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Enumah ZO, Canner JK, Alejo D, Warren DS, Zhou X, Yenokyan G, Matthew T, Lawton JS, Higgins RSD. Persistent Racial and Sex Disparities in Outcomes After Coronary Artery Bypass Surgery: A Retrospective Clinical Registry Review in the Drug-eluting Stent Era. Ann Surg 2020; 272:660-667. [PMID: 32932322 PMCID: PMC8491278 DOI: 10.1097/sla.0000000000004335] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the temporal trends in 30-day mortality by race group for patients undergoing coronary artery bypass grafting (CABG) between 2011 and 2018 and to investigate the effect of race and sex on postoperative outcomes after CABG. SUMMARY BACKGROUND DATA Cardiovascular diseases remain a leading cause of death in the United States with studies demonstrating increased morbidity and mortality for black and female patients undergoing surgery. In the post drug-eluting stent era, studies of racial disparities CABG are outdated. METHODS We performed a retrospective analysis of the Society for Thoracic Surgeons database for patients undergoing CABG between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included postoperative length of stay, surgical site infection, sepsis, pneumonia, stroke, reoperation, reintervention, early extubation, and readmission. RESULTS The study population was comprised of 1,042,506 patients who underwent isolated CABG between 2011 and 2018. Among all races, Black patients had higher rates of preoperative comorbidities. Compared with White patients, Black patients had higher overall mortality (2.76% vs 2.19%, P < 0.001). On univariable regression, Black patients had higher rates of death, infection, pneumonia, and postoperative stroke compared to White patients. On multivariable regression, Black patients had higher odds of 30-day mortality compared to white patients [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.05-1.18]. Similarly, female patients had higher odds of death compared to males (OR = 1.26, 95% CI 1.21-1.30). CONCLUSIONS In the modern era, racial and sex disparities in mortality and postoperative morbidity after coronary bypass surgery persist with Black patients and female patients consistently experiencing worse outcomes than White male patients. Although there may be unknown or underappreciated biological mechanisms at play, future research should focus on socioeconomic, cultural, and multilevel factors.
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Affiliation(s)
| | - Joseph K. Canner
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Diane Alejo
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Daniel S. Warren
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Xun Zhou
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Gayane Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD
| | - Thomas Matthew
- Johns Hopkins Suburban Hospital, Department of Cardiac Surgery, Bethesda, MD
| | - Jennifer S. Lawton
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Robert S. D. Higgins
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
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ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease. J Thorac Cardiovasc Surg 2019; 157:e131-e161. [DOI: 10.1016/j.jtcvs.2018.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Nicolini F, Vezzani A, Romano G, Carino D, Ricci M, Chicco MVD, Gherli T. Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly. Int Heart J 2017; 58:647-653. [PMID: 28966319 DOI: 10.1536/ihj.16-468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Giorgio Romano
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Davide Carino
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | - Matteo Ricci
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
| | | | - Tiziano Gherli
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Nucl Cardiol 2017; 24:1759-1792. [PMID: 28608183 DOI: 10.1007/s12350-017-0917-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.
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Affiliation(s)
- Manesh R Patel
- Duke University Health System, Duke Clinical Research Institute, Durham, NC, USA.
| | - John H Calhoon
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Gregory J Dehmer
- Baylor Scott & White - Temple Memorial, Temple, TX, USA
- Health Science Center, Texas A&M University, Bryan, TX, USA
| | - James Aaron Grantham
- Saint Luke's Hospital, Kansas City, MO, USA
- Kansas City School of Medicine, University of Missouri, Kansas City, MO, USA
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver, CO, USA
- University of Colorado, Aurora, CO, USA
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA, USA
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, NC, USA
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Coviello V, Sartini S, Quattrini L, Baraldi C, Gamberini MC, La Motta C. Cyclodextrin-based nanosponges for the targeted delivery of the anti-restenotic agent DB103: A novel opportunity for the local therapy of vessels wall subjected to percutaneous intervention. Eur J Pharm Biopharm 2017; 117:276-285. [PMID: 28456606 DOI: 10.1016/j.ejpb.2017.04.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
Nano-sized colloidal carriers represent innovative drug delivery systems, as they allow a targeted and prolonged release of poorly water-soluble drugs, improving their bioavailability and modifying their pharmacokinetic parameters. In this work we describe cyclodextrin-based nanosponges, obtained through polimerization of β-cyclodextrin with diphenyl carbonate as the cross-linking agent, loaded with a novel multi-effective heterocyclic compound, DB103, able to regulate key cellular events involved in the remodelling of vessels wall. Fabrication and drug-loading procedures, as well as physical-chemical characterization and drug-release profile of the novel colloidal system are reported. Results achieved demonstrate the ability of nanosponges to enclose efficiently the target drug and release it slowly and continuously, thus suggesting the exploitability of the novel system for the local therapy of vessels wall subjected to percutaneous intervention.
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Affiliation(s)
- Vito Coviello
- Dipartimento di Farmacia, Università di Pisa, Via Bonanno 6, 56126 Pisa, Italy
| | - Stefania Sartini
- Dipartimento di Farmacia, Università di Pisa, Via Bonanno 6, 56126 Pisa, Italy
| | - Luca Quattrini
- Dipartimento di Farmacia, Università di Pisa, Via Bonanno 6, 56126 Pisa, Italy
| | - Cecilia Baraldi
- Dipartimento di Scienze della Vita, Università degli Studi di Modena e Reggio Emilia, Via Giuseppe Campi 103, 41125 Modena, Italy
| | - Maria Cristina Gamberini
- Dipartimento di Scienze della Vita, Università degli Studi di Modena e Reggio Emilia, Via Giuseppe Campi 103, 41125 Modena, Italy
| | - Concettina La Motta
- Dipartimento di Farmacia, Università di Pisa, Via Bonanno 6, 56126 Pisa, Italy.
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Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017; 69:2212-2241. [PMID: 28291663 DOI: 10.1016/j.jacc.2017.02.001] [Citation(s) in RCA: 446] [Impact Index Per Article: 63.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mølstad P, Moer R, Rødevand O. Long-term survival after coronary bypass surgery and percutaneous coronary intervention. Open Heart 2016; 3:e000489. [PMID: 27843567 PMCID: PMC5093374 DOI: 10.1136/openhrt-2016-000489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/09/2016] [Accepted: 09/20/2016] [Indexed: 11/23/2022] Open
Abstract
Objectives To assess whether there exists a long-term difference in survival after treatment with coronary bypass surgery or percutaneous coronary intervention in patients with coronary disease as judged by all-cause mortality. Methods Retrospective study from the Feiring Heart Clinic database of survival in 22 880 patients—15 078 treated with percutaneous coronary intervention and 7802 with bypass surgery followed up to 16 years. Results Cox regression and propensity score analysis showed no difference in survival for one-vessel and two-vessel disease during the whole study period. In three-vessel disease, however, the analysis revealed a consistent and highly significant survival benefit in the first 8 years with an HR of 0.76 (95% CI 0.69 to 0.84, p<0.001) in favour of bypass surgery with similar survival rates in the two treatment strategies after that time period. Conclusions Treatment strategy did not affect survival in one-vessel and two-vessel disease, but bypass surgery offered an improved survival in the first 8 years in patients with three-vessel disease. These results are consistent with most previous reports and the survival benefit should be taken into account when selecting a strategy for this patient group.
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Affiliation(s)
- Per Mølstad
- Department of cardiology , LHL Clinics Feiring , Feiring , Norway
| | - Rasmus Moer
- Department of cardiology , LHL Clinics Feiring , Feiring , Norway
| | - Olaf Rødevand
- Department of cardiology , LHL Clinics Feiring , Feiring , Norway
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Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible? Curr Opin Cardiol 2015; 30:636-42. [PMID: 26352246 DOI: 10.1097/hco.0000000000000222] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. RECENT FINDINGS The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. SUMMARY It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.
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