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Parodi G. TOTAL evidence for drug eluting stent efficacy and safety in STEMI patients. Int J Cardiol 2017; 248:124-125. [PMID: 28724504 DOI: 10.1016/j.ijcard.2017.06.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 11/25/2022]
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2
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Clinical roles of calcium channel blockers in ischemic heart diseases. Hypertens Res 2017; 40:423-428. [PMID: 28123178 DOI: 10.1038/hr.2016.183] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/25/2016] [Accepted: 11/14/2016] [Indexed: 12/31/2022]
Abstract
Calcium (Ca) channel blockers (CCBs) inhibit Ca2+ channels in the myocardium or vascular smooth muscle cells, inhibit myocardium contraction, inhibit the impulse conduction system (anti-arrhythmias) and cause vasodilation. New classifications based on subtypes of Ca channels and α1 subunits have been proposed. Moreover, CCBs have pleiotropic effects on coronary spastic angina (CSA), including variant angina, myocardial infarction (MI) and stent thrombosis (ST). Although the roles of CCBs in clinical situations remain unknown, further studies in this field are expected to broaden our understanding. In this article, we explain the clinical roles of CCBs in ischemic heart diseases, such as CSA, MI and ST, based on previous knowledge and as demonstrated in representative clinical trials.
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Tsai ML, Chen CC, Chen DY, Yang CH, Hsieh MJ, Lee CH, Wang CY, Chang SH, Hsieh IC. Review: The outcomes of different vessel diameter in patients receiving coronary artery stenting. Int J Cardiol 2016; 224:317-322. [PMID: 27665404 DOI: 10.1016/j.ijcard.2016.09.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/08/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Ming-Lung Tsai
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Dong-Yi Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hung Yang
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Jer Hsieh
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lee
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chao-Yung Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, and College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Fogarty TJ, Arko FR, Zarins CK. Ten Years of Advancements in Interventional Cardiology. J Endovasc Ther 2016; 11 Suppl 2:II192-9. [PMID: 15760266 DOI: 10.1177/15266028040110s604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The past decade has seen the evolution of an exciting technology that has changed forever the treatment of aortic aneurysmal disease. From rather crude homemade stent-grafts constructed in the surgical suite to elegant commercially manufactured devices in a variety of configurations and sizes, the aortic endograft has experienced a meteoric rise in popularity to become a beneficial, minimally invasive therapy that can obviate the risk of rupture and death. There are now 3 approved endovascular devices on the market for infrarenal abdominal aortic aneurysm repair, and it is likely that additional and improved devices will become available in the future. This review revisits the developmental history of the aortic endograft, noting the ongoing refinements that have arisen from our experiences with the growing population of stent-graft patients. Although research continues to search for solutions to the problems of endoleak and migration, long-term results even with the earlier second and third-generation devices are better than has been achieved with open surgical repair.
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Affiliation(s)
- Thomas J Fogarty
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, California 94305, USA
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Kim MC, Cho JY, Jeong HC, Lee KH, Park KH, Sim DS, Yoon NS, Youn HJ, Kim KH, Hong YJ, Park HW, Kim JH, Jeong MH, Cho JG, Park JC, Seung KB, Chang K, Ahn Y. Long-Term Clinical Outcomes of Transient and Persistent No Reflow Phenomena following Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction. Korean Circ J 2016; 46:490-8. [PMID: 27482257 PMCID: PMC4965427 DOI: 10.4070/kcj.2016.46.4.490] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/09/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
Background and Objectives There is limited information on the transient or persistent no reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Subjects and Methods The study analyzed 4329 patients with AMI from a Korean multicenter registry who underwent PCI using coronary stents (2668 ST-elevation and 1661 non-ST-elevation myocardial infarction [MI] patients): 4071 patients without any no reflow, 213 with transient no reflow (no reflow with final thrombolysis in myocardial infarction [TIMI] flow grade 3), and 45 with persistent no reflow (no reflow with final TIMI flow grade≤2). The primary endpoint was all-cause mortality during 3-year follow-up. We also analyzed the incidence of cardiac mortality, non-fatal MI, re-hospitalization due to heart failure, target vessel revascularization, and stent thrombosis. Results The persistent no reflow group was associated with higher all-cause mortality (hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.08-3.65, p=0.028) and cardiac mortality (HR 3.28, 95% CI 1.54-6.95, p=0.002) compared with the normal reflow group. Transient no reflow increased all-cause mortality only when compared with normal reflow group (HR 1.58, 95% CI 1.11-2.24, p=0.010). When comparing transient and persistent no reflow, persistent no reflow was associated with increased all-cause mortality (46.7 vs. 24.4%, log rank p=0.033). Conclusion The persistent no reflow phenomenon was associated with a poor in-hospital outcome and increased long-term mortality mainly driven by increased cardiac mortality compared to the transient no reflow phenomenon or normal reflow.
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Affiliation(s)
- Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Jae Yeong Cho
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Hae Chang Jeong
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Ho Park
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Nam Sik Yoon
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Hyun Joo Youn
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Kye Hun Kim
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Jeong Gwan Cho
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Jong Chun Park
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Ki-Bae Seung
- Department of Cardiology, Seoul St Mary's Hospital, The Catholic University School of Medicine, Seoul, Korea
| | - Kiyuk Chang
- Department of Cardiology, Seoul St Mary's Hospital, The Catholic University School of Medicine, Seoul, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Hillegass WB, Brott BC. Percutaneous coronary intervention: ever closer to real world silver bullets!? Catheter Cardiovasc Interv 2015; 85:807-8. [PMID: 25789729 DOI: 10.1002/ccd.25885] [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] [Received: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 11/10/2022]
Abstract
Bare metal and early drug eluting stents have not meaningfully reduced subsequent rates of death and myocardial infarction compared to balloon angioplasty. Second generation drug eluting stents are associated with meaningful reductions in death and myocardial infarction compared to first generation drug eluting stents.
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Affiliation(s)
- William B Hillegass
- Interventional Cardiovascular Section, Heart South Cardiovascular Group, Alabaster, Alabama; Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
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Plasma angiopoietin-1 level, left ventricular ejection fraction, and multivessel disease predict development of 1-year major adverse cardiovascular events in patients with acute ST elevation myocardial infarction — A pilot study. Int J Cardiol 2015; 182:155-60. [DOI: 10.1016/j.ijcard.2014.12.172] [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] [Received: 05/05/2014] [Revised: 11/27/2014] [Accepted: 12/31/2014] [Indexed: 11/18/2022]
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Nagano M, Hokimoto S, Nakao K, Kaikita K, Akasaka T, Ogawa H. Relation between stent thrombosis and calcium channel blocker after drug-eluting stent implantation: Kumamoto Intervention Conference Study (KICS) registry. J Cardiol 2015; 66:333-40. [PMID: 25572022 DOI: 10.1016/j.jjcc.2014.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/10/2014] [Accepted: 11/26/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stent thrombosis (ST) has emerged as a severe complication of percutaneous coronary intervention (PCI). Since the occurrence of ST is lower in Japan than Western countries, there are few data to predict ST after drug-eluting stent (DES) implantation in Japan. We examined the independent predictors of ST incidence after DES implantation in Japanese patients, including the use of calcium channel blockers (CCBs). METHODS AND RESULTS We used data from the Kumamoto Intervention Conference Study registry. There were 6286 consecutive patients enrolled from June 2008 to March 2011. Among them, we analyzed 3493 patients who underwent DES implantation. The incidence of definite/probable ST throughout a median follow-up period of 364 days was 0.57% (20 patients). There were 8 patients with early ST (within 30 days), 8 patients with late ST (between 31 and 365 days), and 4 patients with very late ST (after 1 year). The frequency of CCB use was significantly lower in ST than non-ST patients (25.0% versus 51.4%, respectively, p=0.016). Multiple regression analysis showed that longer stent length (p=0.034), acute coronary syndrome (p=0.039), and the absence of CCB use (p=0.046) were significant and independent predictors of ST within 1 year. CONCLUSIONS These results suggest that CCB use may be associated with a decreased risk of ST after DES implantation within 1 year in Japanese patients.
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Affiliation(s)
- Masahide Nagano
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Cardiovascular Center, Kumamoto Saiseikai Hospital, Kumamoto, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Koichi Nakao
- Cardiovascular Center, Kumamoto Saiseikai Hospital, Kumamoto, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomonori Akasaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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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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11
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Local paclitaxel induces late lumen enlargement in coronary arteries after balloon angioplasty. Clin Res Cardiol 2014; 104:217-25. [DOI: 10.1007/s00392-014-0775-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
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de Boer SP, Serruys PW, Valstar G, Lenzen MJ, de Jaegere PJ, Zijlstra F, Boersma E, van Domburg RT. Life-years gained by smoking cessation after percutaneous coronary intervention. Am J Cardiol 2013; 112:1311-4. [PMID: 23891246 DOI: 10.1016/j.amjcard.2013.05.075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 12/27/2022]
Abstract
Previous studies have shown that smoking cessation after a cardiac event reduces the risk of subsequent mortality in patients. The aim of this study was to describe the effect of smoking cessation in terms of prolonged life-years gained. The study sample comprised 856 patients who underwent percutaneous coronary intervention (PCI; balloon angioplasty) during 1980 to 1985. Patients were followed up for 30 years and smoking status at 1 year could be retrieved in 806 patients. The 27 patients who died within 1 year were excluded from the analysis. The median follow-up was 19.5 years (interquartile range 6.0 to 23.0). Cumulative 30-year survival rate was 29% in the group of patients who quit smoking and 14% in persistent smokers (p = 0.005). After adjustment for baseline characteristics at the time of PCI, smoking cessation remained an independent predictor of lesser mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.46 to 0.71). The estimated life expectancy was 18.5 years in those who quit smoking and 16.4 years in the persistent smokers (p <0.0001). In conclusion, in patients with coronary heart disease who underwent PCI in the late 1980s, smoking cessation resulted in at least 2.1 life-years gained.
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Abstract
In spite of there being several case reports, coronary stent fracture is not a well-recognized entity and incidence rates are likely to be underestimated. In this article, we review different aspects of stent fracture, including incidence, classification, predictors, outcome, diagnosis, and management.
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Drug-coated balloons for treatment of coronary artery disease: updated recommendations from a consensus group. Clin Res Cardiol 2013; 102:785-97. [DOI: 10.1007/s00392-013-0609-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 08/14/2013] [Indexed: 11/26/2022]
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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. 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: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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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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Lodi-Junqueira L, de Sousa MR, da Paixão LC, Kelles SMB, Amaral CFS, Ribeiro AL. Does intravascular ultrasound provide clinical benefits for percutaneous coronary intervention with bare-metal stent implantation? A meta-analysis of randomized controlled trials. Syst Rev 2012; 1:42. [PMID: 22999055 PMCID: PMC3534608 DOI: 10.1186/2046-4053-1-42] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/10/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The role of intravascular ultrasound (IVUS) in percutaneous coronary interventions (PCI) is still controversial despite several previously published meta-analyses. A meta-analysis to evaluate the controversial role of IVUS-guided PCI with bare-metal stenting was performed and a previous published meta-analysis was re-evaluated in order to clarify the discrepancy between results of these studies. METHODS A systematic review was performed by an electronic search of the PubMed, Embase and Web of Knowledge databases and by a manual search of reference lists for randomized controlled trials published until April 2011, with clinical outcomes and, at least, six months of clinical follow-up. A meta-analysis based on the intention to treat was performed with the selected studies. RESULTS Five studies and 1,754 patients were included. There were no differences in death (OR = 1.86; 95% CI = 0.88-3.95; p = 0.10), non-fatal myocardial infarction (OR = 0.65; 95% CI = 0.27-1.58; p = 0.35) and major adverse cardiac events (OR = 0.74; 95% CI = 0.49-1.13; p = 0.16). An analysis of the previous published meta-analysis strongly suggested the presence of publication bias. CONCLUSIONS There is no evidence to recommend routine IVUS-guided PCI with bare-metal stent implantation. This may be explained by the paucity and heterogeneity of the studies published so far.
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Affiliation(s)
- Lucas Lodi-Junqueira
- Instituto de Avaliação de Tecnologias em Saúde (IATS), do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Avenida Alfredo Balena, 110, CEP, 30130-100, Belo Horizonte, MG, Brazil.
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Pursnani S, Korley F, Gopaul R, Kanade P, Chandra N, Shaw RE, Bangalore S. Percutaneous Coronary Intervention Versus Optimal Medical Therapy in Stable Coronary Artery Disease. Circ Cardiovasc Interv 2012; 5:476-90. [DOI: 10.1161/circinterventions.112.970954] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Seema Pursnani
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Frederick Korley
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Ravindra Gopaul
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Pushkar Kanade
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Newry Chandra
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Richard E. Shaw
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
| | - Sripal Bangalore
- From the Johns Hopkins Bloomberg School of Public Health, Baltimore MD (S.P., F.K., P.K., R.G., N.C.); California Pacific Medical Center, San Francisco, CA (S.P., R.S.); and Division of Cardiology, New York University School of Medicine, New York, NY (S.B.)
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Izzo P, Macchi A, De Gennaro L, Gaglione A, Di Biase M, Brunetti ND. Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2012; 1:158-69. [PMID: 24062904 PMCID: PMC3760523 DOI: 10.1177/2048872612449111] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/30/2012] [Indexed: 01/03/2023]
Abstract
Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine.
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Affiliation(s)
- Paolo Izzo
- Cardiology Department, Clinica ‘Villa Bianca’, Bari, Italy
| | - Andrea Macchi
- Cardiology Department, Busto Arsizio Hospital, (VA), Italy
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Palmerini T, Dangas G, Mehran R, Caixeta A, Généreux P, Fahy MP, Xu K, Cristea E, Lansky AJ, Stone GW. Predictors and Implications of Stent Thrombosis in Non–ST-Segment Elevation Acute Coronary Syndromes. Circ Cardiovasc Interv 2011; 4:577-84. [DOI: 10.1161/circinterventions.111.963884] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tullio Palmerini
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - George Dangas
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Roxana Mehran
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Adriano Caixeta
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Philippe Généreux
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Martin P. Fahy
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Ke Xu
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Ecaterina Cristea
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Alexandra J. Lansky
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
| | - Gregg W. Stone
- From Istituto Cardiologia, Policlinico S Orsola, Bologna, Italy (T.P.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (T.P., A.C., P.G., M.F., K.X., E.C., G.W.S.); Mount Sinai Medical Center and the Cardiovascular Research Foundation, New York, NY (G.D., R.M.); and Yale University School of Medicine, New Haven, CT (A.L.)
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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: 1724] [Impact Index Per Article: 132.6] [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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23
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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: 576] [Impact Index Per Article: 44.3] [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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Park KW, Park JJ, Chae IH, Seo JB, Yang HM, Lee HY, Kang HJ, Cho YS, Yeon TJ, Chung WY, Koo BK, Choi DJ, Oh BH, Park YB, Kim HS. Clinical characteristics of coronary drug-eluting stent fracture: insights from a two-center des registry. J Korean Med Sci 2011; 26:53-8. [PMID: 21218030 PMCID: PMC3012850 DOI: 10.3346/jkms.2011.26.1.53] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 09/20/2010] [Indexed: 11/21/2022] Open
Abstract
Stent fracture (SF) has been implicated as a risk factor for in-stent restenosis, but its incidence and clinical characteristics are not well established. Therefore we investigated the conditions associated with stent fracture and its clinical presentation and outcome. Between 2004 and 2007, consecutive cases of SF were collected from the Seoul National University Hospital. Clinical characteristics and outcome of patients with fractured stents were compared with a ten-fold cohort of age and gender matched controls (n = 236). A total of 4,845 patients received percutaneous coronary intervention and 3,315 patients (68.4%) underwent angiographic follow-up. Twenty-eight fractured stents were observed in 24 patients. The incidence of SF was 0.89% for sirolimus-eluting stents (SES) and 0.09% for paclitaxel-eluting stents. Chronic kidney disease, stent implantation in the right coronary artery (RCA), and SES use were independent predictors of drug-eluting stent fracture by multivariate analysis. SF was significantly associated with binary restenosis (11.4% vs 41.7%, P < 0.001) and increased risk of target lesion revascularization (8.1% vs 33.3%, P = 0.001). Patients with SF but without significant restenosis showed excellent outcome despite only medical treatment. In conclusion, SF is associated with increased rates of restenosis and repeat revascularization. Significant risk factors include chronic kidney disease, RCA intervention, and SES use.
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Affiliation(s)
- Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - In-Ho Chae
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Bin Seo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hae-Young Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Young-Seok Cho
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae-Jin Yeon
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woo-Young Chung
- Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Dong-Ju Choi
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Hee Oh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Young-Bae Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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Tentzeris I, Jarai R, Farhan S, Wojta J, Schillinger M, Geppert A, Nürnberg M, Unger G, Huber K. Long-term outcome after drug-eluting stent implantation in comparison with bare metal stents: a single centre experience. Clin Res Cardiol 2010; 100:191-200. [PMID: 20859742 DOI: 10.1007/s00392-010-0228-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 09/07/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of our study was to evaluate the effect of drug-eluting stents (DES) compared with bare-metal stents (BMS) on all-cause mortality and target vessel revascularization (TVR) in a "real-world" clinical setting. METHODS AND RESULTS One thousand four hundred and ninety consecutive patients, who underwent PCI, were included in a prospective registry from January 2003 until December 2006. Patients were divided retrospectively into two groups: those who received a DES and those who received a BMS. The primary combined endpoint all-cause mortality or TVR and the individual endpoints death and TVR were evaluated during a mean follow-up period of 24.56 ± 12.5 months (range 6-52 months). In total 1,033 patients (69.3%) received BMS, while 457 patients (30.7%) received DES. With respect to clinical characteristics, significant differences between groups were found for age, hyperlipidemia, diabetes mellitus, heart failure, previous cerebral insult and presence of acute coronary syndrome (ACS) during intervention. Propensity score analysis was performed in attempt to eliminate this selection bias. With respect to the combined endpoint all-cause death or TVR, 12.9% of patients with DES and 21.3% with BMS (p = 0.015) had an event during the follow-up. 12.3% of patients with BMS but only 5.7% with DES died during the follow-up (p = 0.025). Thirty-three patients (7.2%) of the DES group and 99 patients (9.6%) of the BMS group (p = 0.1) needed TVR. CONCLUSION Our results obtained in a "real-world" clinical setting exhibit a clinical long-term benefit for DES compared with BMS and underline the safety and efficacy of DES over BMS.
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Affiliation(s)
- Ioannis Tentzeris
- 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna, Austria.
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Abstract
Although the therapeutic advantage of percutaneous coronary intervention in acute coronary syndromes have been proved in numerous studies, its position in the treatment of stable angina remains a controversial issue. The results of the recent studies did not lead into definite answers for the proper treatment of chronic coronary artery disease. The identification of the patients that will benefit from the interventional approach is necessary and is probably based on the proper screening for myocardial ischemia with noninvasive diagnostic techniques. In this review article, we mention the most recent studies for the treatment of chronic stable angina with respect to clinical outcome and economical consequences.
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Schellings DAAM, Dambrink JHE, Hoorntje JCA, de Boer MJ, van 't Hof AWJ, Suryapranata H. Long-term comparison of balloon angioplasty with provisional stenting versus routine stenting in patients with non-ST-elevation acute coronary syndrome. Neth Heart J 2010; 18:307-13. [PMID: 20657676 PMCID: PMC2881347 DOI: 10.1007/bf03091781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background. In patients with unstable angina or non-ST-elevation acute coronary syndrome (NSTE-ACS) who are eligible for PCI, routine stenting is the recommended treatment strategy, based on the opinion of experts. Provisional stenting may provide a viable alternative by retaining the early benefits of stenting without its potential late hazards.Method. Patients with NSTE-ACS were randomised to provisional or routine stenting after coronary angiography. Patients were followed for up to ten years. The occurrence of major adverse cardiac events (MACE) was recorded.Results. 237 consecutive patients with NSTE-ACS were randomly assigned to routine stenting (n=116) or provisional stenting (n=121). No difference in the incidence of MACE at 30 days was observed. At six months, angiographic restenosis was lower in the routine stenting group (41 vs. 20%, p=0.02), paralleled by more MACE in the provisional stenting group at one year (40.5 vs. 27.6%, p=0.036). At complete follow-up the difference in MACE was not significant (61.2 vs. 50%, p=0.084) because of relatively more target lesion revascularisations in the routine stent group. There was no difference in the incidence of very late stent thrombosis (1.7 vs. 3.4%, p=0.439). The only independent predictor of MACE was beta-blocker use (RR 0.62 [0.431; 0.892] p=0.010).Conclusion. In selective patients with NSTE-ACS, routine stenting was more beneficial than provisional stenting for a period of up to five years, driven by a reduction in repeat revascularisation procedures. After this period, the benefit was no longer significant. Beta-blocker use was the only independent predictor of MACE throughout the complete follow-up period. (Neth Heart J 2010;18:307-13.).
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Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2010:CD004815. [PMID: 20238333 DOI: 10.1002/14651858.cd004815.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND In patients with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) two strategies are possible, either a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially, with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia. OBJECTIVES To determine the benefits of an invasive compared to conservative strategy for treating UA/NSTEMI in the stent era. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE and EMBASE were searched (1996 to February 2008) with no language restrictions. SELECTION CRITERIA Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI. DATA COLLECTION AND ANALYSIS We identified five studies (7818 participants). Using intention-to-treat analysis with random-effects models, summary estimates of relative risk (RR) with 95% confidence interval (CI) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction, all-cause death or non-fatal myocardial infarction, and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using Chi(2) and variance (I(2) statistic) methods. MAIN RESULTS In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy (RR 1.59, 95% CI 0.96 to 2.64). The invasive strategy did not reduce death on longer-term follow up. Myocardial infarction rates assessed at 6 to 12 months (5 trials) and 3 to 5 years (3 trials) were significantly decreased by an invasive strategy (RR 0.73, 95% CI 0.62 to 0.86; and RR 0.78, 95% CI 0.67 to 0.92 respectively). The incidence of early (< 4 month) and intermediate (6 to 12 month) refractory angina were both significantly decreased by an invasive strategy (RR 0.47, 95% CI 0.32 to 0.68; and RR 0.67, 95% CI 0.55 to 0.83 respectively), as were early and intermediate rehospitalization rates (RR 0.60, 95% CI 0.41to 0.88; and RR 0.67, 95% CI 0.61 to 0.74 respectively). The invasive strategy was associated with a two-fold increase in the RR of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the RR of (minor) bleeding with no hazard of stroke. AUTHORS' CONCLUSIONS Compared to a conservative strategy for UA/NSTEMI, an invasive strategy is associated with reduced rates of refractory angina and rehospitalization in the shorter term and myocardial infarction in the longer term. However, the invasive strategy is associated with a doubled risk of procedure-related heart attack and increased risk of bleeding and procedural biomarker leaks. Available data suggest that an invasive strategy may be particularly useful in those at high risk for recurrent events.
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Affiliation(s)
- Michel R Hoenig
- Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia, 4029
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Rodriguez AE. Emerging drugs for coronary restenosis: the role of systemic oral agents the in stent era. Expert Opin Emerg Drugs 2010; 14:561-76. [PMID: 19712016 DOI: 10.1517/14728210903203808] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction of drug eluting stents (DES) during percutaneous coronary interventions significantly reduces the rate of angiographic restenosis, target lesion and vessel revascularization. In spite of these benefits, other clinical hard end points such as death or myocardial infarction were not reduced and, furthermore, new concerns associated with the presence of late and very late stent thrombosis have been raised. The requirement of long-term dual antiplatelet therapy is another limitation associated with DES. Conversely, in this decade, other options to DES have been simultaneously discussed in observational and randomized studies. Several registries and randomized trials using the systemic approach with anti-inflammatory, immunosuppressive or antiplatelet therapies have been identified and discussed in this manuscript. In spite of all randomized studies with oral therapies in the bare metal stent (BMS) era demonstrating positive reductions in coronary restenosis, this practice has not been introduced clinically. Furthermore, a recent randomized trial comparing oral sirolimus plus BMS versus DES demonstrated that the first approach was cost saving and of comparable efficacy to DES. Conclusive evidence of high incidence of late and very late stent thrombosis with DES, together with clinical limitations for its widespread use, has opened up a large opportunity to search for alternative therapies in coronary restenosis prevention.
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Affiliation(s)
- Alfredo E Rodriguez
- Otamendi Hospital, Post Graduate School of Medicine, Cardiac Unit, Buenos Aires, Argentina.
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Hilliard AA, From AM, Lennon RJ, Singh M, Lerman A, Gersh BJ, Holmes DR, Rihal CS, Prasad A. Percutaneous Revascularization for Stable Coronary Artery Disease. JACC Cardiovasc Interv 2010; 3:172-9. [DOI: 10.1016/j.jcin.2009.11.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/03/2009] [Accepted: 11/18/2009] [Indexed: 10/19/2022]
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Horst B, Rihal CS, Holmes DR, Bresnahan JF, Prasad A, Gau G, Lennon R, Lerman A. Comparison of Drug-Eluting and Bare-Metal Stents for Stable Coronary Artery Disease. JACC Cardiovasc Interv 2009; 2:321-8. [DOI: 10.1016/j.jcin.2008.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 11/10/2008] [Accepted: 11/17/2008] [Indexed: 10/20/2022]
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Kereiakes DJ. Medical and Catheter-Based Therapies for Managing Stable Coronary Disease: Lessons From the COURAGE Trial. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2009; 11:45-53. [PMID: 19141260 DOI: 10.1007/s11936-009-0005-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical and catheter-based therapies play complementary roles in treating patients with stable coronary atherosclerosis. The choice of therapy (or therapies) must be made for each patient based on coronary anatomic suitability and in the context of the patient's lifestyle, functional capacity, level of symptom limitation, and ability to take the prescribed treatment. Objective evidence of myocardial ischemia on nuclear myocardial scintigraphy is quantitatively correlated with the occurrence of death or myocardial infarction in late follow-up, and percutaneous coronary intervention added to optimal medical therapy is more effective than medical therapy alone in reducing ischemia. Coronary angiography and definition of the coronary anatomy should be performed in patients with stable angina pectoris to help in selecting the optimal treatment strategy.
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Affiliation(s)
- Dean J Kereiakes
- Dean J. Kereiakes, MD The Christ Hospital Heart and Vascular Center, The Lindner Center, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA.
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Yeter E, Kurt M, Silay Y, Anderson HV, Denktas AE. Drug-eluting stents for acute myocardial infarction. Expert Opin Pharmacother 2008; 10:19-34. [DOI: 10.1517/14656560802627952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Qureshi AI, Hussein HM, El-Gengaihy A, Abdelmoula M, K. Suri MF. CONCURRENT COMPARISON OF OUTCOMES OF PRIMARY ANGIOPLASTY AND OF STENT PLACEMENT IN HIGH-RISK PATIENTS WITH SYMPTOMATIC INTRACRANIAL STENOSIS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000312363.86855.d0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Qureshi AI, Hussein HM, El-Gengaihy A, Abdelmoula M, K Suri MF. CONCURRENT COMPARISON OF OUTCOMES OF PRIMARY ANGIOPLASTY AND OF STENT PLACEMENT IN HIGH-RISK PATIENTS WITH SYMPTOMATIC INTRACRANIAL STENOSIS. Neurosurgery 2008; 62:1053-60; discussion 1060-2. [PMID: 18580803 DOI: 10.1227/01.neu.0000325867.06764.3a] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA.
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Holmes DR, Gersh BJ, Whitlow P, King SB, Dove JT. Percutaneous Coronary Intervention for Chronic Stable Angina. JACC Cardiovasc Interv 2008; 1:34-43. [DOI: 10.1016/j.jcin.2007.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 10/09/2007] [Accepted: 10/26/2007] [Indexed: 10/22/2022]
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Preserved coronary endothelial function by inhibition of delta protein kinase C in a porcine acute myocardial infarction model. Int J Cardiol 2008; 133:256-9. [PMID: 18242734 DOI: 10.1016/j.ijcard.2007.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 11/17/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies demonstrate impairment of endothelial-dependent vasodilation after ischemia/reperfusion (I/R). Though we have demonstrated that inhibition of delta protein kinase C (delta PKC) at reperfusion reduces myocyte damage and improves cardiac function in a porcine acute myocardial infarction (AMI) model, impact of the selective delta PKC inhibitor on epicardial coronary endothelial function remains unknown. METHODS Either delta PKC inhibitor (delta V1-1, n=5) or saline (n=5) was infused into the left anterior descending artery at the last 1 min of the 30-min ischemia by balloon occlusion. In vivo responses to bradykinin (endothelium-dependent vasodilator) or nitroglycerin (endothelium-independent vasodilator) were analyzed at 24 h after I/R using intravascular ultrasound. Vascular responses were calculated as the ratio of vessel area at each time point (30, 60, 90 and 120 s after the infusion), divided by values at baseline (before the infusion). RESULTS In control pigs, endothelial-dependent vasodilation following bradykinin infusion in infarct-related epicardial coronary artery was impaired, whereas in delta PKC inhibitor-treated pigs the endothelial-dependent vasodilation was preserved. Nitroglycerin infusion caused similar vasodilatory responses in the both groups. CONCLUSIONS This is the first demonstration that a delta PKC inhibitor preserves vasodilator capacity in epicardial coronary arteries in an in vivo porcine AMI model. Because endothelial dysfunction correlates with worse outcome in patients with AMI, this preserved endothelial function in epicardial coronary arteries might result in a better clinical outcome.
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Slottow TLP, Steinberg DH, Roy P, Javaid A, Buch AN, Okabe T, Xue Z, Smith K, Torguson R, Pichard AD, Satler LF, Suddath WO, Kent KM, Waksman R. Drug-eluting stents are associated with similar cardiovascular outcomes when compared to bare metal stents in the setting of acute myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:24-8. [DOI: 10.1016/j.carrev.2007.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 06/08/2007] [Indexed: 10/22/2022]
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Kereiakes DJ, Teirstein PS, Sarembock IJ, Holmes DR, Krucoff MW, O’Neill WW, Waksman R, Williams DO, Popma JJ, Buchbinder M, Mehran R, Meredith IT, Moses JW, Stone GW. The Truth and Consequences of the COURAGE Trial. J Am Coll Cardiol 2007; 50:1598-603. [DOI: 10.1016/j.jacc.2007.07.063] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 06/27/2007] [Accepted: 07/07/2007] [Indexed: 11/25/2022]
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Svilaas T, van der Horst ICC, Zijlstra F. A quantitative estimate of bare-metal stenting compared with balloon angioplasty in patients with acute myocardial infarction: angiographic measures in relation to clinical outcome. Heart 2007; 93:792-800. [PMID: 17569804 PMCID: PMC1994459 DOI: 10.1136/hrt.2006.093740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We performed a systematic review of all randomised controlled trials (RCTs) from the pre-drug-eluting-stent era comparing bare-metal stenting (BMS) with balloon angioplasty in patients with acute myocardial infarction (MI) to examine coronary angiographic parameters of infarct-related vessel patency and to relate the angiographic measures to clinical outcome. The search was restricted to published RCTs in humans. 10 RCTs, (6192 patients) were analysed. Compared with balloon angioplasty, BMS was associated with reduced rates of reocclusion (6.7% vs 10.1%, OR 0.62, 95% CI 0.40 to 0.96, p = 0.03) and restenosis (23.9% vs 39.3%, OR 0.45, 95% CI 0.34 to 0.59, p<0.001), but not with reduced rates of subacute thrombosis (1.7% in both groups). BMS showed a reduction in target vessel revascularisation (TVR; 12.2% vs 19.2%, OR 0.50, 95% CI 0.37 to 0.69, p<0.001), but not in mortality (5.3% vs 5.1%) or reinfarction (3.9% vs 4%). The findings of this study support BMS placement in acute MI. The discrepancy between angiographic and clinical parameters has important implications for future studies investigating further technical improvements in mechanical reperfusion therapy.
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Affiliation(s)
- Tone Svilaas
- Thoraxcenter, Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Pasceri V, Patti G, Speciale G, Pristipino C, Richichi G, Di Sciascio G. Meta-analysis of clinical trials on use of drug-eluting stents for treatment of acute myocardial infarction. Am Heart J 2007; 153:749-54. [PMID: 17452148 DOI: 10.1016/j.ahj.2007.02.016] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Accepted: 02/15/2007] [Indexed: 01/18/2023]
Abstract
BACKGROUND Recent trials have shown the effects of drug-eluting stents (DES) in treatment of acute myocardial infarction (AMI), but data on the clinical outcome are still incomplete. METHODS We performed a meta-analysis of all trials comparing DES and bare-metal stents (BMS) in AMI. RESULTS We found 7 randomized trials comparing the effects of DES and BMS in AMI, enrolling a total of 2357 patients (1177 with DES and 1180 with BMS) with a follow-up of 8 to 12 months. Incidence of major cardiac events (death, myocardial infarction, or revascularization) was 9.3% in patients treated with DES and 17.6% in patients with BMS, with a relative risk (RR) of 0.53 with 95% CI 0.43 to 0.66. Incidence of death or myocardial infarction was similar in the two groups, occurring in 5.8% of patients with DES and 6.9% of patients treated with BMS, with an RR of 0.84 (95% CI 0.62-1.15). Target lesion revascularization occurred in 4.8% of DES and in 12.0% of BMS patients, with an RR of 0.40 (95% CI 0.30-0.54). Stent thrombosis occurred in 2.3% in DES versus 2.6% in BMS patients, with an RR of 0.87 (95% CI 0.53-1.45). There was no heterogeneity among trials in any of the analyses (I2 = 0% for all). CONCLUSIONS Drug-eluting stents significantly reduce need for revascularization in patients with AMI, without changes in incidence of death or myocardial infarction. Use of DES is not associated with an increased risk of stent thrombosis at 1-year follow-up.
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Affiliation(s)
- Vincenzo Pasceri
- Interventional Cardiology Unit, San Filippo Neri Hospital, Rome, Italy.
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Fox K, García MAA, Ardissino D, Buszman P, Camici PG, Crea F, Daly C, de Backer G, Hjemdahl P, López-Sendón J, Morais J, Pepper J, Sechtem U, Simoons M, Thygesen K. [Guidelines on the management of stable angina pectoris. Executive summary]. Rev Esp Cardiol 2007; 59:919-70. [PMID: 17162834 DOI: 10.1157/13092800] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kim Fox
- Sociedad europea de cardiologia
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Percutaneous Coronary Intervention and Stable Angina. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Li JJ, Nie SP, Zhang CY, Gao Z, Zheng X, Guo YL. Is inflammation a contributor for coronary stent restenosis? Med Hypotheses 2007; 68:945-51. [PMID: 17045418 DOI: 10.1016/j.mehy.2006.05.069] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2006] [Accepted: 05/16/2006] [Indexed: 10/24/2022]
Abstract
The development of coronary stent has revolutionized the field of interventional cardiology by reducing the incidence of restenosis after balloon angioplasty. Despite significant progress in its prevention and treatment, however, in-stent restenosis (ISR) is still common, and remains a challenge for the interventional cardiologist. Restenosis after stent implantation is mainly caused by neointimal proliferation through the stent struts. Currently, there are three major factors has been demonstrated to be contributors for ISR, namely patients-, lesion- and genetic-related factors in large number of clinical trials. However, the triggers and pathophysiological mechanisms for ISR are not fully elucidated. Experimental as well as clinical studies indicate a marked activation of inflammatory cells at the site of stent structs, which are likely to play a key role in the process of neointimal proliferation and stent restenosis. Those data suggest that inflammation may be a major contributor for ISR. In fact, coronary stenting is a strong inflammatory stimulus and the acute systemic response to local inflammation produced by coronary stenting is highly individual and predicts restenosis and event-free survival. Thus, the attention should be paid on anti-inflammatory therapeutic approaches for ISR, and the benefit of anti-inflammatory therapy during the periprocedural period and long-term follow-up is dependent on the inflammatory status. Measurement of cytokine and acute phase proteins, such as C-reactive protein, therefore, may be important to identify high-risk subjects and develop specific treatment tailored to the individual patients.
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Affiliation(s)
- Jian-Jun Li
- Department of Cardiology, Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100037, People's Republic of China.
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Helft G, Gilard M, Le Feuvre C, Zaman AG. Drug Insight: antithrombotic therapy after percutaneous coronary intervention in patients with an indication for anticoagulation. ACTA ACUST UNITED AC 2006; 3:673-80. [PMID: 17122800 DOI: 10.1038/ncpcardio0712] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Accepted: 09/01/2006] [Indexed: 01/30/2023]
Abstract
Antiplatelet therapy with aspirin and clopidogrel is standard care following revascularization by percutaneous coronary intervention with stent insertion. This so-called dual therapy is recommended for up to 4 weeks after intervention for bare-metal stents and for 6-12 months after intervention for drug-eluting stents. Although it is estimated that 5% of patients undergoing percutaneous coronary intervention require long-term anticoagulation because of an underlying chronic medical condition, continuing treatment with triple therapy (warfarin, aspirin and clopidogrel) increases the risk of bleeding. In most patients triple antithrombotic therapy seems justified for a short period of time. In some patients, however, a more considered judgment based on absolute need for triple therapy, risk of bleeding and risk of stent thrombosis is required, but the optimum antithrombotic treatment for these patients who require long-term anticoagulation has not been defined. This Review summarizes the existing literature concerning antithrombotic therapy and makes recommendations for initiation and duration of triple therapy in the small proportion of patients already receiving anticoagulant therapy who require percutaneous coronary intervention.
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Affiliation(s)
- Gérard Helft
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Boulevard de l'Hôpital, 75013 Paris, France.
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Smith PK, Califf RM, Tuttle RH, Shaw LK, Lee KL, Delong ER, Lilly RE, Sketch MH, Peterson ED, Jones RH. Selection of Surgical or Percutaneous Coronary Intervention Provides Differential Longevity Benefit. Ann Thorac Surg 2006; 82:1420-8; discussion 1428-9. [PMID: 16996946 DOI: 10.1016/j.athoracsur.2006.04.044] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 04/07/2006] [Accepted: 04/13/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of coronary artery disease (CAD) is evolving with better medications, improvements in percutaneous coronary intervention (PCI), and enhanced techniques for coronary artery bypass grafting (CABG). METHODS In this study, 18,481 patients with significant (>75% stenosis) CAD treated at a single center between 1986 and 2000 were assigned to one of three groups based on initial treatment strategy: medical therapy (MED) (n = 6862), PCI (n = 6292), or CABG (n = 5327). Each group was categorized into 3 groups according to baseline severity of CAD: low-severity (predominantly 1-vessel), intermediate-severity (predominantly 2-vessel), and high-severity (all 3-vessel), and prospectively evaluated in Cox models for all-cause mortality adjusted for cardiac risk, comorbidity, and propensity for selection of a specific treatment. Treatments were compared for the entire period and three eras (1: 1986 to 1990; 2: 1991 to 1995; 3: 1996 to 2000), the last encompassing widespread availability of PCI with stenting. RESULTS Survival significantly improved in all groups for all degrees of CAD, despite increasing severity of illness. Revascularization strategies provided significant survival over MED with 8.1, 10.6, and 23.6 additional months per 15 years of follow-up for low-severity, intermediate-severity, and high-severity CAD, respectively. Therapeutic improvements led to increased survival of 5.3 additional months per 7 years of follow-up (95% confidence interval, 0.2 to 10.2; p = 0.039) in era 3 for CABG compared with PCI for high-severity CAD. CONCLUSIONS Initial revascularization strategies result in significant survival advantage over MED for all CAD levels. Patients with high-severity CAD have reduced survival with PCI compared with those initially treated with CABG.
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Affiliation(s)
- Peter K Smith
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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