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BACKGROUND: In the BARI 2D trial, patients with type 2 diabetes and stable coronary artery disease were randomized to prompt revascularization versus intensive medical therapy (IMT). This analysis sought to evaluate how the availability of drug-eluting stents (DESs) has changed practice and outcomes. METHODS: In BARI 2D, 1,605 patients were in the percutaneous coronary intervention (PCI)-intended stratum. As DES became available midway through recruitment, we report clinical outcomes among patients who underwent IMT versus prompt PCI with bare-metal stents (BMSs) or DES up to 4 years. RESULTS: In North America, after DES became available, selection for the PCI-intended stratum increased from 73% to 79% (P = .003). Fewer BMS than DES patients had total occlusions treated or underwent rotational atherectomy (5.6% vs 9.7%, P = .02, and 1.2% vs 3.7%, P < .01, respectively). Subsequent revascularization (IMT 39%, BMS 29%, DES 21%, P < .01) and target vessel revascularization (BMS 16.1% vs DES 9.6%, P = .03) were lower with DES. Angina at 2 years tended to be less common with DES (IMT 39%, BMS 37%, DES 29%, P = .04, for 3 groups, P = .07 for DES vs BMS). The composite of death, myocardial infarction, or stroke was IMT 16.0%, BMS 20.5%, DES 17.5%; P = .80. CONCLUSIONS: When DES became available in North America, patients were more likely to be selected into the PCI-intended stratum. Compared with patients receiving BMS, those receiving DES tended to have less target vessel revascularization and angina.
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Angioplastia Coronária com Balão/métodos , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Diabetes Mellitus Tipo 2/complicações , Stents Farmacológicos/efeitos adversos , Infarto do Miocárdio/etiologia , Seleção de Pacientes , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Prior trials suggest it is safe to defer transfusion at hemoglobin levels above 7 to 8 g/dL in most patients. Patients with acute coronary syndrome may benefit from higher hemoglobin levels. METHODS: We performed a pilot trial in 110 patients with acute coronary syndrome or stable angina undergoing cardiac catheterization and a hemoglobin <10 g/dL. Patients in the liberal transfusion strategy received one or more units of blood to raise the hemoglobin level ≥10 g/dL. Patients in the restrictive transfusion strategy were permitted to receive blood for symptoms from anemia or for a hemoglobin <8 g/dL. The predefined primary outcome was the composite of death, myocardial infarction, or unscheduled revascularization 30 days post randomization. RESULTS: Baseline characteristics were similar between groups except age (liberal, 67.3; restrictive, 74.3). The mean number of units transfused was 1.6 in the liberal group and 0.6 in the restrictive group. The primary outcome occurred in 6 patients (10.9%) in the liberal group and 14 (25.5%) in the restrictive group (risk difference = 15.0%; 95% confidence interval of difference 0.7% to 29.3%; P = .054 and adjusted for age P = .076). Death at 30 days was less frequent in liberal group (n = 1, 1.8%) compared to restrictive group (n = 7, 13.0%; P = .032). CONCLUSIONS: The liberal transfusion strategy was associated with a trend for fewer major cardiac events and deaths than a more restrictive strategy. These results support the feasibility of and the need for a definitive trial.
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Transfusão de Sangue/métodos , Doença da Artéria Coronariana/terapia , Tomada de Decisões , Hemoglobinas/metabolismo , Cateterismo Cardíaco , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Eletrocardiografia , Seguimentos , Humanos , Incidência , Projetos Piloto , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
Adequate vitamin D levels may promote cardiovascular health by improving endothelial function and down-regulating inflammation. The objective of this pilot trial was to investigate the effects of vitamin D repletion on endothelial function and inflammation in patients with coronary artery disease (CAD). Using a double-blind placebo wait-list control design, 90 subjects with CAD and vitamin D deficiency (< 20 ng/ml) were randomized 1:1 to 50,000 IU of oral ergocalciferol or placebo weekly for 12 weeks. Endothelial function (reactive hyperemia peripheral arterial tonometry, RH-PAT), circulating adhesion molecules, and pro-inflammatory cytokines were measured at baseline and 12 weeks. The median increase in serum 25-vitamin D from baseline was 26 ± 17 ng/ml in the active group and 4 ± 8 ng/ml in the placebo group (between-group difference = 22 ng/ml, p < 0.001). The median within-subject change in RH-PAT score was 0.13 ± 0.73 with active treatment and -0.04 ± 0.63 with placebo (between-group difference = 0.17, p = 0.44). Within-group and between-group differences in intercellular adhesion molecule levels were greater with placebo (between-group difference = 6 ng/ml, p = 0.048). Vascular cell adhesion molecule levels decreased in both groups by a similar magnitude (median difference between groups = 8.5 ng/ml, p = 0.79). There was no difference between groups in magnitude of reduction in interleukin (IL)-12 (-8.6 ng/ml, p = 0.72) and interferon-gamma (0.52 ng/ml, p = 0.88). No significant differences in blood pressure, e-selectin, high-sensitivity c-reactive protein, IL-6 or the chemokine CXCL-10 were found with treatment. In conclusion, repleting vitamin D levels in subjects with CAD failed to demonstrate any benefits on surrogate markers of cardiovascular health. These results question the role of vitamin D supplementation in modifying cardiovascular disease.
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Doença da Artéria Coronariana/tratamento farmacológico , Endotélio Vascular/efeitos dos fármacos , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/uso terapêutico , Adulto , Idoso , Biomarcadores/sangue , Moléculas de Adesão Celular/metabolismo , Doença da Artéria Coronariana/complicações , Suplementos Nutricionais/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Hiperemia/metabolismo , Inflamação/complicações , Inflamação/tratamento farmacológico , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Patients with diabetes mellitus (DM) are at higher risk for adverse outcomes following percutaneous coronary intervention (PCI). METHODS: To determine whether outcomes have improved over time, we analyzed data from 2,838 consecutive patients with medically treated DM, including 1,066 patients (37.6%) treated with insulin, in the National Heart, Lung, and Blood Institute Dynamic Registry undergoing PCI registered in waves 1 (1997-1998), 2 (1999), 3 (2001-2002), 4 (2004), and 5 (2006). We compared baseline demographics and 1-year outcomes in the overall cohort and in analyses stratified by recruitment wave and insulin use. RESULTS: Crude mortality rates by chronological wave were 9.5%, 12.5%, 8.9%, 11.6%, and 6.6% (P value(trend) = .33) among those treated with insulin and, respectively, 9.7%, 6.5%, 4.1%, 5.4%, and 4.7% (P value(trend) = .006) among patients treated with oral agents,. The adjusted hazard ratios of death, myocardial infarction (MI), and overall major adverse cardiovascular events (death, MI, revascularization) in insulin-treated patients with DM in waves 2 to 5 as compared with wave 1 were either higher or the same. In contrast, the similar adjusted hazard ratios for oral agent-treated patients with DM were either similar or lower. CONCLUSIONS: Significant improvements over time in adverse events by 1 year were detected in patients with DM treated with oral agents. In insulin-treated diabetic patients, despite lower rates of repeat revascularization over time, death and MI following PCI have not significantly improved. These findings underscore the need for continued efforts at optimizing outcomes among patients with DM undergoing PCI, especially those requiring insulin treatment.
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Angioplastia Coronária com Balão , Doença da Artéria Coronariana/terapia , Diabetes Mellitus/tratamento farmacológico , Angiopatias Diabéticas/terapia , Idoso , Complicações do Diabetes/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Hyperglycaemia occurs frequently in ST-elevation myocardial infarction (STEMI) and is associated with poor outcomes, for which continuous insulin infusion therapy (CIIT) may be beneficial. Information is limited regarding hyperglycaemia in acute STEMI affecting urban minority populations, or how CIIT fares in such real-world settings. METHODS AND RESULTS: We assembled an acute STEMI registry at an inner-city health system, focusing on patients with initial blood glucose ≥180 mg/dL to determine the impact of CIIT vs usual care. Clinical and outcomes data were added through linkage to electronic records. Inverse-probability-of-treatment weighting using propensity scores (PS) was used to compare CIIT vs no CIIT. The 1067 patients included were mostly Hispanic or African American; 356 had blood glucose ≥180 mg/dL. Such pronounced hyperglycaemia was related to female sex, minority race-ethnicity and lower socioeconomic score, and associated with increased death and death or CVD readmission. CIIT was preferentially used in patients with marked hyperglycaemia and was associated with in-hospital hypoglycaemia (21% vs 11%, P = .019) and, after PS weighting, with increased in-hospital (RR 3.23, 95% CI 0.94, 11.06) and 1-year (RR 2.26, 95% CI 1.02, 4.98) mortality. No significant differences were observed for death at 30 days or throughout follow-up, or death and readmission at any time point. CONCLUSIONS: Pronounced hyperglycaemia was common and associated with adverse prognosis in this urban population. CIIT met with selective use and was associated with hypoglycaemia, together with increased mortality at specific time points. Given the burden of metabolic disease, particularly among race-ethnic minorities, assessing the benefits of CIIT is a prerogative that requires evaluation in large-scale randomized trials.
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BACKGROUND: In the Occluded Artery Trial (OAT), 2,201 stable patients with an occluded infarct-related artery (IRA) were randomized to percutaneous coronary intervention (PCI) or optimal medical treatment alone (MED). There was no difference in the primary end point of death, reinfarction, or congestive heart failure (CHF). We examined the prognostic impact of prerandomization stress testing. METHODS: Stress testing was required by protocol except for patients with single-vessel disease and akinesis/dyskinesis of the infarct zone. The presence of severe inducible ischemia was an exclusion criterion for OAT. We compared outcomes based on performance and results of stress testing. RESULTS: Five hundred ninety-eight (27%) patients (297 PCI, 301 MED) underwent stress testing. Radionuclide imaging or stress echocardiography was performed in 40%. Patients who had stress testing were younger (57 vs 59 years); had higher ejection fractions (49% vs 47%); and had lower rates of death (7.8% vs 13.2%), class IV CHF (2.4% vs 5.5%), and the primary end point (13.9% vs 18.9%) than patients without stress testing (all P < .01). Mild-moderate ischemia was observed in 40% of patients with stress testing and was not related to outcomes. Among patients with inducible ischemia, outcomes were similar for PCI and MED (all P > .10). CONCLUSIONS: In OAT, patients who underwent stress testing had better outcomes than patients who did not, likely related to differences in baseline characteristics. In patients managed with optimal medical therapy or PCI, mild-moderate inducible ischemia was not related to outcomes. The lack of benefit for PCI compared to MED alone was consistent regardless of whether stress testing was performed or inducible ischemia was present.
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Angioplastia Coronária com Balão/métodos , Reestenose Coronária/diagnóstico , Teste de Esforço/métodos , Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/terapia , Reestenose Coronária/etiologia , Reestenose Coronária/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
Background Although admission heart rate predicts higher mortality after acute myocardial infarction ( AMI ), less is known about discharge heart rate. We tested the hypothesis that higher discharge heart rate after AMI is related to increased long-term mortality independent of admission heart rate, and assessed whether ß blockers modify this relationship. Methods and Results In 2 prospective US multicenter registries of AMI , we evaluated the associations of discharge and admission heart rate with 3-year mortality using Cox models. Among 6576 patients with AMI , discharge heart rate was modestly associated with initial heart rate ( r=0.28), comorbidities, and infarct severity. In this cohort, 10.7% did not receive ß blockers at discharge. After full adjustment for demographic, psychosocial, and clinical covariates, discharge heart rate (hazard ratio [HR]=1.14 per 10 beats per minute [bpm]; 95% CI =1.07-1.21 per 10 bpm) was more strongly associated with risk of death than admission heart rate (HR=1.05 per 10 bpm; 95% CI=1.02-1.09 per 10 bpm) when both were entered in the same model ( P=0.043 for comparison). There was a significant interaction between discharge heart rate and ß-blocker use ( P=0.004) on mortality, wherein risk of death was markedly higher among those with high discharge heart rate and not on ß blockers (HR=1.35 per 10 bpm; 95% CI=1.19-1.53 per 10 bpm) versus those with a high discharge heart rate and on ß blockers at discharge (HR=1.10 per 10 bpm; 95% CI=1.03-1.17 per 10 bpm). Conclusions Higher discharge heart rate after AMI was more strongly associated with 3-year mortality than admission heart rate, and the risk associated with higher discharge heart rate was modified by ß blockers at discharge. These findings highlight opportunities for risk stratification and intervention that will require further investigation.
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Frequência Cardíaca/fisiologia , Infarto do Miocárdio/mortalidade , Alta do Paciente/tendências , Sistema de Registros , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Previous risk scores have shown excellent performance. However, the need for real-time risk score computation makes their implementation in an emergent situation challenging. A more simplified approach can provide practitioners with a practical bedside risk stratification tool. METHODS: We developed an easy-to-use tree-structured risk stratification model for patients undergoing early percutaneous coronary intervention (PCI) for acute myocardial infarction. The model was developed on the New York State PCI database for 1999 to 2000 (consisting of 5385 procedures) and was validated using the subsequent 2001 to 2002 database (consisting of 7414 procedures). RESULTS: Tree-structured modeling identified 3 key presenting features: cardiogenic shock, congestive heart failure, and age. In the validation data set, this risk stratification model identified patient groups with in-hospital mortality ranging from 0.5% to 20.6%, more than a 20-fold increased risk. The performance of this model was similar to the Mayo Clinic Risk Score with a discriminative capacity of 82% (95% confidence interval, 79%-84%) versus 80% (95% confidence interval, 77%-82%), respectively. CONCLUSION: Patients undergoing PCI for acute myocardial infarction can be readily stratified into risk categories using the tree-structured model. This provides practicing cardiologists with an internally validated and easy-to-use scheme for in-hospital mortality risk stratification.
Assuntos
Angioplastia Coronária com Balão/mortalidade , Infarto do Miocárdio/terapia , Medição de Risco , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Infarto do Miocárdio/mortalidade , New YorkRESUMO
Patients undergoing primary angioplasty in clinical practice experience a higher risk for adverse events than those enrolled in clinical trials. Whether glycoprotein (GP) IIb/IIIa inhibitor use during primary angioplasty is both safe and effective in real life is unknown. Therefore, we examined the pattern of GP IIb/IIIa use and its effectiveness in a large population-based cohort of 7,321 patients who underwent primary angioplasty in New York State. Propensity analysis was used to account for the nonrandomized use of GP IIb/IIIa inhibitors. Overall, 78.5% of patients who underwent primary angioplasty received GP IIb/IIIa inhibitors. In-hospital mortality was significantly lower with GP IIb/IIIa use (3% vs 6.2%, p <0.0001) after adjustment for both propensity score (odds ratio 0.57, 95% confidence interval 0.44 to 0.74, p <0.0001) and the combination of propensity score and clinical characteristics (odds ratio 0.63, 95% confidence interval 0.45 to 0.88, p = 0.006). Patients with older age and higher Mayo Clinic Risk Score (MCRS) received GP IIb/IIIa inhibitors less often. However, stratified analysis of patients with low to moderate risk (MCRS <12) versus high risk (>or=12) demonstrated that GP IIb/IIIa use lowered risk of mortality both in low- to moderate-risk (1.39% vs 3.23%, p <0.0001) and high-risk patients (16.15% vs 22.41%, p = 0.03). In conclusion, adjunct GP IIb/IIIa inhibitor use during primary angioplasty is effective and associated with improved in-hospital survival rates.
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Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Idoso , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , New York , Medição de Risco , Resultado do TratamentoAssuntos
Benchmarking/normas , Cateterismo Cardíaco/normas , Angiografia Coronária/normas , Laboratórios/normas , Intervenção Coronária Percutânea/normas , Certificação/normas , Lista de Checagem/normas , Competência Clínica/normas , Consenso , Humanos , Padrões de Prática Médica/normas , Indicadores de Qualidade em Assistência à Saúde/normasRESUMO
Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or ß blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.
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Transtornos Relacionados ao Uso de Cocaína/complicações , Cocaína/efeitos adversos , Eletrocardiografia/efeitos dos fármacos , Infarto do Miocárdio/induzido quimicamente , Sistema de Registros , População Urbana , Adulto , Idoso , Transtornos Relacionados ao Uso de Cocaína/epidemiologia , Inibidores da Captação de Dopamina/efeitos adversos , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Cidade de Nova Iorque/epidemiologia , Estudos Prospectivos , Fatores de Risco , Fatores de TempoAssuntos
Angioplastia Coronária com Balão , Circulação Coronária , Oclusão Coronária/fisiopatologia , Oclusão Coronária/terapia , Angioplastia Coronária com Balão/história , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/normas , Doença Crônica , Ponte de Artéria Coronária/normas , Oclusão Coronária/tratamento farmacológico , História do Século XX , História do Século XXI , Humanos , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this study was to compare the short-term outcomes of robotic with conventional on-pump coronary artery bypass grafting (CABG). METHODS: The study population included 2091 consecutive patients who underwent either conventional or robotic CABG from January 2007 to March 2012. Preoperative, intraoperative, and 30-day postoperative variables were collected for each group. To compare the incidence of rapid recovery between conventional and robotic CABG, the surrogate variables of early discharge and discharge to home (vs rehabilitation or acute care facility) were evaluated. A multivariate logistic regression analysis was used. RESULTS: One hundred fifty robotic and 1619 conventional CABG cases were analyzed. Multivariate logistic regression analysis demonstrated that robotic surgery was a strong predictor of lower 30-day complications [odds ratio (OR), 0.24; P = 0.005], short length of stay (OR, 3.31; P < 0.001), and decreased need for an acute care facility (OR, 0.55; P = 0.032). In the presence of complications (New York State Complication Composite), the robotic technique was not associated with a change in discharge status. CONCLUSIONS: In this retrospective review, robotic CABG was associated with a lower 30-day complication rate, a shorter length of stay, and a lower incidence of acute care facility discharge than conventional on-pump CABG. It may suggest a more rapid recovery to preoperative status after robotic surgery; however, only a randomized prospective study could confirm the advantages of a robotic approach.
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Ponte de Artéria Coronária/métodos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Robóticos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New York , Casas de Saúde/estatística & dados numéricos , Recuperação de Função Fisiológica , Estudos RetrospectivosRESUMO
Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.
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Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/patologia , Intervenção Coronária Percutânea/mortalidade , Idoso , Estudos de Coortes , Comorbidade , Vasos Coronários/cirurgia , Efeitos Psicossociais da Doença , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , National Heart, Lung, and Blood Institute (U.S.) , Sistema de Registros , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Spontaneous coronary artery dissection is an important yet rare cause of acute coronary syndrome. The available literature shows a higher risk factor for women, notably during pregnancy and puerperium. The incidence in postmenopausal women is exceedingly rare, and is more commonly seen in association with concurrent predisposing factors.We illustrate an extremely rare case of a 62-year-old post-menopausal woman presenting with an acute myocardial infarction secondary to spontaneous dissection of the left anterior descending artery. Subsequent investigations did not reveal the presence of any co-morbidities.To the best of our knowledge, our patient is one of the oldest documented cases of spontaneous coronary artery dissection on record, and is notable for having no known underlying risk factors for development of spontaneous coronary artery dissection.Given the paucity of literature on spontaneous coronary artery dissection, particularly in postmenopausal women, we believe this case will provide further insight into the clinical presentation and management of this rare entity. CASE PRESENTATION: A 62-year-old previously healthy postmenopausal Hispanic woman presented with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. Revascularization was deferred; our patient received appropriate medical management and remained asymptomatic. A full panel of tests was done to exclude underlying connective tissue disorders and vasculitis. On subsequent follow-up, our patient continued to do well and all work-up was reported as negative. CONCLUSION: We describe the varied presentation and subsequent management of a case of spontaneous coronary artery dissection and highlight the importance of considering spontaneous coronary artery dissection as a differential diagnosis even in older, postmenopausal women.The consequences of a delay in diagnosis and appropriate management are associated with a high mortality and morbidity; hence we believe that reporting all cases of spontaneous coronary artery dissection, particularly in postmenopausal women, will add invaluable information to the limited literature on this rare condition.
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AIMS: Most studies investigating completeness of revascularisation and outcomes for multivessel disease (MVD) patients are limited by small sample size. METHODS AND RESULTS: We searched PUBMED, Cochrane and EMBASE for studies comparing outcomes of MVD patients with complete revascularisation (CR) vs. incomplete revascularisation (IR) in the stent era. We identified nine studies that met our selection criteria. Compared to IR, patients undergoing CR had significantly lower risk of mortality (relative risk (RR): 0.82; 95% confidence interval (CI): 0.68-0.99; p=0.05), non-fatal myocardial infarction (MI) (RR: 0.67; 95% CI: 0.53-0.84; p <0.01) and subsequent coronary artery bypass graft surgery (CABG) (RR: 0.70; 95% CI: 0.52-0.95; p=0.02) whereas no difference was noted in the incidence of repeat percutaneous coronary intervention (PCI) (RR: 0.87; 95% CI: 0.69-1.11; p=0.28). Average weighted follow up was approximately 29 months for mortality, subsequent CABG and Repeat PCI whereas it was 19 months for non-fatal MI. The results were similar after excluding the only RCT or the one study restricted to diabetics or the study restricted to drug-eluting stent use. CONCLUSIONS: In patients with multivessel coronary disease, complete revascularisation with PCI may be associated with better outcomes than incomplete revascularisation.
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Angioplastia Coronária com Balão/métodos , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.
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Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/métodos , Angioplastia Coronária com Balão , Ponte de Artéria Coronária/tendências , Previsões , Humanos , Procedimentos Cirúrgicos Minimamente InvasivosRESUMO
BACKGROUND: Previous studies have demonstrated that patients with COPD are at higher risk for death after percutaneous coronary intervention (PCI), but other clinical outcomes and possible associations with adverse events have not been described. METHODS: Using waves 1 through 5 (1999-2006) of the National Heart, Lung, and Blood Institute Dynamic Registry, patients with COPD (n = 860) and without COPD (n = 10,048) were compared. Baseline demographics, angiographic characteristics, and in-hospital and 1-year adverse events were compared. RESULTS: Patients with COPD were older (mean age 66.8 vs 63.2 years, P < .001), more likely to be women, and more likely to have a history of diabetes, prior myocardial infarction, peripheral arterial disease, renal disease, and smoking. Patients with COPD also had a lower mean ejection fraction (49.1% vs 53.0%, P < .001) and a greater mean number of significant lesions (3.2 vs 3.0, P = .006). Rates of in-hospital death (2.2% vs 1.1%, P = .003) and major entry site complications (6.6% vs 4.2%, P < .001) were higher in pulmonary patients. At discharge, pulmonary patients were significantly less likely to be prescribed aspirin (92.4% vs 95.3%, P < .001), ß-blockers (55.7% vs 76.2%, P < .001), and statins (60.0% vs 66.8%, P < .001). After adjustment, patients with COPD had significantly increased risk of death (hazard ratio [HR] = 1.30, 95% CI = 1.01-1.67) and repeat revascularization (HR = 1.22, 95% CI = 1.02-1.46) at 1 year, compared with patients without COPD. CONCLUSIONS: COPD is associated with higher mortality rates and repeat revascularization within 1 year after PCI. These higher rates of adverse outcomes may be associated with lower rates of guideline-recommended class 1 medications prescribed at discharge.
Assuntos
Angioplastia Coronária com Balão , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Idoso , Comorbidade , Angiografia Coronária , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica/estatística & dados numéricos , National Heart, Lung, and Blood Institute (U.S.) , Avaliação de Resultados em Cuidados de Saúde , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Sistema de Registros , Retratamento , Volume Sistólico , Estados UnidosRESUMO
BACKGROUND: The Occluded Artery Trial (OAT) was a large, randomized controlled trial published in 2006 that demonstrated no benefit to routine percutaneous coronary intervention (PCI) of persistently totally occluded infarct-related arteries (IRA) identified a minimum of 24 hours (on calendar days 3-28) after myocardial infarction (MI). The purpose of this study was to determine the impact of OAT results and consequent change in guideline recommendations for PCI for treatment of persistently occluded IRAs. METHODS: We identified all patients enrolled in the CathPCI Registry, from 2005 to 2008, undergoing catheterization more than 24 hours after MI with a totally occluded native coronary artery and no major OAT exclusion criteria. We examined trends in monthly rates of PCI for occlusions after OAT publication and after guideline revisions. Because reporting of diagnostic catheterizations was not mandatory, we examined trends among hospitals in the highest quartile for reporting of diagnostic procedures. RESULTS: A total of 28,780 patient visits from 896 hospitals were included. Overall, we found no significant decline in the adjusted monthly rate of PCI of occlusions after publication of OAT (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.989-1.006) or after guideline revisions (OR, 1.007; 95% CI, 0.992-1.022). Among hospitals consistently reporting diagnostic catheterizations, there was no significant decline after OAT publication (OR, 1.018; 95% CI, 0.995-1.042), and there was a trend toward decline after guideline revisions (OR, 0.963; 95% CI, 0.920-1.000). CONCLUSION: These findings suggest that the results of OAT and consequent guideline revisions have not, to date, been fully incorporated into clinical practice in a large cross-section of hospitals in the United States.