More than half of CAD patients with or without MSAD do not achieve lipid goals, which are associated with a significantly lower risk for adverse events.


Assuntos
Transtornos Cerebrovasculares/epidemiologia , Doença da Artéria Coronariana/cirurgia , Hipercolesterolemia/terapia , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica , Doença Arterial Periférica/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/epidemiologia , Angina Instável/cirurgia , Aneurisma da Aorta Abdominal/epidemiologia , Causas de Morte , LDL-Colesterol/sangue , Comorbidade , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Hipercolesterolemia/sangue , Hipercolesterolemia/epidemiologia , Incidência , Israel/epidemiologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia
15.
Am J Cardiol ; 128: 67-74, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650926

RESUMO

Patients with elevated but stable levels of high-sensitivity cardiac troponin (hs-cTn) have a high risk of premature death and cardiovascular events. This study aimed to investigate the association between stable hs-cTnT levels and healthcare and resource use in patients with chest pain in the emergency department (ED). We included all patients who presented with chest pain and stable hs-cTnT levels without any concurrent acute medical condition at Karolinska University Hospital, Stockholm, Sweden, from 2011 to 2014. A negative binomial regression model was used to calculate incidence rates and incidence rate ratios with 95% confidence intervals (CIs) for the number of hospital visits, hospital days, and investigations performed during follow-up, in different categories of hs-cTnT levels (reference: hs-cTnT <5 ng/l). A total of 19,437 patients were included. During a follow-up of 4.1 years, 36,617 hospital visits and 206,808 hospital days were observed. Yearly rates of hospital visits and days gradually rose with increasing hs-cTnT levels from 0.3 and 1.27 (<5 ng/l) to 1.7 and 13 (≥50 ng/l) per person. In patients with hs-cTnT levels >14 ng/l, adjusted risks of in-hospital days were more than doubled (adjusted incidence rate ratio (95% CI) 2.31 (2.14 to 2.50), 2.88 (2.55 to 3.26), and 2.89 (2.45 to 3.40) in patients with hs-cTnT levels of 15 to 29, 30 to 49, and ≥50 ng/l, respectively) compared with the reference. Computed tomography, but not coronary angiography, increased with increasing hs-cTnT levels. In conclusion, stable hs-cTnT levels are associated with a higher rate of hospitalization, length of hospital stay, and resource use in patients with chest pain.


Assuntos
Cardiomiopatias/sangue , Hospitalização/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Troponina T/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito , Doença Crônica , Estudos de Coortes , Angiografia Coronária , Serviço Hospitalar de Emergência , Feminino , Recursos em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Suécia
17.
Am J Cardiol ; 128: 94-100, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650931

RESUMO

This study sought to investigate the impact of elective, uncomplicated target lesion revascularization (TLR) on long-term cardiac mortality after percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease. Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in 1 interventional center in Northern Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HZ] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72). In conclusion, elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.


Assuntos
Doença da Artéria Coronariana/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Cardiopatias/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica , Prognóstico , Modelos de Riscos Proporcionais , Acidente Vascular Cerebral/epidemiologia
18.
Rev Med Suisse ; 16(696): 1140-1146, 2020 Jun 03.
Artigo em Francês | MEDLINE | ID: mdl-32496702

RESUMO

The decision to perform coronary revascularization in the setting of chronic coronary syndrome is based on the detection of myocardial ischemia through non-invasive or invasive tests, according to the cardiovascular risk of each patient. This latter will also determine the benefit to be expected with revascularization. The present article is a brief summary of the latest evidence in this domain.


Assuntos
Doença da Artéria Coronariana/cirurgia , Revascularização Miocárdica , Humanos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares
19.
PLoS One ; 15(6): e0233791, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32584909

RESUMO

BACKGROUND: Machine learning (ML) is able to extract patterns and develop algorithms to construct data-driven models. We use ML models to gain insight into the relative importance of variables to predict obstructive coronary artery disease (CAD) using the Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization (CONSERVE) study, as well as to compare prediction of obstructive CAD to the CAD consortium clinical score (CAD2). We further perform ML analysis to gain insight into the role of imaging and clinical variables for revascularization. METHODS: For prediction of obstructive CAD, the entire ICA arm of the study, comprising 719 patients was used. For revascularization, 1,028 patients were randomized to invasive coronary angiography (ICA) or coronary computed tomographic angiography (CCTA). Data was randomly split into 80% training 20% test sets for building and validation. Models used extreme gradient boosting (XGBoost). RESULTS: Mean age was 60.6 ± 11.5 years and 64.3% were female. For the prediction of obstructive CAD, the AUC was significantly higher for ML at 0.779 (95% CI: 0.672-0.886) than for CAD2 (0.696 [95% CI: 0.594-0.798]) (P = 0.01). BMI, age, and angina severity were the most important variables. For revascularization, the model obtained an overall area under the receiver-operation curve (AUC) of 0.958 (95% CI = 0.933-0.983). Performance did not differ whether the imaging parameters used were from ICA (AUC 0.947, 95% CI = 0.903-0.990) or CCTA (AUC 0.941, 95% CI = 0.895-0.988) (P = 0.90). The ML model obtained sensitivity and specificity of 89.2% and 92.9%, respectively. Number of vessels with ≥70% stenosis, maximum segment stenosis severity (SSS) and body mass index (BMI) were the most important variables. Exclusion of imaging variables resulted in performance deterioration, with an AUC of 0.705 (95% CI 0.614-0.795) (P <0.0001). CONCLUSIONS: For obstructive CAD, the ML model outperformed CAD2. BMI is an important variable, although currently not included in most scores. In this ML model, imaging variables were most associated with revascularization. Imaging modality did not influence model performance. Removal of imaging variables reduced model performance.


Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Aprendizado de Máquina , Revascularização Miocárdica/estatística & dados numéricos , Idoso , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos
20.
Herz ; 45(5): 453-457, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32494947

RESUMO

The International Study of Comparative Health Effectiveness With Medical And Invasive Approaches (ISCHEMIA) has the potential to be a game changer in terms of the diagnostic and management approach to patients presenting with chronic coronary syndrome, suggesting that coronary revascularization may become almost like a "bail-out" strategy in the treatment of these patients. However, invasive perfusion assessment as a means of detecting the source of myocardial ischaemia at a lesion level, such as fractional flow reserve (FFR), has been validated in the past and established beyond doubt as a key diagnostic tool. The complementary role of the two approaches will be discussed here.


Assuntos
Doença da Artéria Coronariana , Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Isquemia Miocárdica , Angiografia Coronária , Doença da Artéria Coronariana/fisiopatologia , Humanos , Revascularização Miocárdica , Valor Preditivo dos Testes , Síndrome
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