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1.
Angiology ; 71(1): 48-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31315429

RESUMO

We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).


Assuntos
Estenose Coronária/terapia , Reserva Fracionada de Fluxo Miocárdico , Revascularização Miocárdica , Tempo para o Tratamento , Idoso , Tomada de Decisão Clínica , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
2.
Adv Gerontol ; 32(4): 581-591, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31800187

RESUMO

In the present review, the main attention is focused on the problem of polymorbidity and age-related conditions in elderly patients with CAD who need myocardial revascularization. In addition to a high risk of mortality, elderly patients with polymorbidity are characterized reduced functional activity, cognitive impairment, low quality of life and frequent seeking medical help. There is evidence of the presence of common mechanisms that affect the aging process and the development of a number of associated diseases associated with age. Accordingly, the study of polymorbidity will allow us to develop strategies for the prevention it and understand the aging process and significantly reduce the risks of surgical intervention. In this regard, there is a necessity for research aimed at studying the causal relationship between coronary artery disease and polymorbidity in elderly patients with an additional assessment of functional and cognitive status for the development of specific prognostic tools and treatment strategies.


Assuntos
Doença da Artéria Coronariana , Revascularização Miocárdica , Idoso , Disfunção Cognitiva/complicações , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Humanos , Revascularização Miocárdica/mortalidade , Revascularização Miocárdica/estatística & dados numéricos , Qualidade de Vida , Risco
3.
Int Heart J ; 60(5): 1070-1076, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484856

RESUMO

The efficacy of drug-coated balloons (DCB) for in-stent restenosis (ISR) in hemodialysis (HD) patients remains unclear.We retrospectively evaluated 153 consecutive patients who underwent DCB for ISR with follow-ups for up to 3 years after the procedure between February 2014 and June 2017. Patients were divided into an HD group (n = 39) and a non-HD group (n = 114). The primary endpoint was target lesion revascularization (TLR). The secondary endpoints were all revascularizations and major adverse cardiac events (MACE) defined as cardiac death, myocardial infarction and cerebral infarction. Kaplan-Meier curves of survival free from TLR were compared between the two groups. We also performed propensity score matching and then compared the two matched groups (n = 27 in each group). The acute procedure success rate was similar for the two groups (100% versus 99.1%, P = 0.56). The incidence of TLR was higher in the HD group than in the non-HD group (41.0% versus 9.6%, P < 0.0001). The rate of revascularizations and MACE combined was significantly higher in the HD group than in the non-HD group (64.1% versus 17.5%, P < 0.0001). Kaplan-Meier analyses showed that survival free from TLR was significantly lower in the HD group than in the non-HD group both before and after propensity score matching (P < 0.0001 and P = 0.005, respectively; log-rank test).Contrary to the similar acute procedure success, recurrent ISR and MACE occurred more frequently in HD patients than in non-HD patients after DCB, which indicates poorer long-term efficacy of DCB in HD patients.


Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Cateteres Cardíacos/efeitos adversos , Reestenose Coronária/terapia , Estenose Coronária/terapia , Stents Farmacológicos/efeitos adversos , Diálise Renal/métodos , Idoso , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Estudos de Casos e Controles , Causas de Morte , Materiais Revestidos Biocompatíveis , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/mortalidade , Estenose Coronária/diagnóstico por imagem , Feminino , Seguimentos , Hospitais Universitários , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Revascularização Miocárdica/mortalidade , Paclitaxel/farmacologia , Pontuação de Propensão , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
4.
Int J Cardiovasc Imaging ; 35(7): 1265-1275, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31165941

RESUMO

Assessment of global longitudinal strain (GLS) is superior to ejection fraction (EF) in the evaluation of left ventricular (LV) function in patients with stable coronary artery disease (CAD). However, the role of mechanical dispersion (MD) in this context remains unresolved. We aimed to evaluate the potential role of MD as a marker of LV dysfunction and long-term prognosis in stable CAD. EF, GLS and MD were assessed in 160 patients with stable CAD, 1 year after successful coronary revascularization. Serum levels of high-sensitivity cardiac troponin I (hs-cTnI) and amino-terminal pro B-type natriuretic peptide (NT-proBNP) were quantified as surrogate markers of LV dysfunction. The primary endpoint was defined as all-cause mortality, the secondary endpoint was defined as the composite of all-cause mortality and hospitalization for acute myocardial infarction or heart failure during follow-up. Whereas no associations between EF and the biochemical markers of LV function were found, both GLS and MD correlated positively with increasing levels of hs-cTnI (R = 0.315, P < 0.001 and R = 0.442, P < 0.001, respectively) and NT-proBNP (R = 0.195, P = 0.016 and R = 0.390, P < 0.001, respectively). Median MD was 46 ms (interquartile range [IQR] 37-53) and was successfully quantified in 96% of the patients. During a median follow-up of 8.4 (IQR 8.2-8.8) years, 14 deaths and 29 secondary events occurred. MD was significantly increased in non-survivors, and provided incremental prognostic value when added to EF and GLS. NT-proBNP was superior to the echocardiographic markers in predicting adverse outcomes. MD may be a promising marker of LV dysfunction and adverse prognosis in stable CAD.


Assuntos
Doença da Artéria Coronariana/cirurgia , Ecocardiografia , Revascularização Miocárdica , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Idoso , Biomarcadores/sangue , Causas de Morte , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Peptídeo Natriurético Encefálico/sangue , Readmissão do Paciente , Fragmentos de Peptídeos/sangue , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Troponina I/sangue , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
5.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 217-226, May-June 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1002227

RESUMO

Myocardial revascularization surgery (MRS) is the most frequently performed cardiac surgery in Brazil. However, data on mortality rates among patients undergoing MRS in hospitals other than the main referral centers in the northern Brazil are scarce. Objective: To describe the clinical course of patients that submitted to MRS in the major public cardiology referral hospital in the Brazilian Amazon. Methods: Retrospective cohort analysis, by review of medical records of patients who had undergone MRS at Hospital das Clínicas Gaspar Vianna (FHCGV) from January 2013 to June 2014. Results: A total of 179 patients were evaluated. Mortality rate was 11.7% until 30 days after surgery. Waiting time for surgery ≥ 30 days (OR 2.59, 95%CI 1.02 - 6.56, p = 0.039), infection during hospitalization (OR 3.28, 95%CI 1.15 - 9.39, p = 0.021) and need for hemodialysis after surgery (OR 9.06 95%CI 2.07 - 39.54, p = 0.001) were predictors of mortality after CABG. Conclusion: A high mortality rate in the study population was found, higher than that reported in the literature and in other regions of Brazil


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias , Brasil/epidemiologia , Hospitais Públicos , Revascularização Miocárdica/mortalidade , Comorbidade , Fatores Sexuais , Análise Estatística , Fatores de Risco , Fatores Etários , Resultado do Tratamento , Síndrome Coronariana Aguda/complicações , Estudo Observacional , Infecção/complicações , Angina Instável/complicações , Infarto do Miocárdio , Infarto do Miocárdio/complicações
6.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 217-226, may.-june. 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1005925

RESUMO

Background: Myocardial revascularization surgery (MRS) is the most frequently performed cardiac surgery in Brazil. However, data on mortality rates among patients undergoing MRS in hospitals other than the main referral centers in the northern Brazil are scarce.Objective: To describe the clinical course of patients that submitted to MRS in the major public cardiology referral hospital in the Brazilian Amazon.Methods: Retrospective cohort analysis, by review of medical records of patients who had undergone MRS at Hospital das Clínicas Gaspar Vianna (FHCGV) from January 2013 to June 2014. Results: A total of 179 patients were evaluated. Mortality rate was 11.7% until 30 days after surgery. Waiting time for surgery ≥ 30 days (OR 2.59, 95%CI 1.02 ­ 6.56, p = 0.039), infection during hospitalization (OR 3.28, 95%CI 1.15 ­ 9.39, p = 0.021) and need for hemodialysis after surgery (OR 9.06 95%CI 2.07 ­ 39.54, p = 0.001) were predictors of mortality after CABG. Conclusion: A high mortality rate in the study population was found, higher than that reported in the literature and in other regions of Brazil


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias , Brasil/epidemiologia , Hospitais Públicos , Revascularização Miocárdica/mortalidade , Comorbidade , Fatores Sexuais , Análise Estatística , Fatores de Risco , Fatores Etários , Resultado do Tratamento , Síndrome Coronariana Aguda/complicações , Estudo Observacional , Infecção/complicações , Angina Instável/complicações , Infarto do Miocárdio/complicações
7.
BMC Cardiovasc Disord ; 19(1): 65, 2019 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-30894133

RESUMO

BACKGROUND: Major in-hospital mortality rate in patients with ST-segment Elevation Myocardial Infarction (STEMI) in Sub-Saharan Africa has been reported. Data on follow-up in these patients with STEMI are scarce. We aimed to assess medium and long-term prognosis in patients with STEMI admitted to Abidjan Heart Institute. METHODS: Prospective cohort study including 260 patients admitted for STEMI to Abidjan Heart Institute, from January 1, 2012 to December 31, 2015. We compared mortality and nonfatal cardiovascular complications in revascularized and non-revascularized groups. Survival curve was generated with the Kaplan-Meier method. Predictors of mortality after STEMI were determined by multivariable Cox regression. RESULTS: Of the 260 patients followed up on a median period of 39 months [28-68 months], 94 patients (36.1%) were revascularized and 166 (63.8%) were non-revascularized. Crude all-cause mortality was 10.4%. It was significantly higher in non-revascularized patients (p = 0.04). There was no difference in the occurrence of nonfatal cardiovascular complications in the 2 groups. In multivariable Cox regression, age ≥ 70 years, female gender and heart failure were the predictive factors for death after adjustment. CONCLUSIONS: STEMI remains an important cause of mortality in our practice. Healthcare policies should be developed to improve patient care and long-term outcomes.


Assuntos
Revascularização Miocárdica/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores Etários , Idoso , Causas de Morte , Costa do Marfim/epidemiologia , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
8.
Int J Cardiol ; 277: 47-53, 2019 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-30093138

RESUMO

BACKGROUND: There have been limited and conflicting results regarding the prognostic impact of revascularization treatment on the long-term clinical outcomes of silent ischemia. The current study aimed to determine whether revascularization treatment compared with medical treatment (MT) alone reduces long-term risk of cardiac death of asymptomatic patients with objective evidence of inducible myocardial ischemia. METHODS: A total of 1473 consecutive asymptomatic patients with evidence of inducible myocardial ischemia were selected from a prospective institutional registry. All patients showed at least 1 epicardial coronary stenosis with ≥50% diameter stenosis in coronary angiography. Patients were classified according to their treatment strategies. The primary outcome was cardiac death up to 10 years. RESULTS: Among the total population, 709 patients (48.1%) received revascularization treatment including percutaneous coronary intervention (PCI, n = 558) or coronary artery bypass graft surgery (CABG, n = 151), with the remaining patients (764 patients, 51.9%) receiving MT alone. During the follow-up period, the revascularization treatment group showed a significantly lower risk of cardiac death compared with the MT alone group (25.4% vs. 33.7%, HR 0.624, 95%CI 0.498-0.781, p < 0.001). Among revascularized patients, patients with negative non-invasive stress test results after revascularization showed significantly lower risk of cardiac death compared to those with residual myocardial ischemia (8.9% vs. 18.7%, HR 0.406, 95% CI 0.175-0.942, p = 0.036). CONCLUSIONS: In patients with silent myocardial ischemia, revascularization treatment was associated with significantly lower long-term risk of cardiac death compared with the MT alone group. The current results support contemporary practice of ischemia-directed revascularization, even in patients with silent myocardial ischemia.


Assuntos
Doenças Assintomáticas/terapia , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/terapia , Revascularização Miocárdica/tendências , Idoso , Doenças Assintomáticas/mortalidade , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Isquemia Miocárdica/mortalidade , Revascularização Miocárdica/mortalidade , Intervenção Coronária Percutânea/mortalidade , Intervenção Coronária Percutânea/tendências , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Prospectivos , Sistema de Registros , Tomografia Computadorizada de Emissão de Fóton Único/mortalidade , Tomografia Computadorizada de Emissão de Fóton Único/tendências , Resultado do Tratamento
9.
Circulation ; 139(10): 1249-1258, 2019 03 05.
Artigo em Inglês | MEDLINE | ID: mdl-30586755

RESUMO

BACKGROUND: Percutaneous mechanical circulatory support devices are increasingly used in acute myocardial infarction complicated by cardiogenic shock (AMI-CS), despite limited evidence for their effectiveness. The aim of this study was to evaluate outcomes associated with use of the Impella device compared with intra-aortic balloon pump (IABP) and medical treatment in patients with AMI-CS. METHODS: Data of patients with AMI-CS treated with the Impella device at European tertiary care hospitals were collected retrospectively. All patients underwent early revascularization and received optimal medical treatment. Using IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial inclusion and exclusion criteria, 372 patients were identified and included in this analysis. These patients were matched to 600 patients from the IABP-SHOCK II trial. The following baseline criteria were used as matching parameters: age, sex, mechanical ventilation, ejection fraction, prior cardiopulmonary resuscitation, and lactate. Primary end point was 30-day all-cause mortality. RESULTS: In total, 237 patients treated with an Impella could be matched to 237 patients from the IABP-SHOCK II trial. Baseline parameters were similarly distributed after matching. There was no significant difference in 30-day all-cause mortality (48.5% versus 46.4%, P=0.64). Severe or life-threatening bleeding (8.5% versus 3.0%, P<0.01) and peripheral vascular complications (9.8% versus 3.8%, P=0.01) occurred significantly more often in the Impella group. Limiting the analysis to IABP-treated patients as a control group did not change the results. CONCLUSIONS: In this retrospective analysis of patients with AMI-CS, the use of an Impella device was not associated with lower 30-day mortality compared with matched patients from the IABP-SHOCK II trial treated with an IABP or medical therapy. To further evaluate this, a large randomized trial is warranted to determine the effect of the Impella device on outcome in patients with AMI-CS. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03313687.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Coração Auxiliar , Balão Intra-Aórtico , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Choque Cardiogênico/terapia , Idoso , Fármacos Cardiovasculares/efeitos adversos , Europa (Continente) , Feminino , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Desenho de Prótese , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
10.
Medicine (Baltimore) ; 97(48): e13488, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30508978

RESUMO

Although the prevalence of atrial fibrillation (AF) and percutaneous coronary intervention (PCI) are increasing in Asia, there is a paucity of data concerning the effect of AF in Asian patients undergoing PCI with drug-eluting stents (DESs). Furthermore, the majority of previous studies investigating the effect of AF on prognosis following PCI have exclusively evaluated patients with myocardial infarction (MI). We aimed to evaluate the effect of AF on clinical outcomes of Asian patients undergoing PCI with DES for coronary artery disease (CAD) excluding acute MI.From national health insurance claims data in South Korea, a total of 45,288 patients aged 18 years or older without a known history of CAD, who underwent PCI with DES for the diagnosis of CAD excluding acute MI between 2011 and 2015, were enrolled. Based on the presence or absence of a history of AF at baseline, patients were categorized into the AF group (n = 1715, 3.8%) and no-AF group (n = 43,573, 96.2%). Outcomes including all-cause death, the composite outcome of all-cause death/MI/coronary revascularization, and stroke were compared between 2 groups using a propensity-score-matched analysis.After propensity-score matching, 1709 matched pairs were obtained. During the follow-up period (mean, 2.2 years), the incidence of all-cause death (hazard ratio [HR] 1.117, 95% confidence interval [CI] 0.885-1.411, P = .35) and the composite outcome of all-cause death/MI/coronary revascularization (HR 1.004, 95% CI 0.846-1.192, P = .97) were not significantly different between 2 groups. However, the incidence of stroke was significantly increased in the AF group (HR 1.983, 95% CI 1.474-2.667, P < .001).In Asian patients undergoing PCI for stable CAD, a history of AF was not associated with mortality, but was associated with increased risk of stroke.


Assuntos
Fibrilação Atrial/mortalidade , Doença da Artéria Coronariana/mortalidade , Stents Farmacológicos , Revascularização Miocárdica/mortalidade , Intervenção Coronária Percutânea/mortalidade , Idoso , Fibrilação Atrial/etiologia , Causas de Morte , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/instrumentação , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Período Pré-Operatório , Pontuação de Propensão , República da Coreia , Fatores de Risco , Resultado do Tratamento
12.
Arq Bras Cardiol ; 111(4): 542-550, 2018 Oct.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30281692

RESUMO

BACKGROUND: There are limited data on the prognosis of deferral of lesion treatment in patients with acute coronary syndrome (ACS) based on fractional flow reserve (FFR). OBJECTIVES: To provide a systematic review of the current evidence on the prognosis of deferred lesions in ACS patients compared with deferred lesions in non-ACS patients, on the basis of FFR. METHODS: We searched Medline, EMBASE, and the Cochrane Library for studies published between January 2000 and September 2017 that compared prognosis of deferred revascularization of lesions on the basis of FFR in ACS patients compared with non-ACS patients. We conducted a pooled relative risk meta-analysis of four primary outcomes: mortality, cardiovascular (CV) mortality, myocardial infarction (MI) and target-vessel revascularization (TVR). RESULTS: We identified 7 studies that included a total of 5,107 patients. A pooled meta-analysis showed no significant difference in mortality (relative risk [RR] = 1.44; 95% CI, 0.9-2.4), CV mortality (RR = 1.29; 95% CI = 0.4-4.3) and TVR (RR = 1.46; 95% CI = 0.9-2.3) after deferral of revascularization based on FFR between ACS and non-ACS patients. Such deferral was associated with significant additional risk of MI (RR = 1.83; 95% CI = 1.4-2.4) in ACS patients. CONCLUSION: The prognostic value of FFR in ACS setting is not as good as in stable patients. The results demonstrate an increased risk of MI but not of mortality, CV mortality, and TVR in ACS patients.


Assuntos
Síndrome Coronariana Aguda , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/fisiopatologia , Síndrome Coronariana Aguda/cirurgia , Humanos , Revascularização Miocárdica/métodos , Revascularização Miocárdica/mortalidade , Prognóstico , Medição de Risco , Fatores de Tempo , Tempo para o Tratamento
14.
Eur Heart J ; 39(45): 4030-4039, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30101326

RESUMO

Aims: Evidence suggests an excess risk of non-thromboembolic major adverse cardiac events (MACE) associated with atrial fibrillation (AF), particularly in individuals free of overt coronary artery disease (CAD). Metabolic syndrome (MetS) increases cardiovascular risk in the general population, but less is known how it influences outcomes in AF patients. We aimed to assess whether MetS affects the risk of MACE in AF patients without overt CAD. Methods and results: This prospective, observational study enrolled 843 AF patients (mean-age, 62.5 ± 12.1 years, 38.6% female) without overt CAD. Metabolic syndrome was defined according to the National Cholesterol Education Program. The 5-year composite MACE included myocardial infarction (MI), coronary revascularization, and cardiac death. Metabolic syndrome was present in 302 (35.8%) patients. At 5-year follow-up, 118 (14.0%) patients experienced MACE (2.80%/year). Metabolic syndrome conferred a multivariable adjusted hazard ratio (aHR) of 1.98 for MACE [95% confidence interval (CI), 1.23-3.16; P = 0.004], and for individual outcomes: MI (aHR, 2.00; 95% CI, 1.69-5.11; P < 0.001), revascularization (aHR, 2.33; 95% CI, 1.40-3.87; P = 0.001), and cardiac death (aHR, 2.59; 95% CI, 1.25-5.33; P = 0.011). Following the propensity score (PS)-adjustment for MetS, the association between MetS and MACE (PS-aHR, 1.87; 95% CI, 1.21-3.01; P = 0.012), MI (PS-aHR, 1.72; 95% CI, 1.54-5.00; P = 0.008), revascularization (PS-aHR, 2.18; 95% CI, 1.69-3.11; P = 0.015), and cardiac death (PS-aHR, 2.27; 95% CI, 1.14-5.11; P = 0.023) remained significant. Conclusion: Metabolic syndrome is common in AF patients without overt CAD, and confers an independent, increased risk of MACE, including MI, coronary revascularization, and cardiac death. Given its prognostic implications, prevention and treatment of MetS may reduce the burden of non-thromboembolic complications in AF.


Assuntos
Fibrilação Atrial , Síndrome Metabólica , Infarto do Miocárdio , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/mortalidade , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Síndrome Metabólica/complicações , Síndrome Metabólica/epidemiologia , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Revascularização Miocárdica/mortalidade , Estudos Prospectivos , Fatores de Risco
15.
J Am Heart Assoc ; 7(13)2018 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-29960995

RESUMO

BACKGROUND: There is limited information about the long-term survival of older patients after myocardial infarction (MI). METHODS AND RESULTS: CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long-term mortality (defined as 8 years post index event). Long-term unadjusted Kaplan-Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post-MI was conducted. We used multivariable Cox regression to compare mortality risks between ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence-based medication use at discharge: aspirin 95%, ß-blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight-year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post-MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65-74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight-year mortality was lower among ST-segment-elevation myocardial infarction than non-ST-segment-elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88-1.00). CONCLUSIONS: Long-term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Revascularização Miocárdica/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fármacos Cardiovasculares/efeitos adversos , Feminino , Humanos , Masculino , Medicare , Revascularização Miocárdica/efeitos adversos , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
16.
Int J Cardiol ; 270: 107-112, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29937300

RESUMO

BACKGROUND: FFR-guided coronary intervention is recommended for patients with intermediate stenoses. However, concerns exist with this approach in anatomically prognostic disease. METHODS: In this prospective, multicentre study, we consecutively enrolled patients found to have FFR negative lesions in anatomically significant sites: left main; proximal LAD; last remaining patent vessel; and multiple vessels with concomitant impaired left ventricular systolic function (EF < 40%). As per recommendation, revascularisation was deferred, and patients included into a registry. The primary endpoint was MACE (death, myocardial infarction and unplanned target lesion revascularization). Secondary endpoints were the above individual components. Subgroup analyses were performed for clinical presentation (stable vs. ACS), localization of lesion (ostial vs. non ostial) and renal function. RESULTS: The registry included 292 patients with 297 deferred stenoses. After 1-year, the primary endpoint occurred in 5% of patients, mainly driven by TLR (2.7%). Cardiovascular death occurred in 0.8% and AMI in 0.8%. During a follow-up of 22.2 ±â€¯11 months, MACE occurred in 11.6%. Cardiovascular death occurred in 1.8% and AMI in 2.1%. After multivariate analysis, impaired renal function (OR 1.99; CI 95% 1.74-5.41; p = 0.046) and ostial disease (OR 2.88; CI 95% 1.04-7.38; p = 0.041) were found to be predictors of MACE. Impaired renal function also predicted TLR (OR 2.43; CI 95% 1.17-5.02; p = 0.017). CONCLUSION: FFR-guided revascularisation deferral is safe in the majority of anatomically prognostic disease. However, further evaluation is required in the risk stratification of those patients with ostial disease and renal disease. Registered on ClinicalTrials, NCT02590926.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Revascularização Miocárdica/métodos , Idoso , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Prognóstico , Estudos Prospectivos , Sistema de Registros , Taxa de Sobrevida/tendências
17.
Circ Cardiovasc Interv ; 11(3): e006000, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29870384

RESUMO

BACKGROUND: Coronary artery disease (CAD) is highly prevalent in patients undergoing transcatheter aortic valve replacement. In the overall CAD population, complete revascularization or reasonable incomplete revascularization (ICR) is associated with improved outcomes; whether the same applies for the transcatheter aortic valve replacement population is still a matter of debate. METHODS AND RESULTS: We conducted a systematic review and meta-analysis of studies that examined the prognostic effect of revascularization completeness in patients undergoing transcatheter aortic valve replacement using the residual SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) to separate between reasonable ICR and ICR (using the individual threshold used by each study). Six studies with a total of 3107 patients were included. The duration of follow-up ranged from 0.7 to 3 years. Overall, ICR was associated with an increased risk for mortality. This was true when comparing ICR patients to those with no CAD (odds ratio, 1.85; 95% confidence interval, 1.42-2.40; P<0.01), to those with reasonable ICR (odds ratio, 1.69; 95% confidence interval, 1.26-2.28; P<0.001), or to both groups combined (odds ratio, 1.71; 95% confidence interval, 1.36-2.16; P<0.001). On the contrary, patients in the reasonable ICR category did not show an increased risk for mortality when compared with those with no CAD (odds ratio, 1.11; 95% confidence interval, 0.89-1.39; P=0.33). CONCLUSIONS: Our results suggest that for patients with CAD undergoing transcatheter aortic valve replacement, a residual SYNTAX score-guided revascularization strategy may carry significant benefits in terms of mortality. Adequate revascularization may offer a unique and valuable opportunity to improve the prognosis of these patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Doença da Artéria Coronariana/cirurgia , Revascularização Miocárdica , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Comorbidade , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Humanos , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Prevalência , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
18.
Braz J Cardiovasc Surg ; 33(2): 135-142, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29898142

RESUMO

OBJECTIVE: The aim of this study was to evaluate early clinical outcomes and echocardiographic measurements of the left ventricle in patients who underwent left ventricular aneurysm repair using two different techniques associated to myocardial revascularization. METHODS: Eighty-nine patients (74 males, 15 females; mean age 58±8.4 years; range: 41 to 80 years) underwent post-infarction left ventricular aneurysm repair and myocardial revascularization performed between 1996 and 2016. Ventricular reconstruction was performed using endoventricular circular patch plasty (Dor procedure) (n=48; group A) or linear repair technique (n=41; group B). RESULTS: Multi-vessel disease in 55 (61.7%) and isolated left anterior descending (LAD) disease in 34 (38.2%) patients were identified. Five (5.6%) patients underwent aneurysmectomy alone, while the remaining 84 (94.3%) patients had aneurysmectomy with bypass. The mean number of grafts per patient was 2.1±1.2 with the Dor procedure and 2.9±1.3 with the linear repair technique. In-hospital mortality occurred in 4.1% and 7.3% in group A and group B, respectively (P>0.05). CONCLUSION: The results of our study demonstrate that post-infarction left ventricular aneurysm repair can be performed with both techniques with acceptable surgical risk and with satisfactory hemodynamic improvement.


Assuntos
Aneurisma Cardíaco/cirurgia , Ventrículos do Coração/cirurgia , Revascularização Miocárdica/métodos , Idoso , Ponte de Artéria Coronária/métodos , Ecocardiografia , Feminino , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/mortalidade , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Volume Sistólico/efeitos da radiação , Fatores de Tempo , Resultado do Tratamento
19.
Circ J ; 82(8): 2136-2142, 2018 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-29899202

RESUMO

BACKGROUND: We investigated whether the outcome of revascularization differed from the outcome of medical therapy in chronic kidney disease (CKD) and non-CKD patients with chronic total occlusion (CTO).Methods and Results:A total of 2,010 patients with CTO who underwent revascularization (n=1,355), including percutaneous coronary intervention (n=878) and coronary artery bypass grafting (n=477), or had medical therapy alone (n=655) were examined. The primary outcome was all-cause death during follow-up. Among the non-CKD patients (n=1,679), revascularization had a lower incidence of all-cause death (adjusted hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.41-0.72, P<0.001) compared with medical therapy. Among the CKD patients (n=331), the difference in the incidence of all-cause death was not as marked between the 2 treatments (adjusted HR 0.71, 95% CI 0.48-1.06, P=0.09). There was a significant interaction between kidney function and treatment strategy (revascularization vs. medical therapy) on all-cause death (P for interaction=0.014). CONCLUSIONS: Based on the clinical outcomes, in CTO patients with preexisting CKD, revascularization via PCI or bypass surgery might not be as effective as in non-CKD patients.


Assuntos
Ponte de Artéria Coronária/métodos , Oclusão Coronária/terapia , Revascularização Miocárdica/tendências , Intervenção Coronária Percutânea/métodos , Insuficiência Renal Crônica/complicações , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Oclusão Coronária/tratamento farmacológico , Oclusão Coronária/etiologia , Oclusão Coronária/cirurgia , Feminino , Fármacos Hematológicos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Resultado do Tratamento
20.
Cardiovasc Revasc Med ; 19(6): 647-654, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29909948

RESUMO

BACKGROUND: The optimal revascularization strategy in patients with multi-vessel disease (MVD) presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remains unclear. OBJECTIVE: To investigate the comparative differences between culprit-only revascularization (COR) versus instant multi-vessel revascularization (IMVR) in AMI and CS. METHODS: 13 studies were selected using MEDLINE, EMBASE and the CENTRAL (Inception - 31 November2017). Outcomes were assessed at short-term (in-hospital or ≤30 days duration) and long-term duration (≥6 months). Estimates were reported as random effects relative risk (RR) with 95% confidence interval (CI). RESULTS: In analysis of 7311 patients, COR significantly reduced the relative risk of short-term all-cause mortality (RR: 0.87; 95% CI, 0.77-0.97; p = 0.01, I2 = 50%) and renal failure (RR: 0.75; 95% CI, 0.61-0.94; p = 0.01, I2 = 7%) compared with IMVR. There were no significant differences between both the strategies in terms of reinfarction (RR: 1.25; 95% CI, 0.59-2.63; p = 0.56, I2 = 0%), major bleeding (RR: 0.88; 95% CI, 0.75-1.04; p = 0.14, I2 = 0%) and stroke (RR: 0.77; 95% CI, 0.50-1.17; p = 0.22, I2 = 0%) at short term duration. Similarly, no significant differences were observed between both groups regarding all-cause mortality (RR; 1.01; 95% CI, 0.85-1.20; p = 0.93, I2 = 61%) and reinfarction (RR: 0.71; 95% CI, 0.34-1.47; p = 0.35, I2 = 26%) at long term duration. CONCLUSION: In MVD patients presenting with AMI and CS, IMVR was comparable to COR in terms of all-cause mortality at long term follow up duration. These results are predominantly derived from observational data and more randomized controlled trials are required to validate this impression.


Assuntos
Infarto do Miocárdio/terapia , Revascularização Miocárdica/métodos , Choque Cardiogênico/terapia , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Recidiva , Insuficiência Renal/etiologia , Insuficiência Renal/mortalidade , Insuficiência Renal/fisiopatologia , Medição de Risco , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
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