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Dokollari A, Sicouri S, Hosseinian L, Erten O, Ramlawi B, Bisleri G, Bonacchi M, Sicouri N, Torregrossa G, Sutter FP. Periprocedural Risk Predictors Affecting Long-Term Prognosis in Patients With Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Grafting. Tex Heart Inst J 2024; 51:e238199. [PMID: 38494437 PMCID: PMC11075519 DOI: 10.14503/thij-23-8199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
OBJECTIVE This study sought to identify periprocedural risk predictors that affect long-term prognosis in patients with chronic obstructive pulmonary disease (COPD) undergoing isolated coronary artery bypass grafting (CABG). METHODS All consecutive 4,871 patients undergoing isolated CABG between May 2005 and June 2021 were included. Patients with and without COPD were compared for baseline demographics and preoperative characteristics. A propensity-matched analysis was used to compare the 2 groups. The primary outcome was long-term incidence of all-cause death. RESULTS After matching, 767 patients each were included in the COPD and non-COPD groups; mean age was 71.6 and 71.4 years (P = .7), respectively; 29.3% and 32% (P = .2) were women, respectively. Intraoperatively, median (IQR) operating room time was higher in the COPD group than in the non-COPD group (5.9 [5.2-7.0] hours vs 5.8 [5.1-6.7] hours, respectively; P = .01). Postoperatively, intensive care unit stay (P = .03), hospital length of stay (P = .0004), and fresh frozen plasma transfusion units (P = .012) were higher in the COPD group than in the non-COPD group. Thirty-day mortality was not different between groups (1.3% in the COPD group vs 1% in the non-COPD group; P = .4). Median follow-up time was 4.0 years. The rate of all-cause death was higher in the COPD group than in the non-COPD group (138 patients [18.3%] vs 109 patients [14.5%], respectively; P = .042). Periprocedural risk predictors for all-cause death in patients with COPD were atrial fibrillation, diabetes, male sex, dialysis, ejection fraction less than 50%, peripheral vascular disease, and Society of Thoracic Surgeons Predicted Risk of Mortality score greater than 4%. CONCLUSION Patients with COPD undergoing isolated CABG had a significantly higher incidence of all-cause death than those without COPD. Herein, risk predictors are provided for all-cause death in patients undergoing isolated CABG.
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Affiliation(s)
- Aleksander Dokollari
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Leila Hosseinian
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Ozgun Erten
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Gianluigi Bisleri
- Cardiac Surgery Department, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Massimo Bonacchi
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Noah Sicouri
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Gianluca Torregrossa
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Francis P. Sutter
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
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Kirov H, Caldonazo T, Riedel LL, Tasoudis P, Moschovas A, Diab M, Färber G, Doenst T. Comparing outcomes between coronary artery bypass grafting and percutaneous coronary intervention in octogenarians with left main or multivessel disease. Sci Rep 2023; 13:22323. [PMID: 38102297 PMCID: PMC10724226 DOI: 10.1038/s41598-023-49069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MI). However, CABG benefits are unclear in octogenarians, where surgical risk is often perceived as higher and PCI is chosen more liberally. We performed a meta-analysis of studies comparing outcomes in octogenarians with left main or multivessel disease who underwent CABG or PCI. Primary outcome was late mortality (> 5 years). Secondary outcomes were perioperative mortality, MI, re-revascularization (R-R), acute renal failure (ARF), and stroke. Fourteen studies with 17,942 patients were included. CABG was associated with lower late mortality (hazard ratio, HR: 1.23, 95% confidence interval: CI 1.05-1.44, p < 0.01). In the pooled Kaplan-Meier analysis CABG showed significantly lower risk of death in the follow-up compared to PCI (HR: 1.08, 95%CI 1.02-1.41, p = 0.005). Landmark analyses confirmed the survival advantage of CABG over PCI after 21.5 months of follow-up (HR: 1.31, 1.19-1.44, p < 0.0001), but suggested advantage of PCI over CABG in the first 30-days (HR: 0.72, 0.64-0.82, p < 0.0001) and comparable survival from 1 to 21.5 months (HR: 0.98, 0.92-1.05, p = 0.652). We found lower risk for MI and R-R after CABG but higher perioperative mortality and no differences in ARF and stroke. CABG appears superior to PCI over time in octogenarians with complex CAD. This survival advantage is associated with fewer events of MI and R-R; however, it comes with an increased risk in perioperative mortality.
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Affiliation(s)
- Hristo Kirov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Leoni Lu Riedel
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Panagiotis Tasoudis
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, USA
| | - Alexandros Moschovas
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany.
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany.
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Lin NH, Ho JSY, Djohan AH, Ho VWT, Teo YN, Teo YH, Syn NL, Aye YN, Soh RYH, Yeo TC, Sim HW, Tan HC, Chan MY, Sia CH. Percutaneous coronary intervention in patients aged 80 years old and above: a systematic review and meta-analysis. ASIAINTERVENTION 2022; 8:123-131. [PMID: 36483276 PMCID: PMC9706774 DOI: 10.4244/aij-d-21-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 06/01/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Ischaemic heart disease remains the main cause of death in the world. With increasing age, frailty and comorbidities, senior patients aged 80 years old and above who undergo percutaneous coronary intervention (PCI) are at higher risk of mortality and other complications. AIMS We aimed to examine the overall outcomes for this group of patients. METHODS Four databases (PUBMED, EMBASE, SCOPUS and CENTRAL) were searched. Studies with patients aged 80 years old and above who underwent PCI for all indications were included. Pooled outcomes of all-cause death, cardiac death, in-hospital death, subsequent stroke/transient ischaemic attack (TIA), subsequent myocardial infarction (MI), subsequent congestive cardiac failure (CCF), and overall major adverse cardiac events (MACE) were obtained for meta-analysis. RESULTS From 2,566,004 patients, the pooled cumulative incidence of death was 19.22%, cardiac death was 7.78%, in-hospital death was 7.16%, subsequent stroke/TIA was 1.54%, subsequent MI was 3.58%, subsequent CCF was 4.74%, and MACE was 17.51%. The mortality rate of all patients was high when followed up for 3 years (33.27%). ST-elevation myocardial infarction patients had more outcomes of in-hospital death (14.24% vs 4.89%), stroke/TIA (1.93% vs 0.12%), MI (3.68 vs 1.55%) and 1-year mortality (26.16% vs 13.62%), when compared to non-ST-elevation myocardial infarction patients. CONCLUSIONS There was a high mortality rate at 1 year and 3 years post-PCI in the overall population of senior patients aged 80 years old and above, regardless of indication. This necessitates further studies to explore the implications of these observations.
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Affiliation(s)
- Norman H Lin
- Department of Cardiology, National University Heart Centre, Singapore
| | - Jamie S-Y Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Vanda Wen-Teng Ho
- Division of Geriatric Medicine, University Medicine Cluster, National University Health System, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yin Nwe Aye
- Department of Cardiology, National University Heart Centre, Singapore
| | - Rodney Y H Soh
- Department of Cardiology, National University Heart Centre, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Pavasini R, Sanguettoli F, Zanarelli L, Deserio MA, Bianchi N, Fabbri G, Tebaldi M, Biscaglia S, Campo G. Unsolved Questions in the Revascularization of Older Myocardial Infarction Patients with Multivessel Disease. Rev Cardiovasc Med 2022; 23:344. [PMID: 39077134 PMCID: PMC11267381 DOI: 10.31083/j.rcm2310344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/05/2022] [Accepted: 07/22/2022] [Indexed: 07/31/2024] Open
Abstract
Background In cardiology, the global phenomenon of population ageing poses new major challenges, ranging from more comorbid and frail patients to the presence of complex, calcified and multiple coronary lesions. Considering that elderly patients are under-represented in randomized clinical trials (RCT), the aim of this systematic review is to summarize the current knowledge on the revascularization of the elderly patient with myocardial infarction and multivessel coronary artery disease. Methods A systematic review following PRISMA guidelines has been performed. The search was conducted on Pubmed (Medline), Cochrane library, Google Scholar and Biomed Central databases between January and February 2022. We selected the articles focusing on patients hospitalized for myocardial infarction (MI) with multivessel disease and aged 75 years or older. A total of 36 studies have been included. Results Multivessel coronary artery disease is present in around 50-60% of older patients with MI. The in-hospital mortality rate of patients older than 75 years is double compared to their younger counterpart, and the most prevalent complications after revascularization are bleeding and renal failure. In the treatment of patients with ST elevation MI (STEMI), primary percutaneous coronary intervention should be the first choice over fibrinolysis. However, it is not clear whether this population would benefit from complete revascularization or not. In patients with non-ST elevation MI (NSTEMI), an invasive approach with either percutaneous coronary intervention or coronary artery bypass graft may be chosen, but a conservative strategy is also accepted. There are no data from large trials about the comparison of possible revascularization strategies in NSTEMI patients. Conclusions This systematic review shows that this field of research lacks randomized clinical trials to guide revascularization strategy in older STEMI or NSTEMI patients with MI. New results are expected from ongoing trials.
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Affiliation(s)
- Rita Pavasini
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Federico Sanguettoli
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Luca Zanarelli
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Maria Angela Deserio
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Nicola Bianchi
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Gioele Fabbri
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Matteo Tebaldi
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Simone Biscaglia
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Gianluca Campo
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
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Antithrombotic Therapy in Elderly Patients with Acute Coronary Syndromes. J Clin Med 2022; 11:jcm11113008. [PMID: 35683397 PMCID: PMC9181473 DOI: 10.3390/jcm11113008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.
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Revascularization Strategies for Multivessel Coronary Artery Disease in the Elderly Population. J Surg Res 2021; 270:444-454. [PMID: 34798427 DOI: 10.1016/j.jss.2021.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 09/23/2021] [Accepted: 10/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prospective trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary disease (MVCAD) have included mostly younger patients. We compared treatment strategies in the elderly population. MATERIALS AND METHODS We performed a propensity-score-matched comparison of patients ≥75 y who underwent isolated CABG or PCI for MVCAD between 2011 and 2018, excluding those with prior cardiac surgery and/or significant left main disease. The primary outcome was 5-year Kaplan Meier survival, and secondary outcomes included readmissions and major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS Propensity-matching yielded 536 patients (266 PCI and 266 CABG). Rates of complete revascularization of all stenotic lesions were higher in the CABG arm (86.8% versus 21.8%; P < 0.001). Thirty-d mortality was similar between cohorts, though PCI recipients had shorter hospital stay and greater likelihood of discharge to home. Unadjusted one- (89.1% versus 88.4%) and 5-year (73.8% versus 60.1%) survival were both higher in patients who underwent CABG (P = 0.0332). Patients undergoing CABG had reduced, but nonsignificant cumulative incidence of all-cause hospital readmission and MACCE at 5 y. Subgroup analysis of patients 80 y or older revealed similar late survival benefit with CABG when compared to PCI. Among patients undergoing CABG, there did not appear to be any 5-year benefits from multi-arterial grafting. CONCLUSIONS Despite longer hospitalization and higher rate of nonhome discharge, CABG was associated with improved late survival over PCI in the elderly population. Cardiac surgeons should be included in the multidisciplinary evaluation of older patients with MVCAD.
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7
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Kanazawa N, Yamada S, Fushimi K. Trends in the Use of Cardiac Rehabilitation in Japan Between 2010 and 2017 - An Epidemiological Survey. Circ Rep 2021; 3:569-577. [PMID: 34703934 PMCID: PMC8492403 DOI: 10.1253/circrep.cr-21-0018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/16/2021] [Accepted: 08/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Despite the prognostic effectiveness of cardiac rehabilitation (CR) in patients with cardiovascular disease (CVD), it has been underutilized. Understanding the trend of dissemination of CR over the years would help provide a perspective of CR in Japan. Methods and Results: A retrospective epidemiological survey between fiscal years 2010 and 2017 was conducted using the diagnosis procedure combination database (a Japanese administrative database). Data on 2,046,302 patients with CVD from 1,632 hospitals were extracted. The proportion of CR-certified hospitals among hospitals treating patients with CVD increased from 31.6% in 2010 to 56.6% in 2017. Over the same period, the participation rate in inpatient CR (ICR) increased from 18.3% to 39.0%, but the participation rate in outpatient CR (OCR) remained low (from 1.4% to 2.5%). The CR participation rates varied widely according to the main disease group. Approximately 95% of ICR participants did not continue CR after discharge. Conclusions: The number of CR-certified hospitals increased from 2010 to 2017, leading to increased ICR participation across patients with CVD; however, OCR has remained extremely underutilized. Immediate action is urgently required to increase the use of OCR.
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Affiliation(s)
- Natsuko Kanazawa
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School Tokyo Japan.,Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Tokyo Japan
| | - Sumio Yamada
- Department of Health Sciences, Graduate School of Medicine, Nagoya University Nagoya Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School Tokyo Japan.,Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Tokyo Japan
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Savitz ST, Falk K, Stearns SC, Grove L, Rossi J. Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge. Clin Cardiol 2021; 44:627-635. [PMID: 33755210 PMCID: PMC8119835 DOI: 10.1002/clc.23583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 01/09/2023] Open
Abstract
Background Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential. Hypothesis We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization. Methods We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007–2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30‐day readmissions/death. Results CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30‐day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30‐day readmissions/death compared to PCI. Conclusions While CABG was associated with higher rates of SNF use and 30‐day readmission/death overall, CABG was associated with significantly lower rates of 30‐day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high‐risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.
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Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
- Division of Health Care Delivery ResearchMayo ClinicRochesterMinnesotaUSA
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kristine Falk
- Division of Cardiology, UNC School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Lexie Grove
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Joseph Rossi
- Division of Cardiology, UNC School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Gimbel ME, Willemsen LM, Daggelders MC, Kelder JC, Oirbans T, Beukema KF, Daeter EJ, Ten Berg JM. Long-term follow-up after bypass surgery or coronary stenting in elderly with multivessel disease. Neth Heart J 2020; 28:467-477. [PMID: 32333255 PMCID: PMC7431514 DOI: 10.1007/s12471-020-01415-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background We sought to compare long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in elderly patients with left main or multivessel disease, hypothesising that completeness of revascularisation and severity of coronary artery disease are predictors of adverse outcomes. Methods Patients aged ≥75 years with multivessel disease or left main disease who underwent PCI or CABG between 2012–2016 were included in this retrospective cohort study. Baseline characteristics from the index procedure were collected. Severity of coronary artery disease and completeness of revascularisation were assessed. Primary outcome was all-cause mortality, in addition we captured major adverse cardiac and cerebral events, bleedings, recurrent angina and new onset atrial fibrillation. Results A total of 597 patients were included. Median follow-up was 4 years (interquartile range 2.8–5.3 years). At baseline, patients in the PCI group more often had a previous medical history of CABG and more frequently underwent an urgent procedure compared with patients in the CABG group. Mortality at 5‑year follow-up was significantly higher in patients who underwent PCI compared with CABG (39.9% vs 25.4%, p < 0.001). Furthermore, acute coronary syndrome (ACS), repeat revascularisation and recurrent angina occurred more frequently after PCI, while occurrence of bleedings and new onset atrial fibrillation were more frequent after CABG. Neither completeness of revascularisation nor severity of coronary artery disease was a predictor for any of the outcomes. Conclusion Long-term mortality was higher in elderly patients with multivessel disease undergoing PCI compared with CABG. In addition, patients undergoing PCI had a higher risk of ACS, repeat revascularisation and recurrent angina.
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Affiliation(s)
- M E Gimbel
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - L M Willemsen
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M C Daggelders
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Kelder
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T Oirbans
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - K F Beukema
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J Daeter
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J M Ten Berg
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Skarupskienė I, Adukauskienė D, Kuzminskienė J, Rimkutė L, Balčiuvienė V, Žiginskienė E, Kuzminskis V, Adukauskaitė A, Pentiokinienė D, Bumblytė IA. Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery. Medicina (B Aires) 2017; 53:217-223. [DOI: 10.1016/j.medici.2017.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/16/2017] [Accepted: 06/26/2017] [Indexed: 01/12/2023] Open
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11
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Tan Q, Wang Q, Liu D, Zhang S, Zhang Y, Li Y. Intravascular ultrasound-guided unprotected left main coronary artery stenting in the elderly. Saudi Med J 2016; 36:549-53. [PMID: 25935174 PMCID: PMC4436750 DOI: 10.15537/smj.2015.5.11251] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To investigate whether intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) could improve clinical outcomes compared with angiography-guided PCI in the treatment of unprotected left main coronary artery stenosis (ULMCA) in the elderly. METHODS This controlled study was carried out between October 2009 and September 2012, in Qinhuangdao First Hospital, Hebei Province, China. One hundred and twenty-three consecutive patients with ULMCA, aged 70 or older, were randomized to an IVUS-guided group and a control group. The occurrence of major adverse cardiac events (MACE): death, non-fatal myocardial infarction, or target lesion revascularizations) were recorded after 2 years of follow-up. RESULTS The IVUS-guided group had a lower rate of 2-year MACE than the control group (13.1% versus 29.3%, p=0.031). The incidence of target lesion revascularization was lower in the IVUS-guided group than in the control group (9.1% versus 24%, p=0.045). However, there were no differences in death and myocardial infarction in the 2 groups. On Cox proportional hazard analysis, distal lesion was the independent predictor of MACE (hazard ratio [HR]: 1.99, confidence interval [CI]: 1.129-2.367; p=0.043); IVUS guidance was independent factor of survival free of MACE (HR: 0.414, CI: 0.129-0.867; p=0.033). CONCLUSION The use of IVUS could reduce MACE in elderly patients undergoing ULMCA intervention.
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Affiliation(s)
- Qiang Tan
- Department of Cardiology, Qinhuangdao First Hospital, Hebei Medical University, No. 258 Wenhua Road, Qinhuangdao, Hebei Province 066000, China. E-mail.
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Barsoum EA, Azab B, Patel N, Spagnola J, Shariff MA, Kaleem U, Morcus R, Asti D, McGinn JT, Lafferty J, McCord DA. Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly. Open Cardiovasc Med J 2016; 10:11-8. [PMID: 27014373 PMCID: PMC4780507 DOI: 10.2174/1874192401610010011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/20/2015] [Accepted: 09/22/2015] [Indexed: 11/22/2022] Open
Abstract
Background: Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD. Methods: A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up.
Results: Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014).
Conclusion: Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.
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Affiliation(s)
- Emad A Barsoum
- Department of Medicine, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Basem Azab
- Department of General Surgery, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Nileshkumar Patel
- Department of Medicine, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Jonathan Spagnola
- Department of Medicine, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Masood A Shariff
- Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Umar Kaleem
- Department of Medicine, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Rewais Morcus
- Department of Medicine, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Deepak Asti
- Department of Cardiology, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Joseph T McGinn
- Department of General Surgery, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA; Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - James Lafferty
- Department of Cardiology, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
| | - Donald A McCord
- Department of Cardiology, Staten Island University Hospital, North Shore-LIJ Health System, Staten Island, New York, USA
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Sinclair H, Kunadian V. Coronary revascularisation in older patients with non-ST elevation acute coronary syndromes. Heart 2016; 102:416-24. [PMID: 26740483 DOI: 10.1136/heartjnl-2015-307859] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 11/14/2015] [Indexed: 12/22/2022] Open
Abstract
With an ageing population, older patients with non-ST elevation acute coronary syndrome are at higher risk of adverse outcomes but are far less likely to receive invasive revascularisation, contemporary antiplatelet therapy or drug-eluting stents than their younger counterparts. Accurate risk stratification in the older age groups may aid individualised decision-making with respect to identifying which patients will benefit most from invasive revascularisation, but more research is needed in this field. Based on current knowledge in this field, it would be appropriate following risk stratification to offer optimal medical therapy plus invasive care to older patients at high risk of future cardiovascular events but at low risk of complications and to offer optimal medical therapy alone to those who are deemed low risk of future events with high risk of developing procedural complications and severely frail patients.
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Affiliation(s)
- Hannah Sinclair
- Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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McCune C, McKavanagh P, Menown IB. A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients. Cardiol Ther 2015; 4:95-116. [PMID: 26396083 PMCID: PMC4675753 DOI: 10.1007/s40119-015-0047-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Indexed: 12/21/2022] Open
Abstract
The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.
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Affiliation(s)
- Claire McCune
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK.
| | - Peter McKavanagh
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK
| | - Ian B Menown
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK
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15
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Worrall-Carter L, McEvedy S, Wilson A, Rahman MA. Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome. Catheter Cardiovasc Interv 2015; 87:E128-36. [PMID: 26277889 DOI: 10.1002/ccd.26117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/06/2015] [Accepted: 07/05/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine the impact of gender and comorbidity on use of coronary interventions in patients diagnosed with high-risk non-ST-segment acute coronary syndrome (NSTEACS). BACKGROUND Guidelines recommend the use of coronary angiography for all patients diagnosed with NSTEACS with high-risk features, except in the presence of severe comorbidities. However, little is understood about the relationship between gender, comorbidity, and the use of coronary interventions. METHODS Retrospective analyses of the Victorian Admitted Episodes Data Set (VAED) including all patients diagnosed with NSTEACS with high-risk features on their first admission for ACS between June 2007 and July 2009. Hierarchical logistic regression models and correspondence analyses were used to understand the relationship between gender, comorbidities, and the use of coronary interventions. RESULTS Out of 16,771 NSTEACS patients with high-risk features, 6,338 (38%) were female. Females were older than males (aged ≥75: 62% vs 39%, p < 0.001) and more likely to have multiple comorbidities (≥2: 66% vs 59%, p < 0.001). After adjusting for potential confounders, females were more likely to receive no coronary intervention than males with a similar number of comorbid conditions (no comorbidities: OR 1.62, 95% CI 1.28-2.05; 1 comorbidity: OR 1.67, 95% CI 1.44-1.93; 2 comorbidities: OR 1.93, 95% CI 1.66-2.23; ≥3 comorbidities: OR 1.42, 95% CI 1.27-1.60). CONCLUSIONS Lower rates of coronary intervention in females persisted after adjusting for number of comorbidities which suggests that gender may bias decisions regarding referral for coronary intervention in high-risk NSTEACS independent of other factors.
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Affiliation(s)
- Linda Worrall-Carter
- St Vincent's Centre for Nursing Research (SVCNR), Australian Catholic University, Melbourne, Australia.,St Vincent's Hospital, Melbourne, Australia.,The Cardiovascular Research Centre (CvRC), Australian Catholic University, Melbourne, Australia
| | - Samantha McEvedy
- St Vincent's Centre for Nursing Research (SVCNR), Australian Catholic University, Melbourne, Australia
| | - Andrew Wilson
- St Vincent's Hospital, Melbourne, Australia.,The Cardiovascular Research Centre (CvRC), Australian Catholic University, Melbourne, Australia.,The University of Melbourne, Melbourne, Australia.,Department of Health, VicHealth, Victorian Cardiology Clinical Network, Melbourne, Australia
| | - Muhammad Aziz Rahman
- St Vincent's Centre for Nursing Research (SVCNR), Australian Catholic University, Melbourne, Australia.,The Cardiovascular Research Centre (CvRC), Australian Catholic University, Melbourne, Australia.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.09.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2089] [Impact Index Per Article: 208.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354-94. [PMID: 25249586 DOI: 10.1161/cir.0000000000000133] [Citation(s) in RCA: 747] [Impact Index Per Article: 74.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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19
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e344-426. [PMID: 25249585 DOI: 10.1161/cir.0000000000000134] [Citation(s) in RCA: 636] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Rahman A, Islam AM. Unprotected left main percutaneous coronary intervention in a 108-year-old patient. Korean Circ J 2014; 44:113-7. [PMID: 24653741 PMCID: PMC3958605 DOI: 10.4070/kcj.2014.44.2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/26/2013] [Accepted: 10/01/2013] [Indexed: 02/05/2023] Open
Abstract
With the increase in life expectancy, the proportion of very elderly people is increasing. Coronary artery disease (CAD) is an important cause of mortality and morbidity in this age group, for which myocardial revascularization is often indicated. Percutaneous coronary intervention (PCI) in the very elderly bears the inherent risks of complications and mortality, but the potential benefits may outweigh these risks. A number of observational studies, registries, and few randomized controlled trials have shown the safety and feasibility of PCI in octogenarians and nonagenarians. However, PCI is only rarely done in centenarians; so, the outcome of percutaneous coronary revascularization in this age group is largely unknown. PCI in a centenarian with complex CAD is described here; the patient presented with unstable angina despite optimum medical therapy, and surgery was declined. Good angiographic success was followed by non-cardiac complications, which were managed with a multidisciplinary approach.
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Affiliation(s)
- Afzalur Rahman
- Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh
| | - Akm Monwarul Islam
- Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh
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Kamiya H, Tanzeem N, Akhyari P, Pedraza A, Kallenbach K, Lichtenberg A, Karck M. Impact of severe postoperative complications after cardiac surgery on mortality in patients aged over 80 years. Ann Thorac Cardiovasc Surg 2013; 20:383-9. [PMID: 23903712 DOI: 10.5761/atcs.oa.13-02268] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aims of this study are (1) to investigate the occurrence rate of postoperative complications in patients ≥ 80 years old after cardiac surgery and (2) to elucidate the impact of the most common postoperative complications on mortality. METHODS Between January 1998 and December 2007, 649 patients aged over 80 years received isolated first-time coronary artery bypass graft (CABG), isolated aortic valve replacement (AVR) or a combination of both in our institute. Prospectively entered patient data were analyzed with respect to major complications and outcome parameters. RESULTS Acute renal failure (55.0% vs. 7.5%, p = 0.0001), low cardiac out-put syndrome (43.1% vs. 8.8%, p = 0.0001), sepsis (52.0% vs. 10.3%, p = 0.0001), prolonged respiratory failure with tracheotomy (29.0% vs. 11.0%, p = 0.002), re-thoracotomy due to bleeding (26.9% vs. 10.6%, p = 0.0001), and postoperative laparotomy (30.8% vs. 11.5%, p = 0.033) had a significant impact on mortality. A multivariate analysis revealed that advanced age (OR 1.130, 95%CI; 1.017-1.256, p = 0.023), low output syndrome (OR 5.094, 95%CI; 1.1635-15.871, p = 0.005), renal failure (OR 8.128, 95%CI; 3.347-19.742, p = 0.0001) and sepsis (OR 4.975, 95%CI; 1.420-17.426, p = 0.012) as independent risk factors. CONCLUSIONS The present study demonstrates that among major complications, low output syndrome, renal failure requiring renal replacement therapy and sepsis, dramatically impaired the postoperative course patients aged over 80 years undergoing CABG, AVR or combined CABG and AVR.
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Affiliation(s)
- Hiroyuki Kamiya
- Department of Cardiovascular Surgery, Duesseldorf University Hospital, Duesseldorf, Germany
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22
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Federspiel JJ, Stearns SC, D'Arcy LP, Geissler KH, Beadles CA, Crespin DJ, Carey TS, Rossi JS, Sheridan BC. Resource use trajectories for aged medicare beneficiaries with complex coronary conditions. Health Serv Res 2013; 48:753-72. [PMID: 23347002 DOI: 10.1111/1475-6773.12028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To use coronary revascularization choice to illustrate the application of a method simulating a treatment's effect on subsequent resource use. DATA SOURCES Medicare inpatient and outpatient claims from 2002 to 2008 for patients receiving multivessel revascularization for symptomatic coronary disease in 2003-2004. STUDY DESIGN This retrospective cohort study of 102,877 beneficiaries assessed survival, days in institutional settings, and Medicare payments for up to 6 years following receipt of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). METHODS A three-part estimator designed to provide robust estimates of a treatment's effect in the setting of mortality and censored follow-up was used. The estimator decomposes the treatment effect into effects attributable to survival differences versus treatment-related intensity of resource use. PRINCIPAL FINDINGS After adjustment, on average CABG recipients survived 23 days longer, spent an 11 additional days in institutional settings, and had cumulative Medicare payments that were $12,834 higher than PCI recipients. The majority of the differences in institutional days and payments were due to intensity rather than survival effects. CONCLUSIONS In this example, the survival benefit from CABG was modest and the resource implications were substantial, although further adjustments for treatment selection are needed.
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Affiliation(s)
- Jerome J Federspiel
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA
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D'Arcy LP, Stearns SC, Domino ME, Hanson LC, Weinberger M. Is geriatric care associated with less emergency department use? J Am Geriatr Soc 2012; 61:4-11. [PMID: 23252966 DOI: 10.1111/jgs.12039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether community-dwelling individuals and nursing home (NH) residents treated by a geriatrician were less likely to use the emergency department (ED) than individuals treated by other physicians. DESIGN Retrospective cohort study using data from a national sample of older adults with a history of cardiovascular disease. SETTING Ambulatory care or NH. PARTICIPANTS Fee-for-service Medicare beneficiaries aged 66 and older diagnosed with one or more geriatric conditions from 2004 to 2007 and followed for up to 3 years. MEASUREMENTS Emergency department use was measured in Medicare inpatient and outpatient claims; geriatric care was measured as geriatrician visits in ambulatory or NH settings coded in physician claims. RESULTS Multivariable analyses controlled for observed and unobserved subject characteristics that were constant during the study period. For community-dwelling participants, one or more nonhospital geriatrician visits in a 6-month period were associated with 11.3% lower ED use the following month (95% confidence interval (CI) = 7.5-15.0, N = 287,259). Participants who received primary care from geriatricians were less likely to have ED use than those who had traditional primary care. Results for participants who received consultative care from geriatricians were similar to those for participants who received primary care from geriatricians. Results for NH residents (N = 66,551) were similar to those for community-dwelling participants. CONCLUSION Geriatric care was associated with an estimated 108 fewer ED visits per 1,000 community-dwelling residents and 133 fewer ED visits per 1,000 NH residents per year. Geriatric consultative care in collaboration with primary care providers may be as effective in reducing ED use as geriatric primary care. Increased provision of collaborative care could allow the existing supply of geriatricians to reach a larger number of individuals.
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Affiliation(s)
- Laura P D'Arcy
- Mathematica Policy Research, Inc., Washington, District of Columbia 20002, USA.
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Mediratta N, Chalmers J, Pullan M, McShane J, Shaw M, Poullis M. In-hospital mortality and long-term survival after coronary artery bypass surgery in young patients. Eur J Cardiothorac Surg 2012; 43:1014-21. [DOI: 10.1093/ejcts/ezs459] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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O'Boyle F, Mediratta N, Chalmers J, Al-Rawi O, Mohan K, Shaw M, Poullis M. Long-term survival of patients with pulmonary disease undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg 2012; 43:697-703. [PMID: 23096454 DOI: 10.1093/ejcts/ezs454] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to investigate the long-term survival of patients with obstructive, restrictive and chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). METHODS A prospective database was retrospectively analysed and cross-correlated with the UK strategic tracking service to evaluate survival after primary coronary artery bypass grafts (CABG). Univariate and multivariate Cox regression analyses were performed. Three separate multivariate analyses were performed: COPD GOLD criteria for obstructive and/or restrictive lung disease, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and the FEV1/FVC ratio to investigate the effect of FEV1 and FVC individually. RESULTS We analysed 13 337 primary CABG procedures. The median follow-up was 7 years. Univariate analysis demonstrated that obstructive (P < 0.0001), restrictive (P < 0.0001) and mixed obstructive and restrictive pulmonary disease (P < 0.0001), and COPD as defined by the GOLD criteria (P < 0.0001), are all significant factors determining long-term survival. Cox regression analysis identified age, diabetes, moderate LV, poor LV, peripheral vascular disease, dialysis, left internal mammary artery (LIMA) usage, EuroSCORE, cardiopulmonary bypass and creatinine kinase muscle-brain isoenzyme as significant factors in addition to pulmonary disease that determine long-term survival. Moderate and severe COPD defined by GOLD criteria were significant factors determining long-term survival, but mild COPD had no significant effect. Obstructive and restrictive lung disease were both significant factors determining long-term survival. Restrictive lung disease, however, carried a greater prognostic significance (higher hazard ratio 2.2 vs 1.6) than obstructive. LIMA utilization in patients with COPD was not associated with an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate. CONCLUSIONS Pulmonary disease is a significant factor determining long-term survival. Patients with severe COPD still have a relatively good long-term survival and should not be denied surgery. LIMA utilization in patients with COPD results in a significantly increased long-term survival, without an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate.
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Affiliation(s)
- Francesca O'Boyle
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Van de Werf F, Ardissino D, Bueno H, Collet JP, Gershlick A, Kolh P, Kristensen SD, Silber S, Verheugt F, Wojakowski W. Acute coronary syndromes: considerations for improved acceptance and implementation of management guidelines. Expert Rev Cardiovasc Ther 2012; 10:489-503. [PMID: 22458581 DOI: 10.1586/erc.12.20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The management of acute coronary syndrome in Europe is covered by various European Society of Cardiology guidelines, which although valuable, are complex and may not always provide clear guidance in everyday clinical practice. Consequently, implementation of the guideline recommendations is frequently suboptimal. To complicate matters further, a wealth of new data from large trials examining novel anti-thrombotic agents will become or are already available, necessitating guideline updates. This article summarizes the gaps between current guideline-recommended treatment of acute coronary syndrome and daily practice as dictated by the evidence base, including recent trials. Reasons for the suboptimal implementation of the current European Society of Cardiology guidelines and possible solutions to making these more practice oriented are presented.
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Affiliation(s)
- Frans Van de Werf
- Department of Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Yanagawa B, Algarni KD, Yau TM, Rao V, Brister SJ. Improving results for coronary artery bypass graft surgery in the elderly. Eur J Cardiothorac Surg 2012; 42:507-12. [PMID: 22246966 DOI: 10.1093/ejcts/ezr300] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The proportion of elderly patients undergoing isolated coronary artery bypass grafting (CABG) surgery has steadily increased. We have evaluated temporal trends in hospital outcomes of patients who were 75 years and older undergoing CABG (1990-2010) at our institution. METHODS Data were collected prospectively for 3483 consecutive patients who were 75 years and older (median 78 years; range 75-94) undergoing isolated CABG at our institution over three time cohorts: 1990-96 (n = 817), 1997-2003 (n = 1534) and 2004-10 (n = 1132). RESULTS Overall mortality declined from 6.0% (49/817) in the earliest era (1990-96) to 1.9% (22/1132) in the most recent era (2003-10; P < 0.001). Mortality in low-risk patients (elective, primary surgery with the ejection fraction >40%) was 5.9% (13/220), 0.8% (4/514) and 0% (0/411) in the first, second and third eras, respectively (P < 0.001). Despite the overall increase in comorbidities in our elderly patients, the prevalences of certain risk factors such as poor LV function, urgency of surgery and reoperation have all declined with time. The independent risk factors for mortality in our population were congestive heart failure, left main disease, earlier year of operation, reoperation, preoperative myocardial infarction, cardiopulmonary bypass time, emergent/urgent surgery and peripheral vascular disease. Of these, earlier year of operation (OR: 3.0; 95% CI: 1.8-5.2) was the most significant predictor. Also, age >80 did not predict mortality. CONCLUSIONS The principle finding from this analysis is a contemporary low operative mortality for CABG in an elderly patient cohort. Risk of death is particularly low in a low-risk subset of elderly patients with reasonable LV function undergoing elective, primary CABG.
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Affiliation(s)
- Bobby Yanagawa
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Canada
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O'Boyle F, Mediratta N, Fabri B, Pullan M, Chalmers J, McShane J, Shaw M, Poullis M. Long-term survival after coronary artery bypass surgery stratified by EuroSCORE. Eur J Cardiothorac Surg 2012; 42:101-6; discussion 106-7. [DOI: 10.1093/ejcts/ezr253] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options? CURRENT CARDIOVASCULAR RISK REPORTS 2011. [DOI: 10.1007/s12170-011-0195-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Contemporary perioperative results of cardiac surgery in the elderly- our experience. Indian J Thorac Cardiovasc Surg 2011. [DOI: 10.1007/s12055-010-0076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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