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Lucca MB, Fuchs FC, Almeida AS, Wainstein MV, Fuchs FD, Fuchs SC. Secondary Pharmacological Prevention of Coronary Artery Disease among Patients Submitted to Clinical Management, Percutaneous Coronary Intervention, or Coronary Artery Bypass Graft Surgery. Arq Bras Cardiol 2023; 120:e20220403. [PMID: 36888779 DOI: 10.36660/abc.20220403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/16/2022] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Secondary prevention is recommended for patients with evidence of coronary artery disease (CAD) regardless of the indication for treatment by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). OBJECTIVES This study evaluated whether clinical treatment, PCI or CABG had an influence on adherence to the pharmacological secondary prevention in patients with stable CAD. METHODS This cohort included patients aged ≥40 years with stable CAD confirmed by coronary angiography. The decision for medical treatment alone, or additionally with PCI or CABG, was made by the attending physicians. Adherence to the prescribed drugs recommended by the guidelines for secondary prevention (optimal pharmacological treatment), including antiplatelet agents, lipid-lowering drugs, beta-blockers, and renin-angiotensin-aldosterone system blockers, was assessed at follow-up. Differences were considered significant for p values <0.05. RESULTS From 928 patients enrolled at baseline, 415 had mild CAD and 66 moderate to severe CAD. The average follow-up was 5.2 ± 1.5 years. Patients submitted to CABG were more likely to receive the optimal pharmacological treatment than those submitted to PCI or treated clinically (63.5% versus 39.1% versus 45.7% respectively, p=0.003). Baseline factors independently associated with greater probability of having a prescription of optimal treatment at follow-up were CABG [39% higher (6% - 83%, p=0.017) and diabetes [25% higher (1% - 56%), p=0.042] than their counterparts treated by other methods and participants without diabetes, respectively. CONCLUSIONS Patients with CAD submitted to CABG are more commonly treated with optimal pharmacological secondary prevention than patients treated by PCI or exclusively with medical therapy.
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Affiliation(s)
- Marcelo B Lucca
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Instituto Nacional de Ciência e Tecnologia PREVER - Centro de Pesquisa Clínica - Hospital de Clínicas de Porto Alegre , Porto Alegre , RS - Brasil
| | - Felipe C Fuchs
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil
| | - Adriana S Almeida
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Instituto Nacional de Ciência e Tecnologia PREVER - Centro de Pesquisa Clínica - Hospital de Clínicas de Porto Alegre , Porto Alegre , RS - Brasil
| | - Marco V Wainstein
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil
| | - Flavio D Fuchs
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil
| | - Sandra C Fuchs
- Programa de Pós-graduação em Cardiologia , Faculdade de Medicina , Universidade Federal do Rio Grande do Sul , Porto Alegre , RS - Brasil.,Instituto Nacional de Ciência e Tecnologia PREVER - Centro de Pesquisa Clínica - Hospital de Clínicas de Porto Alegre , Porto Alegre , RS - Brasil
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2
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Farsky PS, White J, Al-Khalidi HR, Sueta CA, Rouleau JL, Panza JA, Velazquez EJ, O'Connor CM. Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2022; 164:1890-1899.e4. [PMID: 33610365 PMCID: PMC8260609 DOI: 10.1016/j.jtcvs.2020.12.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy. METHODS The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug. RESULTS At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation. CONCLUSIONS Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.
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Affiliation(s)
- Pedro S Farsky
- Instituto Dante Pazzanese de Cardiologia and Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Jennifer White
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Carla A Sueta
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jean L Rouleau
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Julio A Panza
- Westchester Medical Center and New York Medical College, Valhalla, NY
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Antoniak DT, Walters RW, Alla VM. Impact of Renin-Angiotensin System Blockers on Mortality in Veterans Undergoing Cardiac Surgery. J Am Heart Assoc 2021; 10:e019731. [PMID: 33969701 PMCID: PMC8200704 DOI: 10.1161/jaha.120.019731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Renin‐angiotensin system blockers (RASBs) have well‐validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30‐day and 1‐year mortality after cardiac surgery. Methods and Results The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10‐year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30‐day and 1‐year mortality than the preoperative exposure/no current exposure (30‐day hazard ratio [HR], 0.25; 95% CI, 0.19–0.33 [P<0.001] and 1‐year HR, 0.40; 95% CI, 0.33–0.48 [P<0.001] or no preoperative exposure/no current exposure (30‐day HR, 0.44; 95% CI, 0.32–0.60 [P<0.001] and 1‐year HR, 0.72; 95% CI, 0.62–0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30‐day (HR, 0.31; 95% CI, 0.14–0.71 [P=0.006]) and 1‐year (HR, 0.64; 95% CI, 0.53–0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group. Conclusions Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.
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Affiliation(s)
- Derrick T Antoniak
- Veterans Affairs Nebraska-Western Iowa Health Care System Omaha NE.,Division of General Internal Medicine Department of Medicine University of Nebraska Medical Center Omaha NE
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences Department of Medicine Creighton University Omaha NE
| | - Venkata M Alla
- Division of Cardiology Department of Medicine Creighton University Omaha NE
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4
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Gharacholou SM, Del-Carpio Munoz F, Motiei A, Sandhu GS, Barsness GW, Gulati R, Wright RS, Pellikka PA, Lewis B, Johnson MP, Lane GE, Pollak PM, Pillai DP, Sabbagh AE, Paul TK, Pham SM, Singh M. Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2020; 135:1-8. [PMID: 32866446 DOI: 10.1016/j.amjcard.2020.08.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022]
Abstract
Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.
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Affiliation(s)
| | | | - Arashk Motiei
- Department of Cardiovascular Medicine, Mayo Health System, Mankato, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - R Scott Wright
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bradley Lewis
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Johnson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Gary E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Peter M Pollak
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Dilip P Pillai
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Timir K Paul
- Division of Cardiology, East Tennessee State University, Johnson City, Tennessee
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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5
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Xenogiannis I, Tajti P, Hall AB, Alaswad K, Rinfret S, Nicholson W, Karmpaliotis D, Mashayekhi K, Furkalo S, Cavalcante JL, Burke MN, Brilakis ES. Update on Cardiac Catheterization in Patients With Prior Coronary Artery Bypass Graft Surgery. JACC Cardiovasc Interv 2019; 12:1635-1649. [DOI: 10.1016/j.jcin.2019.04.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 01/30/2023]
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6
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Pinho-Gomes AC, Azevedo L, Ahn JM, Park SJ, Hamza TH, Farkouh ME, Serruys PW, Milojevic M, Kappetein AP, Stone GW, Lamy A, Fuster V, Taggart DP. Compliance With Guideline-Directed Medical Therapy in Contemporary Coronary Revascularization Trials. J Am Coll Cardiol 2019; 71:591-602. [PMID: 29420954 DOI: 10.1016/j.jacc.2017.11.068] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/26/2017] [Accepted: 11/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite the well-established benefits of secondary cardiovascular prevention, the importance of concurrent medical therapy in clinical trials of coronary revascularization is often overlooked. OBJECTIVES The goal of this study was to assess compliance with guideline-directed medical therapy (GDMT) in clinical trials and its potential impact on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). METHODS The Cochrane Central Register of Controlled Trials and MEDLINE were searched from 2005 to August 2017. Clinical trial registries and reference lists of relevant studies were also searched. Randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization were included. The study outcome was compliance with GDMT, defined as the following: 1) any antiplatelet agent plus beta-blocker plus statin (GDMT1); and 2) any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (GDMT2). Data collection and analysis were performed according to the methodological recommendations of The Cochrane Collaboration. RESULTS From a total of 439 references, 5 trials were included based on our inclusion and exclusion criteria. Overall, compliance with GDMT1 was low and decreased over time from 67% at 1 year to 53% at 5 years. Compliance with GDMT2 was even lower and decreased from 40% at 1 year to 38% at 5 years. Compliance with both GDMT1 and GDMT2 was higher in PCI than in CABG at all time points. Meta-regression suggested an association between lower use of GDMT1 and adverse clinical outcomes in PCI versus CABG at 5 years. CONCLUSIONS Compliance with GDMT in contemporary clinical trials remains suboptimal and is significantly lower after CABG than after PCI, which may influence the comparison of clinical trial endpoints between those study groups.
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Affiliation(s)
| | - Luis Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) & Centre for Health Technology and Services Research (CINTESIS), Faculty of Medicine, Porto University, Porto, Portugal
| | - Jung-Min Ahn
- Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of South Korea
| | - Seung-Jung Park
- Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of South Korea
| | - Taye H Hamza
- New England Research Institutes, Watertown, Massachusetts
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart & Stroke/Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Gregg W Stone
- The New York Presbyterian Hospital, Columbia University Medical Center, Cardiovascular Research Foundation, New York, New York
| | - Andre Lamy
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Valentin Fuster
- Mount Sinai Cardiovascular Institute, New York, New York; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - David P Taggart
- Department of Cardiac Surgery, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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7
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Gilyarevsky SR, Golshmid MV, Kuzmina IM. [Not Available]. KARDIOLOGIIA 2018; 58:17-23. [PMID: 30625074 DOI: 10.18087/cardio.2018.11.10194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
In this article we deal with the problem of low adherence of patients with ischemic heart disease (IHD) to drug therapy congruent to current recommendations including patients who underwent invasive interventions aimed at myocardial revascularization. Based on analysis of literature, we undertake an attempt to answer the question: which of components of this therapy patients with IHD are the least likely to continue taking? We also discuss approaches to the search for optimal composition of a combination preparation with fixed doses of an adreno-blocker and angiotensin converting enzyme inhibitor. Based on analysis of literature we undertook an attempt to answer a question: which of components of this therapy patients with IHD are least likely to continue taking. We also included in this article discussion of approaches to the search of optimal composition of a combination preparation containing fixed doses of a в-adrenoblocker and angiotensin converting enzyme inhibitor, as well as data on the role in the treatment of patients with IHD of bisoprolol and perindopril. Fixed doses of these agents have been included into a novel combination preparation.
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Pereira P, Kapoor A, Sinha A, Agarwal SK, Pande S, Khanna R, Srivastava N, Kumar S, Garg N, Tewari S, Goel P. Do practice gaps exist in evidence-based medication prescription at hospital discharge in patients undergoing coronary artery bypass surgery & coronary angioplasty? Indian J Med Res 2018; 146:722-729. [PMID: 29664030 PMCID: PMC5926343 DOI: 10.4103/ijmr.ijmr_1905_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background & objectives: Prescription patterns of guideline-directed medical therapy (GDMT) after coronary artery bypass surgery [coronary artery bypass graft (CABG)] and percutaneous coronary intervention (PCI) at hospital discharge are often not optimal. In view of scarce data from the developing world, a retrospective analysis of medication advice to patients following CABG and PCI was conducted. Methods: Records of 5948 patients (post-PCI: 5152, post-CABG: 796) who underwent revascularization from 2010 to 2014 at a single tertiary care centre in north India were analyzed. Results: While age and gender distributions were similar, diabetes and stable angina were more frequent in CABG group. Prescription rates for aspirin 100 per cent versus 98.2 per cent were similar, while beta-blockers (BBs, 95.2 vs 90%), statins (98.2 vs 91.6%), angiotensin-converting enzyme inhibitors (89.4 vs 41.4%), nitrates (51.2 vs 1.1%) and calcium channel blockers (6.6 vs 1.6%) were more frequently prescribed following PCI. Despite similar baseline left ventricular ejection fraction (48.1 vs 51.1%), diuretics were prescribed almost universally post-CABG (98.2 vs 10.9%, P<0.001). Nearly all (94.4%) post-CABG patients received a prescription for clopidogrel. Patients undergoing PCI were much more likely to receive higher statin dose; 40-80 mg atorvastatin (72 vs <1%, P<0.001) and a higher dose of BB. Interpretation & conclusions: Significant differences in prescription of GDMT between PCI and CABG patients existed at hospital discharge. A substantial proportion of post-CABG patients did not receive BB and/or statins. These patients were also less likely to receive high-dose statin or optimal BB dose and more likely to routinely receive clopidogrel and diuretics. Such deviations from GDMT need to be rectified to improve quality of cardiac care after coronary revascularization.
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Affiliation(s)
- Pradeep Pereira
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Archana Sinha
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surendra K Agarwal
- Department of Cardiovascular & Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Shantanu Pande
- Department of Cardiovascular & Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Roopali Khanna
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Nilesh Srivastava
- Department of Cardiovascular & Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Naveen Garg
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Pravin Goel
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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9
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Chakos A, Jbara D, Singh K, Yan TD, Tian DH. Network meta-analysis of antiplatelet therapy following coronary artery bypass grafting (CABG): none versus one versus two antiplatelet agents. Ann Cardiothorac Surg 2018; 7:577-585. [PMID: 30505741 DOI: 10.21037/acs.2018.09.02] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. While clear evidence exists for the use of aspirin in maintaining graft patency, the role of dual-antiplatelet therapy in CABG patients is not as well established. This network meta-analysis aimed to compare the short-term post-CABG graft patency outcomes for patients with none, one or two antiplatelet agents. Methods Electronic databases were queried for randomized controlled trials comparing CABG graft patency rates at three months and beyond using various antiplatelet agents or placebo. Drug and graft patency data were compared using a mixed treatment comparison under a Bayesian hierarchical framework. A random-effects consistency model was applied. Direct and indirect comparisons were made between drugs and used to determine the relative efficacy for graft patency. Results The literature search identified 16 papers fulfilling the inclusion criteria, including a total of 3,133 patients with an average of 2.43 [95% confidence interval (CI): 2.20-2.66] grafts per patient. Graft types were incompletely reported, however, saphenous vein grafts (SVGs) were predominantly used [where specifically reported: 4,490 SVG, 1,226 internal mammary artery (IMA) grafts]. In all, five different agents and placebo in various regimens were compared by results of angiographic follow-up conducted at a mean of 10.4 months (95% CI: 9.28-11.5 months). Compared to placebo, aspirin alone [odds ratio (OR) 1.9; 95% credible interval (CrI): 1.3-2.8], aspirin + dipyridamole (OR 1.9; 95% CrI: 1.3-2.6), aspirin + clopidogrel (OR 2.9; 95% CrI: 1.5-5.7) and aspirin + ticagrelor (OR 3.8; 95% CrI: 1.2-13.0) significantly improved graft patency. When compared to aspirin monotherapy, aspirin + clopidogrel (OR 1.6; 95% CrI: 0.86-2.7) and aspirin + ticagrelor (OR 2.0; 95% CrI: 0.69-6.3) had OR that suggested a trend favoring patency compared to aspirin monotherapy, however, these results did not reach significance. Sub-group analysis of SVG graft patency was unable to reach significance (only eight studies with six treatment comparisons were evaluated). Secondary endpoints of death, bleeding, myocardial infarction and cerebrovascular accident were incompletely reported and were pooled but not compared between drug treatment arms. Conclusions Aspirin monotherapy and dual antiplatelet therapy (DAPT) provided significant all-graft patency benefit compared to placebo at three months and beyond. A trend existed for DAPT to improve graft patency compared to aspirin, although this did not reach statistical significance. Further randomized controlled studies comparing aspirin monotherapy to DAPT are required to determine the utility of DAPT in CABG patients for maintaining graft patency.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Dean Jbara
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kamal Singh
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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10
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Verma S, Mazer CD, Fitchett D, Inzucchi SE, Pfarr E, George JT, Zinman B. Empagliflozin reduces cardiovascular events, mortality and renal events in participants with type 2 diabetes after coronary artery bypass graft surgery: subanalysis of the EMPA-REG OUTCOME® randomised trial. Diabetologia 2018; 61:1712-1723. [PMID: 29777264 PMCID: PMC6061159 DOI: 10.1007/s00125-018-4644-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/27/2018] [Indexed: 01/13/2023]
Abstract
AIMS/HYPOTHESIS After coronary artery bypass graft (CABG) surgery in individuals with type 2 diabetes, there remains a considerable residual cardiovascular risk. In the EMPA-REG OUTCOME® trial in participants with type 2 diabetes and established cardiovascular disease, empagliflozin reduced the risk of cardiovascular death by 38%, all-cause mortality by 32%, hospitalisation for heart failure by 35% and incident or worsening nephropathy by 39% vs placebo when given in addition to standard of care. The aim of this post hoc analysis of the EMPA-REG OUTCOME® trial was to determine the effects of the sodium glucose cotransporter 2 inhibitor empagliflozin on cardiovascular events and mortality in participants with type 2 diabetes and a self-reported history of CABG surgery. METHODS The EMPA-REG OUTCOME® trial was a randomised, double-blind, placebo-controlled trial. Participants with type 2 diabetes and established cardiovascular disease were randomised 1:1:1 to receive placebo, empagliflozin 10 mg or empagliflozin 25 mg, once daily, in addition to standard of care. In subgroups by self-reported history of CABG (yes/no) at baseline, we assessed: cardiovascular death; all-cause mortality; hospitalisation for heart failure; and incident or worsening nephropathy (progression to macroalbuminuria, doubling of serum creatinine, initiation of renal replacement therapy or death due to renal disease). Differences in risk between empagliflozin and placebo were assessed using a Cox proportional hazards model. RESULTS At baseline, 25% (1175/4687) of participants who received empagliflozin and 24% (563/2333) of participants who received placebo had a history of CABG surgery. In participants with a history of CABG surgery, HRs (95% CI) with empagliflozin vs placebo were 0.52 (0.32, 0.84) for cardiovascular mortality, 0.57 (0.39, 0.83) for all-cause mortality, 0.50 (0.32, 0.77) for hospitalisation for heart failure and 0.65 (0.50, 0.84) for incident or worsening nephropathy. Results were consistent between participants with and without a history of CABG surgery (p > 0.05 for treatment by subgroup interactions). CONCLUSIONS/INTERPRETATION In participants with type 2 diabetes and a self-reported history of CABG surgery, treatment with empagliflozin was associated with profound reductions in cardiovascular and all-cause mortality, hospitalisation for heart failure, and incident or worsening nephropathy. These data have important implications for the secondary prevention of cardiovascular events after CABG in individuals with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT01131676.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - C David Mazer
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - David Fitchett
- Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Iqbal J, Widmer R, Gersh BJ. State of the art: optimal medical therapy - competing with or complementary to revascularisation in patients with coronary artery disease? EUROINTERVENTION 2018; 13:751-759. [PMID: 28844035 DOI: 10.4244/eij-d-17-00463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The role of coronary revascularisation with PCI and CABG in patients with stable and unstable coronary artery disease (CAD) is well established and there is a general consensus among guidelines as regards the indications for coronary revascularisation. Although revascularisation has undoubtedly revolutionised the treatment of CAD, it is vital to understand the recent advances and importance of the concomitant use of evidence-based optimal medical therapy (OMT). In contemporary practice, OMT should include an antiplatelet agent (or dual antiplatelet therapy when indicated) and a lipid-lowering drug for all patients, and a beta-blocker and an ACE inhibitor (or angiotensin receptor blocker) for the vast majority of patients, along with addressing cardiac risk factors and lifestyle management. OMT is the recommended initial choice for patients with stable angina pectoris, and the indication for revascularisation would be persistence of symptoms despite OMT and/or improvement of prognosis. For patients with acute coronary syndromes or those who underwent coronary revascularisation with either PCI or CABG, long-term use of OMT improves clinical outcomes and prognosis.
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Affiliation(s)
- Javaid Iqbal
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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12
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Iqbal J, Serruys PW. Optimal medical therapy is vital for patients with coronary artery disease and acute coronary syndromes regardless of revascularization strategy. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:140. [PMID: 28462220 DOI: 10.21037/atm.2017.02.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Javaid Iqbal
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Patrick W Serruys
- International Centre for Circulatory Health, Imperial College, London, UK
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13
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Iqbal J, Zhang YJ, Holmes DR, Morice MC, Mack MJ, Kappetein AP, Feldman T, Stahle E, Escaned J, Banning AP, Gunn JP, Colombo A, Steyerberg EW, Mohr FW, Serruys PW. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation 2015; 131:1269-77. [PMID: 25847979 DOI: 10.1161/circulationaha.114.013042] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 01/26/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is a paucity of data on the use of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting (CABG) and its long-term prognostic significance. METHODS AND RESULTS The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is a multicenter, randomized, clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with percutaneous coronary intervention or CABG. Detailed drug history was collected for all patients at discharge and at the 1-month, 6-month, 1-year, 3-year, and 5-year follow-ups. OMT was defined as the combination of at least 1 antiplatelet drug, statin, β-blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. OMT was underused in patients treated with coronary revascularization, especially CABG. OMT was an independent predictor of survival. OMT was associated with a significant reduction in mortality (hazard ratio, 0.64; 95% confidence interval, 0.48-0.85; P=0.002) and composite end point of death/myocardial infarction/stroke (hazard ratio, 0.73; 95% confidence interval, 0.58-0.92; P=0.007) at the 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5 years) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus percutaneous coronary intervention over 5 years). On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy. CONCLUSIONS The use of OMT remains low in patients with complex coronary disease requiring coronary intervention with percutaneous coronary intervention and even lower in patients treated with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT use in postrevascularization patients are warranted. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.
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Affiliation(s)
- Javaid Iqbal
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Yao-Jun Zhang
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - David R Holmes
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Marie-Claude Morice
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Michael J Mack
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Arie Pieter Kappetein
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Ted Feldman
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Elizabeth Stahle
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Javier Escaned
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Adrian P Banning
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Julian P Gunn
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Antonio Colombo
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Ewout W Steyerberg
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Friedrich W Mohr
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Patrick W Serruys
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
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Hlatky MA, Solomon MD, Shilane D, Leong TK, Brindis R, Go AS. Use of Medications for Secondary Prevention After Coronary Bypass Surgery Compared With Percutaneous Coronary Intervention. J Am Coll Cardiol 2013; 61:295-301. [DOI: 10.1016/j.jacc.2012.10.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 10/06/2012] [Accepted: 10/22/2012] [Indexed: 12/17/2022]
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Sezai A, Hata M, Yoshitake I, Kimura H, Takahashi K, Hata H, Shiono M. Results of emergency coronary artery bypass grafting for acute myocardial infarction: importance of intraoperative and postoperative cardiac medical therapy. Ann Thorac Cardiovasc Surg 2012; 18:338-46. [PMID: 22572233 DOI: 10.5761/atcs.oa.11.01821] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The results of emergency coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) are less than satisfactory, and readmission for cardiac events is common. METHODS AND RESULTS 105 patients underwent emergency CABG for AMI. We examined the long-term results of emergency CABG for AMI from the viewpoints of preoperative, intraoperative, and postoperative factors. The operative mortality rate was 11.4%. Risk factors for early death were age ≥80 years, shock, veno-arterial bypass, creatine kinase isoenzyme Mb ≥100 U/L, non-use of a left internal thoracic artery graft and an extracorporeal circulation time ≥120 min. Risk factors for late cardiac events were ejection fraction <40%, non-use of human atrial natriuretic peptide (hANP) therapy, angiotensin II receptor blockers (ARB) and aldosterone blockers, and a 3-month postoperative brain natriuretic peptide level ≥200 pg/ml. CONCLUSIONS Early results of this study are similar to those seen in previous reports, whereas late phase results yield some new and interesting findings. We suggest that intraoperative hANP, and postoperative aldosterone blocker and ARB, following CABG for AMI, will, through control of the renin-angiotensin-aldsterone system, inhibit left ventricular remodelling, reduce the extent of infarction, and improve cardiac function, yielding a favourable long-term prognosis.
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Affiliation(s)
- Akira Sezai
- The Department of Cardiovascular Surgery, Department of Cardiology, Nihon University School of Medicine, Tokyo, Japan.
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Krzych LJ. Treatment of hypertension in patients undergoing coronary artery by-pass grafting. Curr Opin Pharmacol 2012; 12:127-33. [PMID: 22342165 DOI: 10.1016/j.coph.2012.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 01/15/2012] [Accepted: 01/16/2012] [Indexed: 11/30/2022]
Abstract
Hypertension occurs in up to 80% of patients scheduled to coronary artery by-pass grafting (CABG). In hemodynamically stable patients all anti-hypertensive drugs should be continued till a day of surgery. For vast majority of patients there is no need to use blood pressure lowering agents during CABG, however it is necessary to maintain blood pressure level and avoid extreme blood pressure variations. Upon CABG hypotensive therapy should be modified to the needs of the individual patient and should be monitored individually. Treatment of hypertension ought to be started with caution with lowest possible dosage. Aggressive therapy is strongly discouraged to avoid hemodynamic collapse. Beta-blockers should be administered to all CABG patients unless contraindicated.
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Affiliation(s)
- Lukasz J Krzych
- 1st Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
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Benedetto U, Melina G, di Bartolomeo R, Angeloni E, Sansone D, Falaschi G, Capuano F, Comito C, Roscitano A, Sinatra R. n-3 Polyunsaturated Fatty Acids After Coronary Artery Bypass Grafting. Ann Thorac Surg 2011; 91:1169-75. [DOI: 10.1016/j.athoracsur.2010.11.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/24/2010] [Accepted: 11/29/2010] [Indexed: 11/17/2022]
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Sezai A, Minami K, Hata M, Yoshitake I, Wakui S, Takasaka A, Murakami T, Shiono M, Takayama T, Hirayama A. Long-term results (three-year) of emergency coronary artery bypass grafting for patients with unstable angina pectoris. Am J Cardiol 2010; 106:511-6. [PMID: 20691309 DOI: 10.1016/j.amjcard.2010.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 04/01/2010] [Accepted: 04/01/2010] [Indexed: 10/19/2022]
Abstract
Satisfactory results are achieved by elective coronary artery bypass grafting (CABG), but the results of emergency CABG are less than satisfactory and readmission for cardiac events is common. We examined long-term results of emergency CABG for unstable angina pectoris from the viewpoints of preoperative, intraoperative, and postoperative factors. Subjects were 154 patients who underwent emergency CABG for unstable angina pectoris. Operative mortality rate was 1.9%. Univariate analysis showed female gender, chronic renal failure, hemodialysis, nonuse of human atrial natriuretic peptide (hANP), nonuse of angiotensin II receptor blockers and aldosterone blockers, 3-month postoperative brain natriuretic peptide level > or =200 pg/ml, and 3-month postoperative aldosterone level > or =100 pg/ml as risk factors for late cardiac events. Multivariate analysis confirmed nonuse of hANP, nonuse of aldosterone blockers, 3-month brain natriuretic peptide level > or =200 pg/ml, and 3-month aldosterone level > or =100 pg/ml as risk factors. Intraoperative hANP infusion and postoperative treatment with aldosterone blockers and angiotensin II receptor blockers can control the renin-angiotensin-aldosterone system, inhibit left ventricular remodeling, decrease extent of infarction, and improve cardiac function, yielding a favorable long-term prognosis. The best results are obtained by combining good surgical technique and perioperative management with the long-term outcome in mind.
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Redondo S, Ruiz E, Gordillo-Moscoso A, Navarro-Dorado J, Ramajo M, Carnero M, Reguillo F, Rodriguez E, Tejerina T. Role of TGF-beta1 and MAP kinases in the antiproliferative effect of aspirin in human vascular smooth muscle cells. PLoS One 2010; 5:e9800. [PMID: 20339548 PMCID: PMC2842433 DOI: 10.1371/journal.pone.0009800] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 12/26/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We aimed to test the antiproliferative effect of acetylsalicylic acid (ASA) on vascular smooth muscle cells (VSMC) from bypass surgery patients and the role of transforming growth factor beta 1 (TGF-beta1). METHODOLOGY/PRINCIPAL FINDINGS VSMC were isolated from remaining internal mammary artery from patients who underwent bypass surgery. Cell proliferation and DNA fragmentation were assessed by ELISA. Protein expression was assessed by Western blot. ASA inhibited BrdU incorporation at 2 mM. Anti-TGF-beta1 was able to reverse this effect. ASA (2 mM) induced TGF-beta1 secretion; however it was unable to induce Smad activation. ASA increased p38(MAPK) phosphorylation in a TGF-beta1-independent manner. Anti-CD105 (endoglin) was unable to reverse the antiproliferative effect of ASA. Pre-surgical serum levels of TGF-beta1 in patients who took at antiplatelet doses ASA were assessed by ELISA and remained unchanged. CONCLUSIONS/SIGNIFICANCE In vitro antiproliferative effects of aspirin (at antiinflammatory concentration) on human VSMC obtained from bypass patients are mediated by TGF-beta1 and p38(MAPK). Pre-surgical serum levels of TGF- beta1 from bypass patients who took aspirin at antiplatelet doses did not change.
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Affiliation(s)
- Santiago Redondo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Emilio Ruiz
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Jorge Navarro-Dorado
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Marta Ramajo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Manuel Carnero
- Servicio de Cirugía Cardiaca, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Fernando Reguillo
- Servicio de Cirugía Cardiaca, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Enrique Rodriguez
- Servicio de Cirugía Cardiaca, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Teresa Tejerina
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
- * E-mail:
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Lin T, Hasaniya NW, Krider S, Razzouk A, Wang N, Chiong JR. Mortality Reduction With β-Blockers in Ischemic Cardiomyopathy Patients Undergoing Coronary Artery Bypass Grafting. ACTA ACUST UNITED AC 2010; 16:170-4. [DOI: 10.1111/j.1751-7133.2010.00146.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Popovic B, Arnould MA, Selton-Suty C, Latarche C, Angioi M, Carteaux JP, Villemot JP, Aliot E. Comparison of two-year outcomes in patients undergoing isolated coronary artery bypass grafting with and without peripheral artery disease. Am J Cardiol 2009; 104:1377-82. [PMID: 19892053 DOI: 10.1016/j.amjcard.2009.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 12/31/2022]
Abstract
We aimed to evaluate the long-term clinical outcomes among patients with peripheral arterial disease (PAD) after coronary artery bypass grafting. We studied 589 consecutive patients who had undergone isolated coronary artery bypass grafting from January 2003 to June 2005 at our university hospital. The effect of PAD was assessed by comparing the 2-year follow-up data from 2 groups of patients: 243 patients with and 346 without PAD. A large systematic atherosclerosis screening was performed, including cerebrovascular disease, lower extremity artery disease, and abdominal aorta disease and its branches. PAD was defined as a history of treated atherosclerotic disease and significant atherosclerotic stenosis on screening. Patients with PAD were significantly older (70 +/- 9 vs 64 +/- 11 years, p <0.001) and were more often men (p = 0.04) than those without PAD. They had a greater incidence of hypertension (p = 0.002), chronic renal dysfunction (p <0.01), chronic pulmonary disease (p = 0.005), and a history of coronary artery disease (p = 0.03). No significant difference was noted between the 2 groups with regard to the left ventricular ejection fraction. The 2-year cumulative survival rate was 76.6% for patients with PAD and 94.1% for those with isolated coronary disease (p <0.001). In conclusion, after adjusting all significant variables, the presence of PAD appeared as an independent predictive factor for all-cause mortality (adjusted hazard ratio 3.2, 95% confidence interval 1.8 to 5.7, p = 0.001).
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Bach J, Kammerer I, Isgro F, Haubelt H, Vogt A, Saggau W, Hellstern P. The impact of intravenous aspirin administration on platelet aspirin resistance after on-pump coronary artery bypass surgery. Platelets 2009; 20:150-7. [PMID: 19437331 DOI: 10.1080/09537100902780650] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aspirin resistance continues to be a major challenge in patients after coronary artery bypass grafting (CABG). We investigated the impact of intravenous aspirin on platelet function in this clinical setting. Forty-two patients received 100 mg of oral aspirin once daily, beginning on day 1 after the operation. Between day 6 and 8 post operation one oral dose was replaced by an intravenous dose of 300 mg. Platelet function analyzer (PFA-100) closure times (CT), turbidimetric platelet aggregation (TPA) and impedance platelet aggregation (IPA) induced by arachidonic acid (AA), collagen and ADP were measured prior to and 1 h and 24 h after intravenous aspirin. Results obtained prior to the intravenous aspirin were compared with respective values from 120 healthy individuals. Despite the postoperative oral aspirin that was given once daily, ADP-induced TPA (ADPTPA) and IPA values induced by AA, ADP or collagen were significantly greater in patients than in controls, while PFA-100 CT were significantly shorter. Intravenous aspirin induced a significant reduction of platelet aggregability as measured by collagen/epinephrine (CEPI) CT, TPA and IPA induced by AA and collagen 1 h and 24 h after administration. Intravenous aspirin was not found to influence collagen/ADP (CADP) CT and IPA induced by ADP. Concomitantly, the number of patients with laboratory aspirin resistance as measured by CEPI-CT and TPA but not by IPA induced by AA or collagen dropped significantly. Agreement in the detection of aspirin responders and non-responders among platelet function tests was poor. Our findings indicate that the intravenous aspirin appears to be a promising approach for reducing laboratory aspirin resistance during the postoperative phase of CABG.
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Affiliation(s)
- Jürgen Bach
- Institute of Hemostaseology and Transfusion Medicine, Academic City Hospital, Ludwigshafen/Germany
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24
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Abstract
Modern techniques for coronary artery bypass graft (CABG) are highly successful. Nevertheless, over time, grafts do fail and native coronary artery disease does progress. Follow-up of patients after CABG should focus on secondary prevention, including careful attention to all modifiable risk factors for cardiovascular disease. Routine stress testing with or without imaging is usually not necessary if the patient is asymptomatic and engaging in normal physical activities, including moderate exercise without difficulty. Stress testing with electrocardiographic monitoring alone or in conjunction with nuclear myocardial perfusion imaging or echocardiography is commonly used if a patient develops recurrent symptoms post-CABG or is at particular high risk for complications. Computed tomography coronary angiography is a new, very powerful, noninvasive technique that can directly visualize both CABG and the native coronary arteries. Computed tomography coronary angiography is complimentary to functional stress testing in that it provides anatomic information about graft patency and native coronary artery stenoses, but the functional significance of these findings may still require stress testing with nuclear or ultrasound imaging. Further technical improvements, both in surgical techniques and in imaging, and prospective multicenter trials, are needed to better define the best methods for following patients post-CABG.
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Boatman DM, Saeed B, Varghese I, Peters CT, Daye J, Haider A, Roesle M, Banerjee S, Brilakis ES. Prior coronary artery bypass graft surgery patients undergoing diagnostic coronary angiography have multiple uncontrolled coronary artery disease risk factors and high risk for cardiovascular events. Heart Vessels 2009; 24:241-6. [PMID: 19626394 DOI: 10.1007/s00380-008-1114-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Accepted: 09/11/2008] [Indexed: 01/08/2023]
Abstract
Limited contemporary data exist on the cardiovascular risk of patients with prior coronary artery bypass grafting surgery (CABG) requiring diagnostic coronary angiography. We examined the prevalence and control of coronary artery disease risk factors and the outcomes of 367 prior CABG patients who underwent diagnostic coronary angiography between October 1, 2004 and May 31, 2007 at the Dallas Veterans Affairs Medical Center. Mean age was 65 +/- 9 years, 97% were men, and the mean time from CABG to diagnostic angiography was 8.2 +/- 6.1 years. Hypertension, low-density lipoprotein cholesterol, diabetes mellitus, smoking, and obesity were suboptimally controlled in 70%, 59%, 47%, 33%, and 50%, respectively. Intake of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 88% and 81%, respectively. After a mean follow-up of 1.4 +/- 0.8 years, the incidence of death and major cardiovascular events was 10% and 32%, respectively. In spite of significant improvement compared to previous studies and good compliance with indicated medications, contemporary prior CABG patients undergoing coronary angiography still have multiple and poorly controlled coronary artery disease risk factors and high risk for cardiovascular events. Novel pharmacologic and behavioral treatment strategies are needed.
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Affiliation(s)
- Dustin M Boatman
- Division of Cardiovascular Diseases, University of Texas Southwestern Medical School and the Department of Cardiology Dallas Veterans Affairs Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216, USA
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26
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Osmancik PP, Bednar F, Pavkova L, Tousek P, Stros P, Jirasek K. Higher platelet activity is present in patients with restenosis after percutaneous coronary intervention compared with patients with an occlusion of coronary artery bypass graft. Blood Coagul Fibrinolysis 2008; 19:807-12. [PMID: 19002048 DOI: 10.1097/mbc.0b013e3283169223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the study was to compare platelet activity between patients with an occlusion of bypass graft after coronary artery bypass graft surgery and restenosis after percutaneous coronary intervention (PCI); that is, between patients with reappearance of ischemia after two different kinds of coronary revascularization. Thirty patients were studied in a cross-sectional designed study. Fifteen of them were patients with the worst bypass graft patency from Prague-4 study (control protocol-driven coronary angiography performed at 1 year after surgery; originally 47 bypass grafts implanted, 94% of venous grafts occluded). The remaining 15 were patients with restenosis 3-12 months after PCI. Blood samples were drawn at least 12 weeks after coronary angiography. Platelet activity was determined by membrane expression of P-selectin (CD62P, % of positive cells) by flow cytometry, aggregability by ADP aggregometry. Data are expressed as mean +/- SEM. Both groups were similar with respect to age, BMI and presence of diabetes mellitus. No patient suffered from acute coronary syndrome. P-selectin expression was significantly higher in the patients with restenosis compared with patients with bypass graft occlusion (1.96 +/- 0.07 vs. 0.77 +/- 0.03, P < 0.001, Wilcoxon test). ADP aggregometry was not different between groups (55.5 +/- 1.1 vs. 56.1 +/- 0.8, P = NS). Higher platelet activity is present in the patients with restenosis after PCI compared with the patients with the occlusion of bypass graft. Platelet activity play more important role in the development of restenosis after PCI compared with the occlusion of bypass graft after coronary artery bypass graft surgery, at least in the period up to 1 year after revascularization.
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Affiliation(s)
- Pavel P Osmancik
- Cardiocenter, Department of Cardiology, Charles University, University Hospital Kralovske Vinohrady Prague, Czech Republic.
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27
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Brilakis ES, de Lemos JA, Cannon CP, Wiviott SD, Murphy SA, Morrow DA, Sabatine MS, Banerjee S, Blazing MA, Califf RM, Braunwald E. Outcomes of patients with acute coronary syndrome and previous coronary artery bypass grafting (from the Pravastatin or Atorvastatin Evaluation and Infection Therapy [PROVE IT-TIMI 22] and the Aggrastat to Zocor [A to Z] trials). Am J Cardiol 2008; 102:552-8. [PMID: 18721511 DOI: 10.1016/j.amjcard.2008.04.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Revised: 04/17/2008] [Accepted: 04/17/2008] [Indexed: 11/29/2022]
Abstract
We examined the effects of intensive statin therapy in patients with acute coronary syndromes (ACSs) and previous coronary artery bypass graft surgery (CABG) participating in the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE-IT TIMI 22) and the Aggrastat to Zocor (A to Z) trials. Of the 8,655 patients enrolled in PROVE IT-TIMI 22 or A to Z, 640 (7.4%) had undergone CABG before enrollment. After a median follow-up of 2 years, compared with patients without previous CABG, those with previous CABG had a higher risk of cardiovascular death (6.2% vs 2.8%), myocardial infarction (14.2% vs 6.6%), and readmission for ACS (7.9% vs 4.4%, p <0.001 for all comparisons) but a lower rate of repeat coronary revascularization (22.7% vs 26.9%, p = 0.01). Compared with moderate statin therapy, intensive statin therapy appeared to decrease the composite of cardiovascular death, myocardial infarction, stoke, and readmission for an ACS (A to Z primary end point) to a similar extent in patients with (26.1% vs 21.6%, hazard ratio 0.84, p = 0.27) and without (13.9% vs 12.0%, hazard ratio 0.86, p = 0.016) previous CABG, although the decrease was not statistically significant in the previous CABG group, likely due to the small number of patients with previous CABG. In conclusion, compared with patients with ACS without previous CABG, those with previous CABG have a higher risk for adverse cardiac events and may derive similar benefit from intensive statin therapy.
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Affiliation(s)
- Emmanouil S Brilakis
- Cardiovascular Division, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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28
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Filion KB, Pilote L, Rahme E, Eisenberg MJ. Use of Perioperative Cardiac Medical Therapy Among Patients Undergoing Coronary Artery Bypass Graft Surgery. J Card Surg 2008; 23:209-15. [DOI: 10.1111/j.1540-8191.2008.00596.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Filion KB, Pilote L, Rahme E, Eisenberg MJ. Perioperative use of cardiac medical therapy among patients undergoing coronary artery bypass graft surgery: a systematic review. Am Heart J 2007; 154:407-14. [PMID: 17719282 DOI: 10.1016/j.ahj.2007.04.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2006] [Accepted: 04/11/2007] [Indexed: 01/13/2023]
Abstract
BACKGROUND The use of perioperative cardiac medical therapy among patients undergoing coronary artery bypass graft surgery (CABG) has not been closely examined. OBJECTIVES The objective of this study was to systematically review the medical literature examining the effects of perioperative cardiac medical therapy on clinical outcomes among patients undergoing CABG. METHODS Using the Medline database and online clinical trial databases, we reviewed all randomized controlled trials (RCTs) and observational studies examining the effect of perioperative angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, antilipid agents (including statins), aspirin, beta-blockers, and calcium-channel blockers on clinical outcomes. RESULTS Our review identified 27 studies (6 RCTs, 21 observational studies), involving >700,000 patients, that examined the impact of perioperative medical therapy on clinical outcomes after CABG. Although studies provide conflicting results, the literature suggests that perioperative aspirin use may decrease inhospital mortality and myocardial infarction, whereas perioperative angiotensin-converting enzyme inhibitor use does not appear to be beneficial. Perioperative statin use reduces all-cause mortality at 30 days and cardiac death at 60 days and 1 year post-CABG but does not appear to reduce myocardial infarction or congestive heart failure rates. Multiple studies have demonstrated that pre- and postoperative beta-blockers are associated with a decrease in atrial fibrillation. In addition, beta-blockers may reduce inhospital and 30-day mortality, although these results are not consistent across all studies. Calcium-channel blockers do not appear to improve inhospital or 30-day mortality. No studies examined the perioperative use of angiotensin II receptor blockers or nonstatin antilipid agents among CABG patients. CONCLUSIONS The perioperative use of cardiac medical therapy among CABG patients remains understudied. Given their proven benefits among patients with cardiovascular disease and their potential to improve outcomes among CABG patients, further studies, particularly large RCTs, are needed.
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Affiliation(s)
- Kristian B Filion
- Department of Epidemiology, Biostatistics, and Occupational Health, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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30
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Poe SS, Dawson PB, Cafeo C, Sedlander D, Curtis C, Meyer P, Blumenthal R, Baumgartner W, Allen J. Use of the ABC care bundle to standardize guideline implementation in a cardiac surgical population: a pilot study. J Nurs Care Qual 2007; 22:247-54. [PMID: 17563594 DOI: 10.1097/01.ncq.0000277782.29557.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A cardiac surgical progressive care unit implemented the ABC's of Cardiovascular Risk Reduction Care Bundle to determine whether the use of a packaged approach to medication prescription and lifestyle counseling would improve adherence to secondary risk-reduction guidelines in postcoronary artery bypass graft patients. A pilot study was carried out to assess changes in adherence to guideline recommendations post-Care Bundle implementation. Findings support using a systematic strategy to improve guideline adherence in this population.
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Affiliation(s)
- Stephanie S Poe
- Department of Nursing Administration, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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31
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Lorusso R, De Cicco G, Beghi C, Gherli T, Poli E, Corradi D, Maestri R, Bonadonna S, Mancini T, Giustina A. Functional effects of nitric oxide-releasing aspirin on vein conduits of diabetic patients undergoing CABG. Int J Cardiol 2007; 118:164-9. [PMID: 17027104 DOI: 10.1016/j.ijcard.2006.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2006] [Revised: 06/26/2006] [Accepted: 07/11/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) is known to negatively affect biological properties of venous vasculature, and, particularly, to reduce endothelium-derived nitric oxide release. This condition might influence venous graft function following coronary artery bypass surgery (CABG). The aim of this study was to evaluate the functional effects of a NO-releasing aspirin (NORA) on vein grafts (VG) of diabetics and control patients undergoing elective CABG. METHODS In 40 consecutive ischemic heart disease patients, the effects of NORA were tested on segments of saphenous vein conduits harvested during elective CABG. Twenty patients had type-2 DM (mean age 69+/-2), whereas 20 patients had no DM (NDM) and represented the control group (mean age 67+/-4). Functional responses were tested by exposing VGs to NORA and to standard vasoactive agents in an organ-bath preparation. Histological features of VGs were also assessed by light and electronic microscopy. RESULTS Significant impairment of endothelial-dependent vasodilation (acetylcholine induced) was documented in VGs of DM subjects. NORA induced a significant and comparable vascular relaxation in all venous segments of NDM and DM patients (56+/-12% of maximal relaxation vs 61+/-11% in the control group, respectively). Histology showed variable extent of vascular layer and cellular abnormalities in VGs of diabetics (intimal hyperplasia, calcific deposition, endothelial cell degeneration) likely responsible of the endothelial functional impairment, whereas control group VG showed preserved structures. CONCLUSIONS This preliminary study confirms the impairment of endothelium-dependent vasodilative property of VGs in DM patients. It also indicates that NORA effectively induces vasodilation of VGs which was effective also in DM patients thereby representing a promising therapy for diabetics undergoing CABG with the use of VGs, although further studies are mandatory to conclusively assess the safety and benefits of this pharmacological agent.
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Affiliation(s)
- Roberto Lorusso
- Experimental Cardiac Surgery Laboratory and Cardiac Surgery Unit, Civic Hospital, Brescia, Italy.
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32
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Antoniades C, Tousoulis D, Stefanadis C. Nitric oxide-releasing aspirin: Will it say NO to atherothrombosis? Int J Cardiol 2007; 118:170-2. [PMID: 16997401 DOI: 10.1016/j.ijcard.2006.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 08/04/2006] [Indexed: 11/25/2022]
Abstract
Aspirin is a powerful anti-platelet drug widely used in patients with coronary atherosclerosis, but its side effects and especially its toxicity for gastrointestinal tract limit its usefulness in specific groups of patients. A new category of agents, nitric oxide-releasing aspirins (such as NCX-4016), seems to provide an alternative solution. Although this drug is still at phase II clinical trials, it has provided promising results until now. When administered in vivo, it is separated into an aspirin moiety and an NO-donating complex, providing both the antithrombotic effect of aspirin and the gastroprotective effect of NO. Additionally, it increases NO bioavailability as a vascular level, and it may have the antiatherogenic properties of endogenously produced NO. Finally, recent evidence suggests that it may also improve functional aspects of vein grafts used in CABG, with possible benefit on graft patency. However, the outcome of the large ongoing trials is needed before any conclusion is made about the role of NO-releasing aspirins in cardiovascular disease.
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Fox KM, Bertrand ME, Remme WJ, Ferrari R, Simoons ML, Deckers JW. Efficacy of perindopril in reducing risk of cardiac events in patients with revascularized coronary artery disease. Am Heart J 2007; 153:629-35. [PMID: 17383303 DOI: 10.1016/j.ahj.2007.01.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 01/16/2007] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of the study was to assess the effect on cardiac events of adding perindopril 8 mg once daily to standard preventive therapy in the subgroup of EUROPA patients with previous revascularization and without previous myocardial infarction (MI). METHODS We conducted a subgroup analysis of the EUROPA study patients according to their revascularization and previous MI history. Among the 12,218 patients of EUROPA, we identified 6709 (54.9%) patients who had a previous revascularization. Approximately equal proportions had undergone percutaneous coronary intervention (3122) or coronary artery bypass grafting (3136). Of the revascularized patients, 3047 (24.9%) patients had not experienced a previous MI. RESULTS Out of the 6709 revascularized patients, 3340 were treated with perindopril and 3369 with placebo. Baseline characteristics were similar to the whole EUROPA population in terms of demographics, medical history, physical examination (heart rate, blood pressure), and medications at screening. The mean patient age was 60 years, and 85% were men. The relative risk reduction with perindopril 8 mg was 17.3% (95% CI 1.3%-30.8%, P = .035) for the composite primary end point of cardiovascular death, nonfatal MI, and resuscitated cardiac arrest and was 23% (95% CI 4.9%-37.6%, P = .015) for fatal and nonfatal MI. In the 3047 revascularized patients without a history of MI, perindopril was associated with a relative risk reduction of 31.7% for fatal and nonfatal MI (95% CI 4.4%-51.2%, P = .026). CONCLUSION Perindopril 8 mg daily is beneficial for primary and secondary prevention of cardiac events in patients with coronary artery disease without clinical evidence of heart failure including those with previous revascularization.
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Affiliation(s)
- Kim M Fox
- Cardiology Department, Royal Brompton Hospital, Sydney Street, London, UK.
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34
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Shahian DM, Edwards FH, Ferraris VA, Haan CK, Rich JB, Normand SLT, DeLong ER, O'Brien SM, Shewan CM, Dokholyan RS, Peterson ED. Quality Measurement in Adult Cardiac Surgery: Part 1—Conceptual Framework and Measure Selection. Ann Thorac Surg 2007; 83:S3-12. [PMID: 17383407 DOI: 10.1016/j.athoracsur.2007.01.053] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Revised: 01/10/2007] [Accepted: 01/12/2007] [Indexed: 10/23/2022]
Affiliation(s)
- David M Shahian
- Tufts University School of Medicine, Boston, Massachusetts, USA.
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35
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Osmancik PP, Bednar F, Móciková H, Stros P, Jirasek K, Straka Z, Widimsky P. The comparison of platelet activity between patients with patent vs. occluded coronary artery bypass grafts. Thromb Res 2007; 120:523-9. [PMID: 17303221 DOI: 10.1016/j.thromres.2006.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Revised: 11/17/2006] [Accepted: 12/15/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Pavel P Osmancik
- Cardiocenter, Department of Cardiology, 3rd Medical School, Charles University and University Hospital Kralovske Vinohrady Prague, Czech Republic.
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Gheorghiade M, Sopko G, De Luca L, Velazquez EJ, Parker JD, Binkley PF, Sadowski Z, Golba KS, Prior DL, Rouleau JL, Bonow RO. Navigating the crossroads of coronary artery disease and heart failure. Circulation 2006; 114:1202-13. [PMID: 16966596 DOI: 10.1161/circulationaha.106.623199] [Citation(s) in RCA: 264] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
MESH Headings
- Cardiac Output, Low/epidemiology
- Cardiac Output, Low/etiology
- Cardiac Output, Low/physiopathology
- Cardiac Output, Low/therapy
- Coronary Artery Disease/complications
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/pathology
- Death, Sudden, Cardiac/prevention & control
- Electrophysiology
- Humans
- Incidence
- Myocardial Ischemia/etiology
- Myocardial Ischemia/physiopathology
- Myocardial Ischemia/prevention & control
- Myocardial Ischemia/therapy
- Prognosis
- Systole/physiology
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Affiliation(s)
- Mihai Gheorghiade
- Northwestern University Feinberg School of Medicine, Galter 10-240, 201 E Huron St, Chicago, IL 60611, USA
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37
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Jones RH. The Year in Cardiovascular Surgery. J Am Coll Cardiol 2006; 47:2094-107. [PMID: 16697330 DOI: 10.1016/j.jacc.2006.02.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 01/31/2006] [Accepted: 02/07/2006] [Indexed: 11/17/2022]
Affiliation(s)
- Robert H Jones
- Department of Surgery, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27715, USA.
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38
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Osman F, Qaisar S, Pitt M. Cardiac medical therapy post-coronary bypass grafting. J Am Coll Cardiol 2005; 46:933-4; author reply 934-5. [PMID: 16139148 DOI: 10.1016/j.jacc.2005.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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39
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Chacko KA. Cardiac medical therapy following coronary artery bypass graft surgery. J Am Coll Cardiol 2005; 46:934; author reply 934-5. [PMID: 16139150 DOI: 10.1016/j.jacc.2005.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Reply. J Am Coll Cardiol 2005. [DOI: 10.1016/j.jacc.2005.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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