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Marques Antunes M, Nunes-Ferreira A, Duarte GS, Gouveia E Melo R, Sucena Rodrigues B, Guerra NC, Nobre A, Pinto FJ, Costa J, Caldeira D. Preoperative statin therapy for adults undergoing cardiac surgery. Cochrane Database Syst Rev 2024; 7:CD008493. [PMID: 39037762 PMCID: PMC11262559 DOI: 10.1002/14651858.cd008493.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5-hydroxy-3-methylglutaryl-co-enzyme A (HMG-CoA) reductase inhibitors) are well-known for their anti-inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. OBJECTIVES To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. SEARCH METHODS We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. Primary outcomes were short-term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. MAIN RESULTS We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short-term mortality (RR 1.36, 95% CI 0.72 to 2.59; I2 = 0%; 6 RCTs, 5260 participants; low-certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low-certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I2 = 0%; 5 RCTs, 4645 participants; moderate-certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I2 = 60%; 8 RCTs, 5592 participants; low-certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I2 = 0%; 4 RCTs, 5143 participants; low-certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I2 = 57%; 4 RCTs, 4728 participants; very low-certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI -1.62 to 4.41; I2 = 43%; 3 RCTs, 4528 participants; moderate-certainty evidence) and overall hospital stay (MD -0.31 days, 95% CI -0.64 to 0.03; I2 = 84%; 5 RCTs, 4788 participants; moderate-certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. AUTHORS' CONCLUSIONS In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events.
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Affiliation(s)
- Miguel Marques Antunes
- Centro Cardiovascular da Universidade de Lisboa - CCUL@RISE, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central (CHULC), Centro Clínico Académico de Lisboa (CCAL), Lisbon, Portugal
| | - Afonso Nunes-Ferreira
- Department of Cardiology/Heart and Vessels, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Hospital da Luz Lisboa, Lisbon, Portugal
| | - Ryan Gouveia E Melo
- Centro Cardiovascular da Universidade de Lisboa - CCUL@RISE, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Department of Vascular Surgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal, Lisbon, Portugal
| | | | - Nuno C Guerra
- Department of Cardiothoracic Surgery, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL@RISE, Lisbon, Portugal
| | - Angelo Nobre
- Department of Cardiothoracic Surgery, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL@RISE, Lisbon, Portugal
| | - Fausto J Pinto
- Department of Cardiology/Heart and Vessels, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Daniel Caldeira
- Department of Cardiology/Heart and Vessels, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Laboratório de Farmacologia Clínica e Terapêutica / Centro Cardiovascular da Universidade de Lisboa - CCUL@RISE / CEMBE - Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Pölzl L, Thielmann M, Sterzinger P, Nägele F, Hirsch J, Graber M, Engler C, Eder J, Lohmann R, Schmidt S, Staggl S, Heuts S, Ulmer H, Grimm M, Ruttmann-Ulmer E, Bonaros N, Holfeld J, Gollmann-Tepeköylü C. Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery. Ann Thorac Surg 2024:S0003-4975(24)00538-1. [PMID: 38964702 DOI: 10.1016/j.athoracsur.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/23/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality. METHODS A consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined. RESULTS Lower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002). CONCLUSIONS We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.
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Affiliation(s)
- Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Philipp Sterzinger
- Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Clemens Engler
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Jonas Eder
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Ronja Lohmann
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Sophia Schmidt
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Simon Staggl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | | | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
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Xing Y, Xie SY, Deng W, Tang QZ. Cardiolipin in myocardial ischaemia-reperfusion injury: From molecular mechanisms to clinical strategies. Biomed Pharmacother 2024; 176:116936. [PMID: 38878685 DOI: 10.1016/j.biopha.2024.116936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024] Open
Abstract
Myocardial reperfusion injury occurs when blood flow is restored after ischemia, an essential process to salvage ischemic tissue. However, this phenomenon is intricate, characterized by various harmful effects. Tissue damage in ischemia-reperfusion injury arises from various factors, including the production of reactive oxygen species, the sequestration of proinflammatory immune cells in ischemic tissues, the induction of endoplasmic reticulum stress, and the occurrence of postischemic capillary no-reflow. Secretory phospholipase A2 (sPLA2) plays a crucial role in the eicosanoid pathway by releasing free arachidonic acid from membrane phospholipids' sn-2 position. This liberated arachidonic acid serves as a substrate for various eicosanoid biosynthetic enzymes, including cyclooxygenases, lipoxygenases, and cytochromes P450, ultimately resulting in inflammation and an elevated risk of reperfusion injury. Therefore, the activation of sPLA2 directly correlates with the heightened and accelerated damage observed in myocardial ischemia-reperfusion injury (MIRI). Presently, clinical trials are in progress for medications aimed at sPLA2, presenting promising avenues for intervention. Cardiolipin (CL) plays a crucial role in maintaining mitochondrial function, and its alteration is closely linked to mitochondrial dysfunction observed in MIRI. This paper provides a critical analysis of CL modifications concerning mitochondrial dysfunction in MIRI, along with its associated molecular mechanisms. Additionally, it delves into various pharmacological approaches to prevent or alleviate MIRI, whether by directly targeting mitochondrial CL or through indirect means.
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Affiliation(s)
- Yun Xing
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan 430060, PR China
| | - Sai-Yang Xie
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan 430060, PR China
| | - Wei Deng
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan 430060, PR China
| | - Qi-Zhu Tang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, PR China; Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan 430060, PR China.
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Yan Y, Zhao C, Niu J, Yan P, Li J, Wang D, Li G. Rationale and Design of the IMPROVE Trial: A Multicenter, Randomized, Controlled, Open-label, Blinded-endpoint Trial Assessing the Efficacy of Remote Ischemic Conditioning in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting. Adv Ther 2024; 41:3003-3012. [PMID: 38616242 DOI: 10.1007/s12325-024-02836-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/07/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Despite the appearance of off-pump coronary artery bypass grafting (CABG), ischemia-reperfusion injury (IRI) in the perioperative period still arouses concerns of clinicians. Remote ischemic conditioning (RIC) is the process of repeated ischemia and reperfusion in the peripheral vessels, which is proven to reduce IRI in vital organs. However, the effect of RIC in patients undergoing off-pump CABG is still unclear. METHODS This IMPROVE trial is a national, multicenter, randomized, controlled, open-label, blinded-endpoint clinical trial designed to assess whether RIC intervention can improve short-term prognosis of patients undergoing off-pump CABG. It plans to enroll 648 patients who will be randomly assigned into a RIC group or control group. Patients in the RIC group will receive four cycles of 5 min of pressurization (about 200 mmHg) and 5 min of rest in the 3 days before and 7 days after the surgery. PLANNED OUTCOMES The primary outcome is the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) within the 3-month follow-up. MACCE is defined as all-cause death, myocardial infarction, stroke, and coronary revascularization surgery. CLINICAL TRIAL REGISTRATION NCT06141525 (ClinicalTrials.gov).
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Affiliation(s)
- Yang Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| | - Changying Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jialan Niu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Pengyun Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jing Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Cardiovascular Surgery, People's Hospital of Qinghai Province, Xining, China
| | - Duolao Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
- Department of Neurology, Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Spagnolo M, Occhipinti G, Laudani C, Greco A, Capodanno D. Periprocedural myocardial infarction and injury. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:433-445. [PMID: 38323856 DOI: 10.1093/ehjacc/zuae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Abstract
Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Claudio Laudani
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Antonio Greco
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
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Crea F. Focus on ischaemic heart disease: prevention with colchicine, role of the brain-heart axis, new therapeutic targets for ischaemia-reperfusion injury. Eur Heart J 2024; 45:1577-1581. [PMID: 38738301 DOI: 10.1093/eurheartj/ehae270] [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: 05/14/2024] Open
Affiliation(s)
- Filippo Crea
- Centre of Excellence of Cardiovascular Sciences, Gemelli Isola Hospital, Rome, Italy
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7
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Pölzl L, Lohmann R, Sterzinger P, Nägele F, Hirsch J, Graber M, Engler C, Eder J, Abfalterer H, Ulmer H, Griesmacher A, Grimm M, Bonaros N, Ruttmann-Ulmer E, Holfeld J, Gollmann-Tepeköylü C. Complexity of coronary artery disease and the release of cardiac biomarkers after CABG. Front Cardiovasc Med 2024; 11:1345439. [PMID: 38370160 PMCID: PMC10870426 DOI: 10.3389/fcvm.2024.1345439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Objective In patients with complex coronary artery disease (CAD) undergoing cardiac surgery, myocardial protection might be impaired due to microvascular obstruction, resulting in myocardial injury and subsequent biomarker release. Therefore, this study investigated the correlation between the complexity of CAD, reflected by the SYNTAX Score, and the release of cardiac biomarkers after CABG. Methods In a consecutive series of 919 patients undergoing isolated CABG SYNTAX scores I and II were calculated to assess the complexity of CAD. Levels of high sensitivity cardiac troponin T (hs-cTnT) and creatine kinase-myocardial band (CK-MB) were routinely measured once before and serially after surgery. Patients were divided into tertiles according to their SYNTAX Scores I and II. Spearman correlations and regression models were performed to measure the degree of association between the release of hs-cTnT and CK-MB and the SYNTAX Scores. Results Patients with a higher SYNTAX Score I had more comorbidities reflected in a higher EuroSCORE II. Preoperatively, higher levels of cardiac biomarkers were found in patients with higher SYNTAX Score II. No correlation was observed between hs-cTnT, CK-MB and SYNTAX Score I or II. Regression models did not show any association between cardiac biomarkers and the complexity of CAD. Conclusion The complexity of CAD is not associated with the release of cardiac biomarkers after CABG. Factors influencing postoperative biomarker release need to be elucidated in future trials to include postoperative biomarker release into risk stratification models predicting outcome after cardiac surgery.
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Affiliation(s)
- Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronja Lohmann
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Sterzinger
- Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Engler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jonas Eder
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Abfalterer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Clinical Chemistry and Laboratory Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Gaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, Boden WE, Devereaux PJ, Doenst T, Farkouh M, Freemantle N, Fremes S, Puskas J, Landoni G, Lawton J, Myers PO, Redfors B, Sandner S. European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery. Eur J Cardiothorac Surg 2024; 65:ezad415. [PMID: 38420786 DOI: 10.1093/ejcts/ezad415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024] Open
Abstract
Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Michael Farkouh
- Academic Affairs, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Nicholas Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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9
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Semagin AA, Lukin OP, Fokin AA. [Comparative analysis of in-hospital and long-term results of patients with acute dysfunction of coronary bypass grafts depending on treatment tactics]. Khirurgiia (Mosk) 2024:50-57. [PMID: 38258688 DOI: 10.17116/hirurgia202401150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Comparative analysis of in-hospital and long-term mortality of patients in whom acute dysfunction of coronary bypass grafts was detected in the early postoperative period depending on conservative or surgical tactics. MATERIAL AND METHODS The study is a retrospective analysis of data from 8801 patients who underwent elective coronary artery bypass grafting (CABG) between 2011 and 2022 at the Federal Center for Cardiovascular Surgery (Russia, Chelyabinsk). Among them, 196 patients underwent emergency coronary artery bypass grafting due to suspected perioperative myocardial infarction in the early postoperative period. In 119 patients, dysfunction of coronary bypass grafts was detected, in 77 patients no pathological changes were found. The criteria for inclusion in the study were patients with dysfunction of coronary bypass grafts (n=119). The 1st group included patients who underwent conservative therapy (n=33), the 2nd group (n=86) included those who underwent repeated myocardial revascularization. The primary endpoint was hospital mortality, secondary endpoints were long-term mortality and adverse cardiovascular events (myocardial infarction, stroke, repeat myocardial revascularization). Patients were surveyed via telephone. RESULTS In-hospital mortality in the group of surgical reintervention was 8.1%, in the group of conservative treatment - 9.1% (p=0.867). According to the results of multivariate analysis, predictors of hospital mortality in patients of both groups were extracorporeal membrane oxygenation (p=0.014), time of artificial circulation (p=0.031), duration of artificial ventilation (p=0.001), number of days in intensive care (p<0.001). When analyzing long-term mortality using the Kaplan-Meier method in group 1 and group 2, no statistically significant differences were found; in the group of conservative therapy - 85±9.6 [66.2-103.7] months versus 108.2±4.8 [98.8-117.6] months in the surgery group (log-rank p=0.06). When analyzing long-term mortality from cardiovascular causes and the occurrence of adverse cardiovascular events, statistically significant differences were determined: in the group of conservative therapy - 92.5±9.3 [74.2-110.7] months versus 117.8±3.3 [111.2-124.3] months in the surgical treatment group (log-rank p=0.007) and 78.1±9.2 [60-96.3] months versus 98.9±3.9 [91.3-106.5] months (log-rank p=0.008), respectively. CONCLUSION In-hospital mortality was comparable between groups. Long-term mortality from cardiovascular causes and the number of adverse cardiovascular events were significantly higher in the conservative therapy group. With timely detection of acute dysfunction of coronary bypass grafts, an active surgical approach has an advantage over conservative tactics and can improve the long-term prognosis of patients.
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Affiliation(s)
- A A Semagin
- Federal Center for Cardiovascular Surgery, Ministry of Health of Russia, Chelyabinsk, Russia
| | - O P Lukin
- Federal Center for Cardiovascular Surgery, Ministry of Health of Russia, Chelyabinsk, Russia
- Federal State Budgetary Educational Institution of Higher Professional Education «South Ural State Medical University» of the Ministry of Health of Russia, Chelyabinsk, Russia
| | - A A Fokin
- Federal State Budgetary Educational Institution of Higher Professional Education «South Ural State Medical University» of the Ministry of Health of Russia, Chelyabinsk, Russia
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10
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Jaffe AS, Mills NL, Mueller C. Peri-procedural myocardial infarction/injury after percutaneous coronary intervention. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:878-880. [PMID: 37983314 DOI: 10.1093/ehjacc/zuad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Allan S Jaffe
- Departments of Cardiology and Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
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11
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Wu L, Guo S, Han L, Song X, Zhao Z, Cekderi AB. Autonomous detection of myocarditis based on the fusion of improved quantum genetic algorithm and adaptive differential evolution optimization back propagation neural network. Health Inf Sci Syst 2023; 11:33. [PMID: 37538261 PMCID: PMC10393931 DOI: 10.1007/s13755-023-00237-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/19/2023] [Indexed: 08/05/2023] Open
Abstract
Myocarditis is cardiac damage caused by a viral infection. Its result often leads to a variety of arrhythmias. However, rapid and reliable identification of myocarditis has a great impact on early diagnosis, expedited treatment, and improved patient survival rates. Therefore, a novel strategy for the autonomous detection of myocarditis is suggested in this work. First, the improved quantum genetic algorithm (IQGA) is proposed to extract the optimal features of ECG beat and heart rate variability (HRV) from raw ECG signals. Second, the backpropagation neural network (BPNN) is optimized using the adaptive differential evolution (ADE) algorithm to classify various ECG signal types with high accuracy. This study examines analogies among five different ECG signal types: normal, abnormal, myocarditis, myocardial infarction (MI), and prior myocardial infarction (PMI). Additionally, the study uses binary and multiclass classification to group myocarditis with other cardiovascular disorders in order to assess how well the algorithm performs in categorization. The experimental results demonstrate that the combination of IQGA and ADE-BPNN can effectively increase the precision and accuracy of myocarditis autonomous diagnosis. In addition, HRV assesses the method's robustness, and the classification tool can detect viruses in myocarditis patients one week before symptoms worsen. The model can be utilized in intensive care units or wearable monitoring devices and has strong performance in the detection of myocarditis.
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Affiliation(s)
- Lei Wu
- National Key Lab of Autonomous Intelligent Unmanned Systems, School of Automation, Beijing Institute of Technology, Beijing, China
| | - Shuli Guo
- National Key Lab of Autonomous Intelligent Unmanned Systems, School of Automation, Beijing Institute of Technology, Beijing, China
| | - Lina Han
- Department of Cardiology, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xiaowei Song
- National Key Lab of Autonomous Intelligent Unmanned Systems, School of Automation, Beijing Institute of Technology, Beijing, China
| | - Zhilei Zhao
- National Key Lab of Autonomous Intelligent Unmanned Systems, School of Automation, Beijing Institute of Technology, Beijing, China
| | - Anil Baris Cekderi
- National Key Lab of Autonomous Intelligent Unmanned Systems, School of Automation, Beijing Institute of Technology, Beijing, China
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12
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Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, Falk V, Gaudino M, McMurray JJV, Mehran R, Milojevic M, Sousa Uva M. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur Heart J 2023; 44:4310-4320. [PMID: 37632756 DOI: 10.1093/eurheartj/ehad476] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 07/15/2023] [Indexed: 08/28/2023] Open
Abstract
In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.
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Affiliation(s)
- Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, 73 Eccles St, Dublin D07 KWR1, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St Stephen's Green, D02 YN77 Dublin, Ireland
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite H405, M4N3M5 Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico 'Gaspare Rodolico-San Marco', University of Catania, Catania, Italy
| | - Martin Czerny
- Clinic for Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany
- Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Physiology and Cardiac Surgery, Porto University Medical School, Porto, Portugal
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13
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Pölzl L, Engler C, Sterzinger P, Lohmann R, Nägele F, Hirsch J, Graber M, Eder J, Reinstadler S, Sappler N, Kilo J, Tancevski I, Bachmann S, Abfalterer H, Ruttmann-Ulmer E, Ulmer H, Griesmacher A, Heuts S, Thielmann M, Bauer A, Grimm M, Bonaros N, Holfeld J, Gollmann-Tepeköylü C. Association of High-Sensitivity Cardiac Troponin T With 30-Day and 5-Year Mortality After Cardiac Surgery. J Am Coll Cardiol 2023; 82:1301-1312. [PMID: 37730286 DOI: 10.1016/j.jacc.2023.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The relevance of perioperative myocardial injury (PMI) after cardiac surgery for 30-day mortality and long-term survival remains to be determined. OBJECTIVES This study assessed the association of PMI after cardiac surgery, reflected by postoperative troponin release, with 30-day mortality and long-term survival after: 1) coronary artery bypass grafting (CABG); 2) isolated aortic valve replacement (AVR) surgery; and 3) all other cardiac surgeries. METHODS A consecutive cohort of 8,292 patients undergoing cardiac surgery with serial perioperative high-sensitivity cardiac troponin T (hs-cTnT) measurements was retrospectively analyzed. The relationship between postoperative hs-cTnT release and 30-day mortality or 5-year mortality was analyzed after adjustment with EuroSCORE II using a Cox proportional hazards model. hs-cTnT thresholds for 30-day and 5-year mortality were determined for isolated CABG (32.3%), AVR (14%), and other cardiac surgery (53.8%). RESULTS High postoperative hs-cTnT levels were associated with higher 30-day mortality but not 5-year mortality. In CABG, median peak concentration of postoperative hs-cTnT was 1,044 ng/L, in AVR it was 502 ng/L, and in other cardiac surgery it was 1,110 ng/L. hs-cTnT thresholds defining mortality-associated PMI were as follows: for CABG, 2,385 ng/L (170× the upper reference limit of normal in a seemingly healthy population [URL]); for AVR, 568 ng/L (41× URL); and for other cardiac procedures, 1,873 ng/L (134× URL). hs-cTnT levels above the cutoffs resulted in an HR for 30-day mortality for CABG of 12.56 (P < 0.001), for AVR of 4.44 (P = 0.004), and for other cardiac surgery of 3.97 (P < 0.001). CONCLUSIONS PMI reflected by perioperative hs-cTnT release is associated with the expected 30-day mortality but not 5-year mortality. Postoperative hs-cTnT cutoffs to identify survival-relevant PMI are higher than suggested in current definitions.
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Affiliation(s)
- Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Engler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Sterzinger
- Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Ronja Lohmann
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jonas Eder
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolay Sappler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Juliane Kilo
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ivan Tancevski
- Department of Internal Medicine I, Innsbruck Medical University, Innsbruck, Austria
| | - Sebastian Bachmann
- Central Institute of Clinical Chemistry and Laboratory Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Abfalterer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Clinical Chemistry and Laboratory Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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14
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Gaudino M, Dangas GD, Angiolillo DJ, Brodt J, Chikwe J, DeAnda A, Hameed I, Rodgers ML, Sandner S, Sun LY, Yong CM. Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2023; 148:442-454. [PMID: 37345559 DOI: 10.1161/cir.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
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15
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Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, Falk V, Gaudino M, McMurray JJV, Mehran R, Milojevic M, Uva MS. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur J Cardiothorac Surg 2023; 64:ezad286. [PMID: 37632766 DOI: 10.1093/ejcts/ezad286] [Citation(s) in RCA: 1] [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: 05/04/2023] [Revised: 06/06/2023] [Accepted: 07/15/2023] [Indexed: 08/28/2023] Open
Abstract
Task Force structure and summary of clinical evidence of 2022 ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; LM, left main; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. a'Event' refers to the composite of death, myocardial infarction (according to Universal Definition of Myocardial Infarction if available, otherwise protocol defined) or stroke. In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.
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Affiliation(s)
- Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, 73 Eccles St, Dublin D07 KWR1, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite H405, M4N3M5 Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico 'Gaspare Rodolico-San Marco', University of Catania, Catania, Italy
| | - Martin Czerny
- Clinic for Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany
- Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Physiology and Cardiac Surgery, Porto University Medical School, Porto, Portugal
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16
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Kavsak PA, Belley-Cote EP, Whitlock RP, Lamy A. Cardiac troponin testing in cardiac surgery. Expert Rev Cardiovasc Ther 2023; 21:729-731. [PMID: 37947177 DOI: 10.1080/14779072.2023.2283123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - André Lamy
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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17
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Crea F. Ischaemic heart disease: from the celebration of Heberden's description of angina pectoris to novel therapeutic targets for angiogenesis and myocardial fibrosis. Eur Heart J 2023; 44:1669-1673. [PMID: 37179122 DOI: 10.1093/eurheartj/ehad278] [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: 05/15/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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18
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Heuts S, Gollmann-Tepeköylü C, Denessen EJS, Olsthoorn JR, Romeo JLR, Maessen JG, van ‘t Hof AWJ, Bekers O, Hammarsten O, Pölzl L, Holfeld J, Bonaros N, van der Horst ICC, Davidson SM, Thielmann M, Mingels AMA. Cardiac troponin release following coronary artery bypass grafting: mechanisms and clinical implications. Eur Heart J 2023; 44:100-112. [PMID: 36337034 PMCID: PMC9897191 DOI: 10.1093/eurheartj/ehac604] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/13/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
The use of biomarkers is undisputed in the diagnosis of primary myocardial infarction (MI), but their value for identifying MI is less well studied in the postoperative phase following coronary artery bypass grafting (CABG). To identify patients with periprocedural MI (PMI), several conflicting definitions of PMI have been proposed, relying either on cardiac troponin (cTn) or the MB isoenzyme of creatine kinase, with or without supporting evidence of ischaemia. However, CABG inherently induces the release of cardiac biomarkers, as reflected by significant cTn concentrations in patients with uncomplicated postoperative courses. Still, the underlying (patho)physiological release mechanisms of cTn are incompletely understood, complicating adequate interpretation of postoperative increases in cTn concentrations. Therefore, the aim of the current review is to present these potential underlying mechanisms of cTn release in general, and following CABG in particular (Graphical Abstract). Based on these mechanisms, dissimilarities in the release of cTnI and cTnT are discussed, with potentially important implications for clinical practice. Consequently, currently proposed cTn biomarker cut-offs by the prevailing definitions of PMI might warrant re-assessment, with differentiation in cut-offs for the separate available assays and surgical strategies. To resolve these issues, future prospective studies are warranted to determine the prognostic influence of biomarker release in general and PMI in particular.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | | - Ellen J S Denessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Jamie L R Romeo
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Arnoud W J van ‘t Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Otto Bekers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ola Hammarsten
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Alma M A Mingels
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
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19
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Shen ZL, Liu Z, Zhang P, Chen WZ, Dong WX, Chen WH, Lin F, Zang WF, Yan XL, Yu Z. Prognostic significance of postoperative loss of skeletal muscle mass in patients underwent coronary artery bypass grafting. Front Nutr 2022; 9:970729. [PMID: 36118747 PMCID: PMC9478409 DOI: 10.3389/fnut.2022.970729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Increasing life expectancy of coronary artery bypass grafting (CABG) remains to be the major concern of cardiac surgeons. However, few studies have investigated the effect of postoperative skeletal muscle index (SMI) loss on prognosis. This study aims to evaluate the prognostic role of postoperative SMI loss ≥ 5% after CABG, in order to develop a novel nomogram to predict overall survival (OS). Methods Patients underwent CABG via midline sternotomy from December 2015 to March 2021 were recruited in this study. Preoperative and postoperative 3 months chest computed tomography (CT) images were compared to assess changes in SMI at T12 level. Based on this, patients were classified into the presence or absence of SMI loss ≥ 5%. The association between postoperative SMI loss ≥ 5% and OS was then analyzed by the Kaplan-Meier curves and Cox model. A novel nomogram incorporating independent clinical prognostic variables was also developed. Results The study enrolled 506 patients receiving CABG, of whom 98 patients experienced T12 SMI loss ≥ 5% and had a significantly worse OS (P < 0.0001). Multivariate regression analysis showed that T12 SMI per cent change (%T12 SMI-change) was an independent prognostic factor for OS (HR = 0.809, 95% CI = 0.749–0.874). The nomogram incorporating %T12 SMI-change with other variables was accurate for predicting OS. Besides, we also found that postoperative oral nutritional supplement (ONS) can rescue T12 SMI loss. Conclusion Postoperative SMI loss can predict survival outcome after CABG. The nomogram incorporating changes in SMI provides a superior performance than existing systems.
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Affiliation(s)
- Zi-Le Shen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhang Liu
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Peng Zhang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei-Zhe Chen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Xi Dong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wen-Hao Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feng Lin
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wang-Fu Zang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Wang-Fu Zang,
| | - Xia-Lin Yan
- Department of Colorectal Anal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Xia-Lin Yan,
| | - Zhen Yu
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhen Yu,
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20
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Chaitman BR, Cyr DD, Alexander KP, Pracoń R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv 2022; 15:e012103. [PMID: 35973009 PMCID: PMC10865178 DOI: 10.1161/circinterventions.122.012103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported. METHODS MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate. RESULTS The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI. CONCLUSIONS In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
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Affiliation(s)
| | - Derek D. Cyr
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | - Radosław Pracoń
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Mazowieckie, Poland
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, India
| | | | | | - Jerome L. Fleg
- National National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Renato D. Lopes
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Frank W. Rockhold
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA and the Cardiovascular Research Foundation, New York, NY, USA
| | - David J. Maron
- Stanford University School of Medicine, Stanford, CA, USA
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21
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Crea F. The challenge of risk stratification in aortic aneurysms, congenital heart disease, and coronary bypass surgery. Eur Heart J 2022; 43:2343-2346. [PMID: 35772806 DOI: 10.1093/eurheartj/ehac334] [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: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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