Mortality and myocardial infarction following surgical versus percutaneous revascularization of isolated left anterior descending artery disease: a meta-analysis

Long-term Incidence of Myocardial Infarction and Death After CABG and PCI for Isolated Left Anterior Descending Artery Disease: A Meta-analysis of Randomized Controlled Trials

Background

To compare the long-term incidence of myocardial infarction (MI) and death in patients randomized to coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) for treatment of isolated left anterior descending (LAD) coronary artery disease.

Methods

We systematically identified all randomized controlled trials comparing PCI with stenting to CABG with a left internal mammary artery (LIMA) graft in patients with isolated LAD disease who had at least 4 years of follow-up. The primary outcome of interest was MI. Secondary outcomes were all-cause mortality and target vessel revascularization (TVR).

Results

Four trials were included in the current analysis, with a total of 573 patients randomized to CABG with a LIMA (n = 285) vs PCI (n = 288) and followed for 4 to 10 years. At latest follow-up (weighted mean 8.3 years), there was no statistically significant difference in the risk of MI between CABG and PCI (relative risk [RR], 1.33; 95% CI, 0.62-2.83; P = .46), nor was there a statistically significant difference in mortality between the groups (RR, 1.04; 95% CI, 0.70-1.65; P = .84). There was a significantly lower risk of TVR after CABG compared with PCI (RR, 0.27; 95% CI, 0.15-0.46; P < .001).

Conclusions

The current meta-analysis suggests that there is insufficient evidence that CABG with a LIMA confers protection against MI or death compared to PCI with a stent for isolated LAD disease. CABG was, however, associated with reduced rates of TVR.

Percutaneous coronary invervention versus coronary artery bypass grafting: a meta-analysis

OBJECTIVE

To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease.

METHODS

MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up.

RESULTS

This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01).

CONCLUSIONS

Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.

Minimally invasive direct coronary artery bypass in the era of percutaneous coronary intervention

AIM

Minimally invasive coronary artery bypass (MIDCAB) allows revascularization of the left anterior descending coronary (LAD) artery through a less traumatic surgical approach. However, the procedure is technically challenging and concern still exists, mainly based on graft patency. The purpose of this study is to critically evaluate short and long-term benefits of this surgical treatment.

METHODS

Between June 1997 and July 2012, 306 patients underwent MIDCAB on LAD. The mean age was 62 ± 10 years (range, 32-87 years) and 264 patients (86.3%) were men. Mean ejection fraction was 54%. Eighty-nine procedures (29.1%) were performed using a hybrid approach by means of MIDCAB and postoperative (60 patients, 67.4%) or preoperative (29 patients, 32.6%) percutaneous interventions on non-LAD vessels. A EuroScore more than 6 was found in 43 (14%) patients. The average follow-up time was 9.5 ± 3.2 years and was 89% complete.

RESULTS

Six patients (1.9%) required intraoperative conversion to sternotomy, whereas cardiopulmonary bypass institution after the sternotomy was necessary in one. Postoperative acute myocardial infarction occurring nine patients (2.9%), low output syndrome in four (1.3%). Postoperative mortality was 1.6% (n = 5), and perioperative stroke rate 0.6% (n = 2). Five and 10-year survival were 94.1 and 86.9%, respectively. Freedom from death due to cardiac events and major cardiac and cerebral events at 10 years was, respectively, 97.1 and 92.1%.

CONCLUSIONS

The results confirm the favorable short and long-term results of the MIDCAB procedure. MIDCAB, in experienced centers, can represent an alternative treatment option for LAD disease.

Temporal trend analysis of avoidable mortality in Taiwan, 1971-2008: overall progress, with areas for further medical or public health investment

BACKGROUND

Avoidable mortality (AM), or "unnecessary untimely death," is considered an indicator of health care quality. We investigated trends in the age-standardized mortality rates (ASMRs) and associated standard expected years of life lost (SEYLL) for deaths amenable to medical care or public health measures in Taiwan from 1971-2008, with an emphasis on identifying areas where additional medical or public health investment may help reduce the burden of AM.

METHODS

Taiwan's ASMRs per 100,000 for AM and other causes of death were calculated using data from the National Death Certificate Registry in five-year bins from 1971 to 2008. SEYLL rates per 100,000 were calculated annually from 1971 to 2008 using the same data source.

RESULTS

ASMR for almost all AM and other causes of death declined dramatically from 1971 to 2008 except for lung cancer (16.6% and 7.4% increase among men and women, respectively) and breast cancer (109.8% increase among women). In the same period, SEYLL due to lung cancer increased from 269.2 to 555.7 for men and 249.7 to 342.5 for women. For women, SEYLL due to breast cancer increased from 263.5 in 1971 to 659.3 in 2008. There were gender-specific differences in the reduction (or increase) in AM rates, with women showing larger rates of reduction or smaller rates of increase. Among men, AM fell by 65.9% from 1971-1975 to 2006-2008, and deaths from other causes increased by 15.6%. Among women, AM and deaths from other causes fell by 80.8% and 59.8% respectively. SEYLL decreased, respectively among males and females, from 23,147.3 and 24,081.1 in 1971 to 11,261.8 and 5,929.6 in 2008.

CONCLUSION

From 1971 to 2008, Taiwan experienced a dramatic reduction in most AM and corresponding SEYLL except for lung cancer (for both males and females) and breast cancer (for females). Additional effort should be devoted to public health measures to combat the rising prevalence of smoking in Taiwan, which may be responsible for the increasing AM from lung cancer. If AM in breast cancer continues unabated in the future, greater policy emphasis on the early detection and treatment of breast cancer may also be warranted.

Survival of cancer patients treated with mistletoe extract (Iscador): a systematic literature review

Background

In Europe, extracts from Viscum album (VA-E), the European white-berry mistletoe, are widely used to treat patients with cancer.

Methods

We searched several databases such as Cochrane, EMBASE, NCCAM, NLM, DIMDI, CAMbase, and Medline. Inclusion criteria were controlled clinical studies on parameters associated with survival in cancer patients treated with Iscador. Outcome data were extracted as they were given in the publication, and expressed as hazard ratios (HR), their logarithm, and the respective standard errors using standard formulas.

Results

We found 49 publications on the clinical effects of Iscador usage on survival of cancer patients which met our criteria. Among them, 41 studies and strata provided enough data to extract hazard ratios (HR) and their standard errors (Iscador versus no extra treatment). The majority of studies reported positive effects in favour of the Iscador application. Heterogeneity of study results was moderate (I² = 38.3%, p < 0.0001). The funnel plots were considerably skewed, indicating a publication bias, a notion which is corroborated by statistical means (AC = -1.3, CI: -1.9 to -0.6, p <= 0.0001). A random effect meta-analysis estimated the overall hazard ratio at HR = 0.59 (CI: 0.53 to 0.66, p < 0.0001). Randomized studies showed less effects than non-randomized studies (ratio of HRs: 1.24, CI: 0.79 to 1.92, p = 0.35), and matched-pair studies gave significantly better results than others (ratio of HRs: 0.33; CI: 0.17 to 0.65, p = 0.0012).

Conclusions

Pooled analysis of clinical studies suggests that adjuvant treatment of cancer patients with the mistletoe extract Iscador is associated with a better survival. Despite obvious limitations, and strong hints for a publication bias which limits the evidence found in this meta-analysis, one can not ignore the fact that studies with positive effects of VA-E on survival of cancer patients are accumulating. Future studies evaluating the effects of Iscador should focus on a transparent design and description of endpoints in order to provide greater insight into a treatment often being depreciated as ineffective, but highly valued by cancer patients.

Hyperglycemia attenuates angiogenic capability of survivin in endothelial cells

Survivin, an anti-apoptotic protein, can be induced by hypoxia and contributes to angiogenic activity in endothelial cells. To determine the potential mechanism of survivin in endothelial dysfunction caused by hyperglycemia in diabetes, we evaluated the role of survivin in hyperglycemia and its effect on endothelial homeostasis. We demonstrated that an increase of D-glucose was sufficient to down-regulate survivin expression, impacting survivin's angiogenic role in endothelial cells. We additionally showed that survivin expression was increased in response to hypoxia yet this reaction was mitigated when the endothelial cells were in hyperglycemic conditions prior to hypoxia. Hyperglycemia also affected survivin-related proliferation and migration of endothelial cells and increased the number of apoptotic cells. In the ischemic porcine myocardium, the expression of survivin was induced. Moreover, survivin expression in the aorta, myocardium, and isolated endothelial cells was attenuated in a porcine model of diabetes in comparison to non-diabetes, which correlated negatively with the levels of fasting blood sugars and positively with territory perfusion. These results demonstrate that hyperglycemia critically alters survivin expression in vitro and in vivo, which leads to attenuation of angiogenic activity and impacts endothelial metabolism.

Sirolimus-eluting stent implantation for treatment of proximal left anterior descending coronary artery lesions: long-term outcome and predictors of adverse cardiac events

OBJECTIVES

Acute and long-term results after sirolimus-eluting stent (SES) implantation of proximal left anterior descending coronary artery (LAD) disease were evaluated.

BACKGROUND

Although SES has been used increasingly for the treatment of LAD disease, data regarding their safety and efficacy in a real-world population are limited.

METHODS

We investigate the short- and long-term results in 966 patients who underwent SES implantation for stenosis of proximal LAD.

RESULTS

The procedural success rate was 97.6%, and procedural non-Q-wave myocardial infarction (MI) rate was 14.5%. In-hospital major complications occurred in five patients (0.5%), including three deaths and two Q-wave MIs. During follow-up (20.4 +/- 8.9 months), there were 16 deaths (1.7%; 10 cardiac, 6 noncardiac), 2 Q-wave MIs, and 22 target lesion revascularizations (2.3%). Late stent thrombosis occurred in two patients (0.2%), 14 and 23 months after the procedure. The event-free survival rates for cardiac death/Q-wave MI were 98.6% +/- 0.4% at 1 year and 97.8% +/- 0.6% at 2 years. The cumulative probabilities of survival without major adverse cardiac events (MACE) were 96.7% +/- 0.6% at 1 year and 95.4% +/- 0.8% at 2 years. In multivariate analysis, stented length (HR 1.04, 95%CI 1.01-1.07, P = 0.009) and infarct-related artery (HR 5.18, 95%CI 1.09-24.64, P = 0.039) were independently related to cardiac death/Q-wave MI. In addition, stented length (HR 1.04, 95%CI 1.02-1.06, P < 0.001) and left ventricular dysfunction (HR 2.66, 95%CI 1.07-6.63, P = 0.036) were significant independent predictors of MACE.

CONCLUSIONS

SES implantation for proximal LAD disease appears safe and effective in a real-world population, and the independent predictors of MACE included stented length and left ventricular dysfunction.

Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery

OBJECTIVE

To compare outcomes between minimally invasive left internal thoracic artery bypass and percutaneous coronary artery stenting as primary interventions for isolated lesions of the left anterior descending artery.

DESIGN

Meta-analysis of randomised and non-randomised comparative peer reviewed publications.

DATA SOURCES

Embase, Medline, Cochrane, Google Scholar, and Health Technology Assessment databases (1966-2005).

REVIEW METHODS

Studies comparing the two procedures as the primary intervention for isolated left anterior descending artery stenosis were identified and the following extracted: study design, population characteristics, severity of coronary artery disease, cardiovascular risk factors, and outcomes of interest.

RESULTS

12 studies (1952 patients) reporting results from eight groups were included: one was a retrospective design, one prospective non-randomised, and six prospective randomised. Meta-analysis of randomised trials showed a higher rate of recurrence of angina (odds ratio 2.62, 95% confidence interval 1.32 to 5.21), incidence of major adverse coronary and cerebral events (2.86, 1.62 to 5.08), and need for repeat revascularisation (4.63, 2.52 to 8.51) with percutaneous stenting. No significant difference was found in myocardial infarction, stroke, or mortality at maximum follow-up between interventions.

CONCLUSIONS

Minimally invasive left internal thoracic artery bypass for isolated lesions of the left anterior descending artery resulted in fewer complications in the mid-term compared with percutaneous transluminal coronary artery stenting.

Avoidable mortality across Canada from 1975 to 1999

BACKGROUND

The concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes.

METHODS

National and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975-1979, 1980-1985, 1985-1989, 1990-1994, and 1995-1999). The proportion of all-cause mortality attributable to avoidable causes was also determined.

RESULTS

From 1975-1979 to 1995-1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends.

CONCLUSION

The regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health.