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Redfors B, Spertus JA, Yancy C, Masterson-Creber R, Stone GW, Gaudino MFL. Expanding revascularization trials to women and underserved minorities and shifting to patient-centered outcomes: RECHARGE trials program. Curr Opin Cardiol 2024; 39:478-484. [PMID: 39254647 DOI: 10.1097/hco.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
PURPOSE OF REVIEW We review the limited available evidence informing coronary revascularization decisions in women and minorities, and introduce the RECHARGE trial program, which consists of two separate but integrated parallel multicenter, randomized trials comparing coronary artery bypass grafting (CABG) to percutaneous coronary intervention (PCI), one exclusively enrolling women (RECHARGE:Women) and one exclusively enrolling Black or Hispanic patients (RECHARGE:Minorities). RECENT FINDINGS The extensive evidence base supporting coronary revascularization suffers from under-representation of women, minorities and minoritized populations, and the use of heterogeneous primary composite outcomes whose components have varying strengths of association with prognosis and quality-of-life (QOL). In RECHARGE, participants will be followed for up to 10 years, with QOL assessments at baseline, 30 days, 3 months, every 6 months for 3 years, and annually thereafter. The primary endpoint is the hierarchical composite of time to all-cause mortality, time-averaged change from baseline in the physical component of the SF-12v2 physical summary score, and time-averaged change from baseline in the mental component of the SF12v2 summary score, evaluated using a win ratio. Independently adjudicated major adverse cardiovascular and noncardiovascular events and disease-specific QoL will be secondary endpoints. SUMMARY The RECHARGE trials are the first revascularization trials to enroll exclusively women and minority patients and to use patient-centered outcomes as their primary outcome.
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Affiliation(s)
- Bjorn Redfors
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Population Health Sciences, Weill Cornell Medicine, New York
| | - John A Spertus
- University of Missouri - Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City
| | - Clyde Yancy
- Northwestern University, Feinberg School of Medicine, Evanston, Illinois
| | | | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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2
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Fujimoto Y, Sakakura K, Jinnouchi H, Taniguchi Y, Tsukui T, Watanabe Y, Yamamoto K, Seguchi M, Wada H, Fujita H. Comparison of Outcomes of Elective Percutaneous Coronary Intervention between Complex and High-Risk Intervention in Indicated Patients (CHIP) versus Non-CHIP. J Atheroscler Thromb 2023; 30:1229-1241. [PMID: 36529503 PMCID: PMC10499455 DOI: 10.5551/jat.63956] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/31/2022] [Indexed: 09/05/2023] Open
Abstract
AIMS Complex and high-risk intervention in indicated patients (CHIP) is an emerging concept in the contemporary percutaneous coronary intervention (PCI). CHIP is known to consist three factors, namely, (1) patient factors, (2) complicated heart disease, and (3) complex PCI. However, it remains unclear whether additional CHIP factors further increase the incidence of complications in complex PCI. Thus, in this study, we aim to compare the incidence of complications among definite CHIP, possible CHIP, and non-CHIP in terms of complex PCI and to further investigate the association between CHIP and complications. METHODS The primary aim of this study was to determine the major complications in PCI. We included 989 PCI lesions and divided those into definite CHIP (n=140), possible CHIP (n=397), and the non-CHIP groups (n=452). RESULTS The incidence of major complications was noted to be the highest in the definite CHIP, followed by the possible CHIP, and lowest in the non-CHIP (p=0.001). The multivariate logistic regression analysis using a generalized estimating equation revealed definite CHIP (versus non-CHIP: odds ratio (OR) 2.099, 95% confidence interval (CI) 1.062-4.150, p=0.033) was significantly associated with major complications after controlling for confounding factors. Another multivariate logistic regression analysis revealed immunosuppressive drugs (OR 3.040, 95% CI 1.251-7.386, p=0.014), unstable hemodynamics (OR 5.753, 95% CI 1.217-27.201, p=0.027), and frailty (OR 2.039, 95% CI 1.108-3.751, p=0.022) were significantly associated with major complications among CHIP factors. CONCLUSIONS The incidence of major complications in complex PCI was determined to be the highest in the definite CHIP, followed by the possible CHIP and lowest in the non-CHIP. Thus, more attention should be given to the three components of CHIP to prevent major complications in complex PCI.
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Affiliation(s)
- Yudai Fujimoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yusuke Watanabe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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3
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Fujimoto Y, Sakakura K, Fujita H. Complex and high-risk intervention in indicated patients (CHIP) in contemporary clinical practice. Cardiovasc Interv Ther 2023:10.1007/s12928-023-00930-1. [DOI: 10.1007/s12928-023-00930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
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4
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Prasad A, Gersh BJ. Stable Coronary Artery Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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5
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Greco A, Buccheri S, Tamburino C, Capodanno D. Risk Stratification Approach to Multivessel Coronary Artery Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Almeida AS, Fuchs SC, Fuchs FC, Silva AG, Lucca MB, Scopel S, Fuchs FD. Effectiveness of Clinical, Surgical and Percutaneous Treatment to Prevent Cardiovascular Events in Patients Referred for Elective Coronary Angiography: An Observational Study. Vasc Health Risk Manag 2020; 16:285-297. [PMID: 32764949 PMCID: PMC7371461 DOI: 10.2147/vhrm.s246963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/26/2020] [Indexed: 01/09/2023] Open
Abstract
Purpose To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography. Patients and Methods A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes. Results All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG. Conclusion Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.
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Affiliation(s)
- Adriana Silveira Almeida
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sandra C Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Felipe C Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline Gonçalves Silva
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Balbinot Lucca
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Samuel Scopel
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Flávio D Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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7
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De Palo M, Quagliara T, Dachille A, Carrozzo A, Giardinelli F, Mureddu S, Mastro F, Rotunno C, Paparella D. Trials Comparing Percutaneous And Surgical Myocardial Revascularization: A Review. Rev Recent Clin Trials 2019; 14:95-105. [PMID: 30706789 DOI: 10.2174/1574887114666190201102353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/10/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Ischemic heart diseases are the major leading cause of death worldwide. Revascularization procedures dramatically reduced the overall risk for death related to acute coronary syndromes. Two kinds of myocardial revascularization can grossly be outlined: percutaneous coronary intervention (PCI) and surgical coronary artery bypass graft intervention (CABG). The net clinical benefit coming from these two kinds of procedures is still under debate. METHODS We have traced the state-of-the-art background about myocardial revascularization procedures by comparing the most important trials dealing with the evaluation of percutaneous interventions versus a surgical approach to coronary artery diseases. RESULTS Both PCI and CABG have become effective treatments for revascularization of patients suffering from advanced CAD. The advance in technology and procedural techniques made PCI an attractive and, to some extent, more reliable procedure in the context of CAD. However, there are still patients that cannot undergo PCI and have to be rather directed towards CABG. CONCLUSION CABG still remains the best strategy for the treatment of multiple vessel CAD due to improved results in term of survival and freedom from reintervention. Anyway, a systematic, multidisciplinary approach to revascularization is the fundamental behaviour to be chased in order to effectively help the patients in overcoming its diseases. The creation of the "heart team" seems to be a good option for the correct treatment of patients suffering from stable and unstable CAD.
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Affiliation(s)
- Micaela De Palo
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy.,Department of Cardiovascular Diseases, Mater Dei Hospital, Bari, Italy
| | - Teresa Quagliara
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Annamaria Dachille
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Alessandro Carrozzo
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Giardinelli
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Simone Mureddu
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Florinda Mastro
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | | | - Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy.,Department of Cardiovascular Surgery, GVM Care and Research, Santa Maria Hospital, Bari, Italy
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8
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Lowering risk score profile during PCI in multiple vessel disease is associated with low adverse events: The ERACI risk score. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018. [DOI: 10.1016/j.carrev.2018.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW In spite of the benefits of drug eluting (DES), these advantages were not translated to better outcome when percutaneous coronary interventions (PCI) were compared with coronary artery bypass surgery. PCI strategy allowing stent deployment in all intermediate lesions including small vessels together with DES design may be the reasons of these findings. RECENT FINDINGS Recently randomized and observational studies demonstrated using functional flow reserve analysis, residual Syntax score risk, or residual ERACI score after PCI that a reasonably incomplete revascularization was associated with good long-term outcome and low events rate at follow-up. In the ERACI IV study, which included patients with multiple vessel disease and left main, all intermediate lesions and severe lesions in small vessels were excluded from the revascularization strategy, and the 3-year follow-up results showed a remarkable low incidence of death/MI and stroke. Intermediate stenosis or severe lesions in small vessels should not be incorporated in the PCI strategy in order to define patient clinical cardiac prognosis or completeness of revascularization.
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10
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Schwann TA. The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem. Surg Clin North Am 2017; 97:835-865. [PMID: 28728719 DOI: 10.1016/j.suc.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine & Life Sciences, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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11
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Carnero-Alcázar M, Villagrán-Medinilla E. Nuestra verdad sobre SYNTAX. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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12
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Rodriguez AE, Pavlovsky H, Del Pozo JF. Understanding the Outcome of Randomized Trials with Drug-Eluting Stents and Coronary Artery Bypass Graft in Patients with Multivessel Disease: A Review of a 25-Year Journey. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:195-199. [PMID: 27980442 PMCID: PMC5145267 DOI: 10.4137/cmc.s40645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/21/2016] [Accepted: 10/09/2016] [Indexed: 12/15/2022]
Abstract
Randomized clinical trials (RCTs) with first- and second-generation drug-eluting stents (DESs) confirmed the superiority of coronary artery bypass surgery (CABG) in patients with multiple vessel disease. In spite of different DES designs, investigators in these trials used similar percutaneous coronary intervention (PCI) strategies hoping to achieve complete revascularization, meaning that all intermediate lesions would be stented. One of these studies also included small vessels in the revascularization policy. On this revision, authors searched for a potential explanation of these intriguing findings and also for solutions to this problem, not seen years ago when other RCTs compared CABG with PCI in the previous DES era. After they revised old and new scientific data, they concluded that improved DES design is not itself enough to narrow the gap between PCI and CABG and that in the future RCTs we should institute more conservative strategies avoiding unnecessary multiple DES implantation.
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Affiliation(s)
- Alfredo E. Rodriguez
- Head, Cardiac Unit, Otamendi Hospital, Buenos Aires, Argentina
- Director and Founder, Cardiovascular Research Center (CECI), Buenos Aires, Argentina
| | - Hernán Pavlovsky
- Fellow, Cardiac Unit, Otamendi Hospital, Buenos Aires, Argentina
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Prasad A, Gersh BJ. Stable Coronary Artery Disease. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Bernard J. Gersh
- Mayo Clinic and Mayo Clinic College of Medicine; Rochester MN USA
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14
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Charytan DM, Desai M, Mathur M, Stern NM, Brooks MM, Krzych LJ, Schuler GC, Kaehler J, Rodriguez-Granillo AM, Hueb W, Reeves BC, Thiele H, Rodriguez AE, Buszman PP, Buszman PE, Maurer R, Winkelmayer WC. Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease. Kidney Int 2016; 90:411-421. [PMID: 27259368 DOI: 10.1016/j.kint.2016.03.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/02/2016] [Accepted: 03/24/2016] [Indexed: 10/21/2022]
Abstract
Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.
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Affiliation(s)
- David M Charytan
- Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA.
| | - Manisha Desai
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Maya Mathur
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Noam M Stern
- Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Maria M Brooks
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Lukasz J Krzych
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Jan Kaehler
- Department of Cardiology, Klinikum Herford, Herford, Germany
| | | | - Whady Hueb
- Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Holger Thiele
- University Heart Center Luebeck and German Heart Research Center (DZHK), Luebeck, Germany
| | - Alfredo E Rodriguez
- Cardiac Unit, Otamendi Hospital, Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Piotr P Buszman
- Silesian Center for Heart Diseases, Zabrze, Poland; American Heart of Poland, Katowice, Poland
| | | | - Rie Maurer
- Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
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Salvatore A, Boukhris M, Giubilato S, Tomasello SD, Castaing M, Giunta R, Marzà F, Abdelbasset HM, Khamis H, Galassi AR. Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome. J Saudi Heart Assoc 2016; 28:63-72. [PMID: 27053895 PMCID: PMC4803775 DOI: 10.1016/j.jsha.2015.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/10/2015] [Accepted: 07/21/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND SYNTAX score II (SS II) integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality. AIMS We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes (ACS) population with severe coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). METHODS From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 (13.6%) showed severe CAD (three-vessel disease and/or left main involvement). Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization. RESULTS The median SS II was 29 (range, 14-59). Overall, MACCE occurred in 25% of patients (cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%). The 1-year MACCE-free survival was significantly lower in patients with SS (⩾29), than in those with SS II (<29) (64.2% vs. 87.2%, respectively; p = 0.007). In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval (CI): 1.02-5.85; p = 0.031] and SS II ⩾29 (hazard ratio 2.74, 95% CI: 1.30-8.21; p = 0.011) were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 (95% CI: 0.58-0.81). For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 (p = 0.09). CONCLUSION SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI.
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Affiliation(s)
- Azzarelli Salvatore
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Marouane Boukhris
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
- Faculty of Medicine of Tunis,University of Tunis El Manar, Tunisia
| | - Simona Giubilato
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Salvatore Davide Tomasello
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Marine Castaing
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Rocco Giunta
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Francesco Marzà
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
| | - Hosam Mohamad Abdelbasset
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
- Maadi Military Hospital, Military Medical Academy, Cairo, Egypt
| | | | - Alfredo Ruggero Galassi
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy
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Haiek C, Fernández-Pereira C, Santaera O, Mieres J, Rifourcat I, Lloberas J, Larribau M, Pocoví A, Rodriguez-Granillo AM, Sarmiento RA, Antoniucci D, Rodriguez AE. Second vs. First generation drug eluting stents in multiple vessel disease and left main stenosis: Two-year follow-up of the observational, prospective, controlled, and multicenter ERACI IV registry. Catheter Cardiovasc Interv 2016; 89:37-46. [PMID: 26947138 DOI: 10.1002/ccd.26468] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/11/2016] [Accepted: 01/18/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To compare second generation drug eluting stents (2DES) with first generation (1DES) for the treatment of patients (pts) with multiple coronary vessel disease (MVD). BACKGROUND Although 2DES improved safety and efficacy compared to 1DES, MVD remains a challenge for percutaneous coronary interventions. METHODS ERACI IV was a prospective, observational, and controlled study in pts with MVD including left main and treated with 2DES (Firebird 2, Microport). We included 225 pts in 15 sites from Argentina. Primary endpoint was the incidence of major adverse cardiovascular events (MACCE) defined as death, myocardial infarction (MI), cerebrovascular accident (CVA) and unplanned revascularization; and to compare with 225 pts from ERACI III study (1DES). PCI strategy was planned to treat lesions ≥70% in vessels ≥ 2.00 mm, introducing a modified Syntax score (SS) where severe lesions in vessels < 2.0 mm and intermediate lesions were not scored. RESULTS Baseline characteristics showed that compared to ERACI III, ERACI IV pts had higher number of diabetics (P = 0.02), previous revascularization (P = 0.007), unstable angina IIb/IIIc (P < 0.001) and three vessels/left main disease (P = 0.003). Modified SS was 22.2 ± 11. At 2 years of follow-up ERACI IV group had significantly lower incidence of death+ MI + CVA, (P = 0.01) and MACCE (P = 0.001). MACCE rate was similar in diabetics, (5.8%) and nondiabetics (7.0%). After performing a matched propensity score, MACCE remain significantly lower in ERACI IV (P = 0.005). CONCLUSION This registry showed that 2DES in MVD has a remarkable low incidence of MACCE in unadjusted and adjusted analysis. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Carlos Haiek
- Interventional Cardiology Department, Sanatorio De La Trinidad, Quilmes, Buenos Aires Province, Argentina
| | - Carlos Fernández-Pereira
- Interventional Cardiology Department, Clinica IMA, Adrogué, Buenos Aires Province, Argentina.,Clinical Research Department, Centro De Estudios En Cardiología Intervencionista, Buenos Aires City, Argentina
| | - Omar Santaera
- Interventional Cardiology Department, Clínica Privada Provincial, Merlo, Buenos Aires Province, Argentina
| | - Juan Mieres
- Clinical Research Department, Centro De Estudios En Cardiología Intervencionista, Buenos Aires City, Argentina.,Interventional Department, Sanatorio Las Lomas, San Isidro, Buenos Aires Province, Argentina
| | - Ignacio Rifourcat
- Interventional Cardiology Department, Instituto De Diagnóstico Y Tratamiento De Afecciones Cardiovasculares, La Plata, Buenos Aires Province, Argentina
| | - Juan Lloberas
- Interventional Cardiology Department, Sanatorio San Miguel, San Miguel, Buenos Aires Province, Argentina
| | - Miguel Larribau
- Interventional Cardiology Department, Hospital Español, Godoy Cruz City, Mendoza Province, Argentina
| | - Antonio Pocoví
- Interventional Cardiology Department, Centro Medico Talar, San Isidro, Buenos Aires Province, Argentina
| | | | - Ricardo A Sarmiento
- Interventional Cardiology Department, Hospital El Cruce, Florencio Varela, Buenos Aires Province, Argentina
| | | | - Alfredo E Rodriguez
- Clinical Research Department, Centro De Estudios En Cardiología Intervencionista, Buenos Aires City, Argentina.,Cardiology Department, Sanatorio Otamendi Y Miroli, Buenos Aires City, Argentina
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Roberts EB, Perry R, Booth J, Sigwart U, Stables RH. Adverse events following percutaneous and surgical coronary revascularisation: Analysis of non-MACE outcomes in the Stent or Surgery (SoS) Trial. Int J Cardiol 2016; 202:7-12. [PMID: 26372883 DOI: 10.1016/j.ijcard.2015.08.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/06/2015] [Accepted: 08/14/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To analyse adverse events requiring or prolonging hospitalisation in the Stent or Surgery (SoS) trial. BACKGROUND Many adverse events following coronary revascularisation are non-major adverse cardiovascular events (non-MACE). Trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) have reported rates of mortality and MACE only. MATERIAL AND METHODS Comparisons between PCI and CABG groups in the SOS trial were by intention to treat. For patients with non-fatal/non-MACE, number of events per 100 patient years follow-up and duration of hospital stay were assessed. Competing risk analysis was used to illustrate temporal pattern of adverse outcomes. RESULTS During 2 y median follow up, 1 one or more adverse event occurred in 47.3% (231) of the PCI group and 53% (265) of the CABG group (p=0.086). Non-fatal/non-MACE occurred in 11.9% of the PCI group and 38.6% of the CABG group (p<0.001). Non-fatal/non-MACE per 100 patient years follow-up was 17.49 (PCI) and 35.04 (CABG), rate ratio 2.0, 95% CI 1.7 to 2.4, p<0.001. Cumulative non-fatal/non-MACE associated hospital stays were 1387 and 3287 days in PCI and CABG groups respectively. Median duration of hospitalisation per non-fatal/non-MACE was 5 days (interquartile range 2 to 11.75 days) in the PCI group and 6 days (interquartile range 2 to 12 days) in the CABG group, p=0.245. CONCLUSIONS CABG had lower cumulative incidence of fatal or MACE outcomes, higher cumulative incidence of non-fatal/non-MACE outcomes, and longer cumulative hospitalisation periods compared to the PCI group.
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Affiliation(s)
- Elved B Roberts
- University Hospitals of Leicester and Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP, United Kingdom.
| | - Raphael Perry
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, United Kingdom
| | - Jean Booth
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
| | - Ulrich Sigwart
- Cardiology Center, University Hospital of Geneva, 24 Rue Micheli du Crest, 1211 Geneva, Switzerland
| | - Rod H Stables
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, United Kingdom
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Caruba T, Chevreul K, Zarca K, Cadier B, Juillière Y, Dubourg O, Sabatier B, Danchin N. Annual cost of stable coronary artery disease in France: A modeling study. Arch Cardiovasc Dis 2015; 108:576-88. [PMID: 26433733 DOI: 10.1016/j.acvd.2015.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 05/13/2015] [Accepted: 06/04/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have analyzed the cost of treatment of chronic angina pectoris, especially in European countries. AIM To determine, using a modeling approach, the cost of care in 2012 for 1year of treatment of patients with stable angina, according to four therapeutic options: optimal medical therapy (OMT); percutaneous coronary intervention with bare-metal stent (PCI-BMS); PCI with drug-eluting stent (PCI-DES); and coronary artery bypass graft (CABG). METHODS Six different clinical scenarios that could occur over 1year were defined: clinical success; recurrence of symptoms without hospitalization; myocardial infarction (MI); subsequent revascularization; death from non-cardiac cause; and cardiac death. The probability of a patient being in one of the six clinical scenarios, according to the therapeutic options used, was determined from a literature search. A direct medical cost for each of the therapeutic options was calculated from the perspective of French statutory health insurance. RESULTS The annual costs per patient for each strategy, according to their efficacy results, were, in our models, €1567 with OMT, €5908 with PCI-BMS, €6623 with PCI-DES and €16,612 with CABG. These costs were significantly different (P<0.05). A part of these costs was related to management of complications (recurrence of symptoms, MI and death) during the year (between 3% and 38% depending on the therapeutic options studied); this part of the expenditure was lowest with the CABG therapeutic option. CONCLUSION OMT appears to be the least costly option, and, if reasonable from a clinical point of view, might achieve appreciable savings in health expenditure.
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Affiliation(s)
- Thibaut Caruba
- AP-HP, hôpital européen Georges-Pompidou, Pharmacie, 20, rue Leblanc, 75015 Paris, France.
| | - Karine Chevreul
- AP-HP, Hôtel-Dieu, URC Eco, 1, place du parvis Notre-Dame, 75004 Paris, France; Inserm, ECEVE, U1123, Paris, France
| | - Kevin Zarca
- AP-HP, Hôtel-Dieu, URC Eco, 1, place du parvis Notre-Dame, 75004 Paris, France
| | - Benjamin Cadier
- AP-HP, Hôtel-Dieu, URC Eco, 1, place du parvis Notre-Dame, 75004 Paris, France
| | - Yves Juillière
- CHU Nancy-Brabois, Institut Lorrain du cœur et des vaisseaux, cardiologie, 54500 Vandœuvre-lès-Nancy, France
| | - Olivier Dubourg
- AP-HP, hôpital Ambroise-Paré, cardiologie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Brigitte Sabatier
- AP-HP, hôpital européen Georges-Pompidou, Pharmacie, 20, rue Leblanc, 75015 Paris, France; Inserm, centre de recherche des cordeliers, UMR 1138, équipe 22, 75006 Paris, France
| | - Nicolas Danchin
- AP-HP, hôpital européen Georges-Pompidou, cardiologie, 20, rue Leblanc, 75015 Paris, France; Université René-Descartes, faculté de médecine, 15, rue de l'École-de-médecine, 75006 Paris, France
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Rodriguez AE, Fernandez-Pereira C, Mieres J, Santaera O, Antoniucci D. Modifying angiographic syntax score according to PCI strategy: lessons learnt from ERACI IV Study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:418-20. [PMID: 26254552 DOI: 10.1016/j.carrev.2015.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/26/2015] [Accepted: 07/07/2015] [Indexed: 11/30/2022]
Abstract
In recent years an angiographic score was introduced in clinical practice to stratified different levels of risk after percutaneous coronary interventions (PCI) with drug eluting stents. The SYNTAX score (SS) classified patients in three different risk levels and was included in revascularization guidelines that patients allocated with low SS could be equally treated with either PCI or CABG, whereas those with intermediate or high SS were better off with CABG. However, using original SS each coronary lesion with a diameter stenosis ≥50% in vessels ≥1.5 mm was scored. In ERACI IV registry we used a revascularization strategy during PCI where operators were advised to only treat lesions≥than 70% in a≥2.0 mm reference vessel; therefore, no intermediate lesions should be treated, and severe stenosis in vessels<2.0 mm was discouraged as well. If we recalculated SS using the above-mentioned operators' advices all intermediate lesions were not scored, and severe stenosis in vessels<2.0 mm were excluded for the analysis, including bifurcations, trifurcations and chronic total occlusions; after this new scoring, the original SS dropped significantly which is in accordance with the goal of complete functional revascularization strategy of the ERACI IV study and the low one year adverse events of such study. In conclusion, if we performed an SS scoring, only severe stenosis in vessels with a reference diameter ≥2.0 mm would allow a more rational assessment of coronary anatomy, and the use of a more conservative PCI strategy.
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Affiliation(s)
- Alfredo E Rodriguez
- Cardiovascular Research Center (CECI) and Cardiac Unit Otamendi Hospital, Buenos Aires, Argentina.
| | - Carlos Fernandez-Pereira
- Cardiovascular Research Center (CECI) and Cardiac Unit Otamendi Hospital, Buenos Aires, Argentina
| | - Juan Mieres
- Cardiovascular Research Center (CECI) and Cardiac Unit Otamendi Hospital, Buenos Aires, Argentina
| | - Omar Santaera
- Cardiac Unit Clinica Provincial, Merlo, Buenos Aires, Argentina
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Meraj PM, Jauhar R, Singh A. Bare Metal Stents Versus Drug Eluting Stents: Where Do We Stand in 2015? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:393. [DOI: 10.1007/s11936-015-0393-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Smit Y, Vlayen J, Koppenaal H, Eefting F, Kappetein AP, Mariani MA. Percutaneous coronary invervention versus coronary artery bypass grafting: a meta-analysis. J Thorac Cardiovasc Surg 2014; 149:831-8.e1-13. [PMID: 25467373 DOI: 10.1016/j.jtcvs.2014.10.112] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 10/17/2014] [Accepted: 10/25/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease. METHODS MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up. RESULTS This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01). CONCLUSIONS Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.
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Affiliation(s)
- Yolba Smit
- Independent Researcher, Leuth, The Netherlands
| | | | | | - Frank Eefting
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Caruba T, Katsahian S, Schramm C, Charles Nelson A, Durieux P, Bégué D, Juillière Y, Dubourg O, Danchin N, Sabatier B. Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies. PLoS One 2014; 9:e98371. [PMID: 24896266 PMCID: PMC4045726 DOI: 10.1371/journal.pone.0098371] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/01/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction and Objectives Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG). Methods RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs. Results Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG. Conclusions Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.
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Affiliation(s)
- Thibaut Caruba
- Pharmacie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- * E-mail:
| | - Sandrine Katsahian
- URC Hôpital Henri Mondor, APHP, Créteil, France
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
| | | | | | - Pierre Durieux
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
- Département de Santé Publique et Informatique, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Dominique Bégué
- Faculté de Pharmacie, Université René Descartes, Paris, France
| | - Yves Juillière
- Cardiologie, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, Nancy, France
| | - Olivier Dubourg
- Cardiologie, Hôpital Ambroise Paré, APHP, Boulogne Billancourt, France
- Université de Versailles-Saint Quentin, Montigny-Le-Bretonneux, France
| | - Nicolas Danchin
- Cardiologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Faculté de Médecine, Université René Descartes, Paris, France
| | - Brigitte Sabatier
- Pharmacie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
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Osnabrugge RLJ, Head SJ, Bogers AJJC, Kappetein AP. Multivessel coronary artery disease: quantifying how recent trials should influence clinical practice. Expert Rev Cardiovasc Ther 2014; 11:903-18. [DOI: 10.1586/14779072.2013.811977] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Li X, Kong M, Jiang D, Dong A. Comparing coronary artery bypass grafting with drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis. Interact Cardiovasc Thorac Surg 2013; 18:347-54. [PMID: 24345688 DOI: 10.1093/icvts/ivt509] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Although drug-eluting stents (DESs) reduce the rate of target vessel revascularization compared with bare-metal stents, the results of DESs for patients with diabetes and multivessel coronary artery disease (CAD) in the DES era are inconsistent. This meta-analysis was undertaken to assess the efficacy and safety of coronary artery bypass grafting (CABG) compared with drug-eluting stent implantation in patients with diabetes mellitus and multivessel coronary artery disease. METHODS We conducted a search of Medline, EMBASE from January 2003 to July 2013 by two reviewers independently, using the terms 'coronary artery bypass graft surgery', 'drug-eluting stent', 'sirolimus-eluting stent', 'paclitaxel-eluting stent', 'diabetes mellitus' and 'multivessel disease', according to established criteria. Studies comparing CABG with DES in patients with diabetes and multivessel CAD with a minimum follow-up of 1 year were included. RESULTS Thirteen studies including 6653 patients with diabetes (3237 who underwent CABG and 3416 who underwent DES implantation) met the selection criteria. The mean follow-up period was 2.9 years (range 1-5). Compared with DES, CABG was associated with a lower risk for major adverse cardiac events (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.46-0.58), driven mainly by a lower risk for repeat revascularization (OR 0.29, 95% CI 0.23-0.35). There was no significant difference with regard to death (OR 0.89, 95% CI 0.75-1.05). Patients in the CABG group had a higher risk for stroke events (OR 2.09, 95% CI 1.45-3.02). CONCLUSIONS Percutaneous coronary intervention with DES in patients with diabetes and multivessel CAD is safe, but has a high risk of long-term repeat revascularization. CABG should remain the standard procedure for diabetic patients with multivessel CAD.
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Affiliation(s)
- Xuebiao Li
- Cardiothoracic Surgery, Department of Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Raza S, Sabik JF, Ellis SG, Houghtaling PL, Rodgers KC, Stockins A, Lytle BW, Blackstone EH. Survival prediction models for coronary intervention: strategic decision support. Ann Thorac Surg 2013; 97:522-8. [PMID: 24021771 DOI: 10.1016/j.athoracsur.2013.06.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/10/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND For a given patient with coronary artery disease, it is uncertain which therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), maximizes long-term survival. Hence, we developed survival models for CABG and PCI using bare-metal stents (BMS) or drug-eluting stents (DES), programmed a decision-support tool, and identified its potential usefulness. METHODS From 1995 to 2007, 23,182 patients underwent primary isolated CABG (n=13,114) or first-time PCI with BMS (n=6,964) or DES (n=3,104). Follow-up was 6.3±3.9 years. Survival models were developed independently for each therapy, then all factors appearing in any of the three models were forced into a final model for each. These were programmed into a decision-support tool. Predicted differences in 5-year survival for the same patient among the three therapies were calculated. RESULTS Unadjusted survival was 96%, 86%, and 68% at 1, 5, and 10 years after CABG, 94%, 83%, and 68% after BMS, and 95% and 84% (no 10-year estimate) after DES, respectively. Risk factors for early and mid-term mortality were identified, leading to variable-rich (25 variables) prediction models. Patients most likely to experience a 5-year survival benefit from DES were those undergoing emergency revascularization for acute infarction, and patients most likely to benefit from CABG had extensive coronary artery disease and numerous comorbidities. CONCLUSIONS Detailed prediction models for prognosis after PCI and CABG are useful for developing a clinically relevant, strategic decision-support tool that reveals who may experience a long-term survival benefit from each modality.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kerry C Rodgers
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aleck Stockins
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus. Curr Cardiol Rep 2013; 15:323. [PMID: 23250660 DOI: 10.1007/s11886-012-0323-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1238] [Impact Index Per Article: 103.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Revascularization for left main and multivessel coronary artery disease in the drug-eluting stent era: integration of recent drug-eluting stent trials. Curr Cardiol Rep 2012; 14:468-76. [PMID: 22638907 DOI: 10.1007/s11886-012-0274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
As older patients comprise a greater proportion of the population, the incidence of multivessel and left main coronary artery disease is increasing. Given the improvements in percutaneous coronary intervention, more patients are suitable for this revascularization strategy. However, the optimal revascularization strategy remains a moving target. Numerous trials, extending from the bypass surgery versus medical therapy era to the most current drug-eluting stent versus bypass surgery era, provide information to select the most appropriate revascularization strategy. The objective of this review is to summarize these data.
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Weintraub WS, Grau-Sepulveda MV, Weiss JM, O'Brien SM, Peterson ED, Kolm P, Zhang Z, Klein LW, Shaw RE, McKay C, Ritzenthaler LL, Popma JJ, Messenger JC, Shahian DM, Grover FL, Mayer JE, Shewan CM, Garratt KN, Moussa ID, Dangas GD, Edwards FH. Comparative effectiveness of revascularization strategies. N Engl J Med 2012; 366:1467-76. [PMID: 22452338 PMCID: PMC4671393 DOI: 10.1056/nejmoa1110717] [Citation(s) in RCA: 420] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG. METHODS We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias. RESULTS Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis. CONCLUSIONS In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1730] [Impact Index Per Article: 133.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 902] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 582] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Galassi AR, Marzá F, Azzarelli S, Tomasello SD. Role of Stress Myocardial Scintigraphy in the Evaluation of Incompletely Revascularized Post-PCI Patients. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2011; 2011:180936. [PMID: 21941646 PMCID: PMC3177365 DOI: 10.1155/2011/180936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 03/21/2011] [Accepted: 06/14/2011] [Indexed: 11/17/2022]
Abstract
Percutaneous coronary intervention (PCI) is actually the most used method of revascularization. Although complete revascularization remains a desirable goal, it may not be possible or not easy to plan in many patients. Thus, incomplete revascularization might be a preferred treatment strategy in selected patient categories. Stress myocardial scintigraphy, because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram, is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization.
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Affiliation(s)
- Alfredo R. Galassi
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Francesco Marzá
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Salvatore Azzarelli
- Division of Cardiology, Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy
| | - Salvatore D. Tomasello
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
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Prasad A, Gersh BJ. Stable Angina. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Takayama T, Hiro T, Hirayama A. Is angioplasty able to become the gold standard of treatment beyond bypass surgery for patients with multivessel coronary artery disease? Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side). Circ J 2010; 74:2744-9. [PMID: 21084756 DOI: 10.1253/circj.cj-10-1012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This article reviews the treatment of patients with multivessel coronary artery disease (CAD). Percutaneous coronary intervention (PCI) has been challenging coronary artery bypass grafting (CABG) as the gold standard of care for patients with multivessel disease; however, the application of PCI to these patients has been mainly limited by restenosis. Up to the beginning of the 2000s, many large-scale, randomized trials addressed this issue by comparing CABG to PCI with balloon angioplasty or bare metal stents in not only Western countries but also in Asian countries. These studies demonstrated similar rates of all-cause death and myocardial infarction in both groups, although the need for revascularization remained significantly lower in the CABG group. PCI with drug-eluting stents (DES) is safe and may represent a viable alternative to CABG for selected patients with diabetes and multivessel CAD. Moreover, DES implantation under intravascular ultrasound guidance and with fractional flow reserve might have the potential to influence treatment strategy and reduce both DES thrombosis and repeat revascularization. The evolution of DES and advanced vascular imaging would mean that PCI continues to challenge CABG as treatment of choice for patients who need revascularization for a better prognosis.
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Affiliation(s)
- Tadateru Takayama
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
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40
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Romick BG, Srinivas VS. Functionally unrevascularized chronic total occlusions: a step closer to indentifying the CTO patient who benefits from PCI. J Interv Cardiol 2010; 23:149-51. [PMID: 20465722 DOI: 10.1111/j.1540-8183.2010.00540.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Benjamin G Romick
- Division of Cardiology, Montefiore Medical Center, New York 10461-2372, USA
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41
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Berger AK, Herzog CA. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in CKD. Am J Kidney Dis 2010; 55:15-20. [DOI: 10.1053/j.ajkd.2009.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 09/24/2009] [Indexed: 11/11/2022]
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Buszman P, Wiernek S, Szymanski R, Bialkowska B, Buszman P, Fil W, Stables R, Bochenek A, Martin J, Tendera M. Percutaneous versus surgical revascularization for multivessel coronary artery disease: A single center 10 year follow-up of SOS trial patients. Catheter Cardiovasc Interv 2009; 74:420-6. [DOI: 10.1002/ccd.22015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lemesle G, Bonello L, de Labriolle A, Steinberg DH, Roy P, Pinto Slottow TL, Torguson R, Kaneshige K, Xue Z, Suddath WO, Satler LF, Kent KM, Lindsay J, Pichard AD, Waksman R. Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease. Catheter Cardiovasc Interv 2009; 73:612-7. [PMID: 19309700 DOI: 10.1002/ccd.21883] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Syntax score prognostic value has recently been highlighted in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary artery disease (CAD), however its prognostic value in patients undergoing coronary artery bypass grafting (CABG) for multivessel CAD is still unknown. The aim of this study was to evaluate the prognostic value of the Syntax score in patients undergoing CABG for 3-vessel CAD. METHODS A cohort of 320 consecutive patients with multivessel (3-vessel) CAD who were subjected for CABG were included in this study and divided into tertiles according to the Syntax score (<24.5, 24.5-34, and >34). During the 1-year follow-up, cardiovascular events including death, myocardial infarction (MI), and stroke were systematically indexed. The primary end point was the composite criteria death/MI/stroke. RESULTS The Syntax score ranged from 11-74 with a mean of 31.2 +/- 12.6 and a median of 28.5 [22-38]. Baseline clinical characteristics were similar among the tertiles. No statistical difference was found for the composite criteria death/MI/stroke: 9.4% versus 7.5% versus 10.4% in the groups with a Syntax score <24.5, 24.5-34, and >34, respectively (P = 0.754). CONCLUSION Unlike for PCI, the Syntax score has a poor prognostic value for severe cardiovascular events in patients undergoing CABG for 3-vessel CAD. Other risk scores should be used to predict the outcome of this population.
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Augustovski F, Iglesias C, Manca A, Drummond M, Rubinstein A, Martí SG. Barriers to generalizability of health economic evaluations in Latin America and the Caribbean region. PHARMACOECONOMICS 2009; 27:919-929. [PMID: 19888792 DOI: 10.2165/11313670-000000000-00000] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Use and acceptance of health economic evaluations (HEEs) has been much greater in developed than in developing nations. Nevertheless, while developing countries lag behind in the development of HEE methods, they could benefit from the progress made in other countries and concentrate on ways in which existing methods can be used or would need to be modified to fulfill their specific needs. HEEs, as context-specific tools, are not easily generalizable from setting to setting. Existing studies regarding generalizability and transferability of HEEs have primarily been conducted in developed countries. Therefore, a legitimate question for policy makers in Latin America and the Caribbean region (LAC) is to what extent HEEs conducted in industrialized economies and in LAC are generalizable to LAC (trans-regional) and to other LAC countries (intra-regional), respectively. We conducted a systematic review, searching the NHS Economic Evaluation Database (NHS EED), Office of Health Economics Health Economic Evaluation Database (HEED), LILACS (Latin America health bibliographic database) and NEVALAT (Latin American Network on HEE) to identify HEEs published between 1980 and 2004. We included individual patient- and model-based HEEs (cost-effectiveness, cost-utility, cost-benefit and cost-consequences analyses) that involved at least one LAC country. Data were extracted by three independent reviewers using a checklist validated by regional and international experts. From 521 studies retrieved, 72 were full HEEs (39% randomized controlled trials [RCTs], 32% models, 17% non-randomized studies and 12% mixed trial-modeling approach). Over one-third of identified studies did not specifically report the type of HEE. Cost-effectiveness and cost-consequence analyses accounted for almost 80% of the studies. The three Latin American countries with the highest participation in HEE studies were Brazil, Argentina and Mexico. While we found relatively good standards of reporting the study's question, population, interventions, comparators and conclusions, the overall reporting was poor, and evidence of unfamiliarity with international guidelines was evident (i.e. absence of incremental analysis, of discounting long-term costs and effects). Analysis or description of place-to-place variability was infrequent. Of the 49 trial-based analyses, 43% were single centre, 33% multinational and 18% multicentre national. Main reporting problems included issues related to sample representativeness, data collection and data analysis. Of the 32 model-based studies (most commonly using epidemiological models), main problems included the inadequacy of search strategy, range selection for sensitivity analysis and theoretical justifications. There are a number of issues associated with the reporting and methodology used in multinational and local HEE studies relevant for LAC that preclude the assessment of their generalizability and potential transferability. Although the quality of reporting and methodology used in model-based HEEs was somewhat higher than those from trial-based HEEs, economic evaluation methodology was usually weak and less developed than the analysis of clinical data. Improving these aspects in LAC HEE studies is paramount to maximizing their potential benefits such as increasing the generalizability/transferability of their results.
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Affiliation(s)
- Federico Augustovski
- Instituto de Efectividad Clínica y Sanitaria-Servicio de Medicina Familiar y Comunitaria, Hospital Italiano, Buenos Aires, Argentina
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Wang ZJ, Zhou YJ, Liu YY, Shi DM, Zhao YX, Guo YH, Cheng WJ, Yu M. Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for the Treatment of Multivessel Coronary Artery Disease in Patients With Chronic Kidney Disease. Circ J 2009; 73:1228-34. [DOI: 10.1253/circj.cj-08-1091] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Zhi Jian Wang
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Yu Jie Zhou
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Yu Yang Liu
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Dong Mei Shi
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Ying Xin Zhao
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Yong He Guo
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Wan Jun Cheng
- Department of Cardiology, Anzhen Hospital, Capital Medical University
| | - Miao Yu
- Department of Cardiology, Anzhen Hospital, Capital Medical University
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Kasai T, Kajimoto K, Miyauchi K, Kubota N, Kurata T, Amano A, Daida H. Propensity analysis of 12 years outcome after bypass graft or balloon angioplasty in patients with multivessel coronary artery disease. J Cardiol 2008; 52:186-194. [PMID: 19027596 DOI: 10.1016/j.jjcc.2008.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/22/2008] [Accepted: 06/26/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Randomized trials have shown that long-term mortality rates are similar between patients with multivessel coronary artery disease (CAD) treated by percutaneous coronary intervention (PCI) and by coronary artery bypass graft (CABG). However, there are scant data regarding more than 10 years long-term follow-up in Asian populations. Therefore, we performed a pooled analysis of our observational data evaluating long-term outcomes of PCI as compared with CABG in patients with multivessel disease among a Japanese population. METHODS AND RESULTS We enrolled 1364 patients, of whom 225 (16.5%) and 1139 (83.5%) underwent PCI and CABG, respectively. During follow-up (12.8±3.4 years), 377 patients died (cardiac death, 125; cardiovascular death, 177) and 322 underwent revascularization. We predicted the probability of undergoing PCI using propensity analysis. After adjusting for baseline variables including propensity score, PCI and CABG did not differ in terms of all-cause (hazard ratio (HR) 1.12; 95% confidence interval (CI) 0.72-1.73; p=0.62), cardiac (HR 0.62; 95%CI 0.32-1.23; p=0.17), and cardiovascular mortality (HR 0.83; 95%CI 0.45-1.52; p=0.54). However, the incidence of revascularization was significantly higher in the PCI group than in the CABG group (HR 0.20; 95%CI 0.15-0.28; p<0.0001). CONCLUSION Although PCI was associated with a significantly higher risk of revascularization than CABG, long-term mortality rates did not significantly differ between the two procedures in this oriental population.
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Affiliation(s)
- Takatoshi Kasai
- Department of Cardiology, Juntendo University, School of Medicine, Tokyo, Japan
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Sleilaty G, Achouh P, Fabiani JN. [Stenting or coronary artery bypass surgery for triple vessel disease?]. Ann Cardiol Angeiol (Paris) 2008; 58:104-12. [PMID: 18930176 DOI: 10.1016/j.ancard.2008.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 07/09/2008] [Indexed: 11/25/2022]
Abstract
This review was undertaken to objectively analyse the cumulated medical literature on techniques of myocardial revascularization (angioplasty, bare metal stenting, drug eluting stenting, coronary artery surgery) in multivessel coronary artery disease. Randomized trials, meta analyses and registries comparing these treatment modalities show a short and long term advantage of surgery over percutaneous techniques for angina recurrence and need for repeat revascularization, although mortality and myocardial infarction rate do not seem statistically different. Diabetes mellitus, chronic renal failure and female gender represent high risk subgroups. Data on drug eluting stents are to date limited to the short term; however, it does not seem that drug eluting stents have resolved the need for repeat revascularization. Stenting addresses focal lesion whereas future revascularization occurs on other coronary sites by progression of coronary disease. Cardiologists should objectively inform the consenting coronary multivessel disease patient on the risk of repeat revascularization inherent to percutaneous techniques and on the weight of actual data favouring surgery in multivessel disease.
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Affiliation(s)
- G Sleilaty
- Service de chirurgie cardiovasculaire, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France
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Brar SS, Syros G, Dangas G. Multivessel disease: percutaneous coronary intervention for classic coronary artery bypass grafting indications. Angiology 2008; 59:83S-8S. [PMID: 18544582 DOI: 10.1177/0003319708318862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multivessel coronary artery disease is characterized by involvement of greater than 1 epicardial coronary artery or the unprotected left main. The choice of revascularization strategy in this setting remains a critical issue in cardiology. Although coronary artery bypass grafting has traditionally been the revascularization strategy for most patients with multivessel disease, there has been a gradual shift toward percutaneous revascularization. Early randomized clinical trials showed coronary artery bypass grafting to be superior to medical therapy. However, trials comparing coronary artery bypass grafting to bare metal stenting have not shown a mortality benefit. Advancements in interventional techniques will continue to challenge the notion that coronary artery bypass grafting is the standard therapy for patients with multivessel coronary disease. Several ongoing randomized clinical trials comparing coronary artery bypass grafting to drug-eluting stents will provide valuable insight into the role of each procedure. In this article, we review the existing literature and discuss future directions in the management of the patient with multivessel disease.
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Affiliation(s)
- Somjot S Brar
- Center for Interventional Vascular Therapy, Columbia University Medical Center, New York, New York 10032, USA
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Hubacek J, Kalla S, Galbraith PD, Graham MM, Knudtson ML, Ghali WA. Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting. Can J Cardiol 2008; 24:121-6. [PMID: 18273485 DOI: 10.1016/s0828-282x(08)70567-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear. OBJECTIVES To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG]). METHODS The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared. RESULTS Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125). CONCLUSIONS The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients.
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Srinivas VS, Selzer F, Wilensky RL, Holmes DR, Cohen HA, Monrad ES, Jacobs AK, Kelsey SF, Williams DO, Kip KE. Completeness of Revascularization for Multivessel Coronary Artery Disease and Its Effect on One-Year Outcome: A Report from the NHLBI Dynamic Registry. J Interv Cardiol 2007; 20:373-80. [PMID: 17880334 DOI: 10.1111/j.1540-8183.2007.00273.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
When percutaneous coronary intervention (PCI) is performed in patients with multivessel coronary disease, a targeted revascularization (TR) of diseased vessels is performed more often than complete revascularization (CR). We compared baseline characteristics and 1-year outcomes of patients undergoing TR by operator choice (n = 1,091), TR because CR was unachievable (n = 375), and CR (n = 315) in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry. Patients receiving TR because CR was unachievable were older, had more comorbidities, worse ejection fraction, less often received 2b/3a inhibitors and stents, and less frequently achieved complete angiographic success than either patients receiving TR by choice or CR. Despite these considerable differences, cumulative rates of 1-year mortality, the need for repeat PCI, or coronary bypass surgery were similar in patients who received CR, TR by choice, or TR because CR was unachievable. In multivariable models, after adjustment for clinical characteristics and propensity to receive CR, the hazard ratio for CR versus TR was 1.10 (95% CI: 0.58-2.10) for 1-year mortality; 0.89 (0.60-1.32) for repeat PCI, and 0.92 (0.66-1.29) for repeat PCI or coronary bypass surgery. In conclusion, despite the presence of more unfavorable characteristics, patients undergoing TR demonstrate 1-year outcomes equivalent to those having CR, supporting its continued use in selected patients.
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