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Lobo MF, Azzone V, Resnic FS, Melica B, Teixeira-Pinto A, Azevedo LF, Freitas A, Nisa C, Bacelar-Nicolau L, Rocha-Gonçalves FN, Pereira-Miguel J, Costa-Pereira A, Normand SL. The Atlantic divide in coronary heart disease: Epidemiology and patient care in the US and Portugal. Rev Port Cardiol 2017; 36:583-593. [PMID: 28886892 DOI: 10.1016/j.repc.2016.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/04/2016] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available. METHODS We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries. RESULTS Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries. CONCLUSIONS Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.
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Affiliation(s)
- Mariana F Lobo
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Vanessa Azzone
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Frederic S Resnic
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington and Tufts University School of Medicine, Boston, MA, United States
| | - Bruno Melica
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Serviço de Cardiologia, Unidade de Diagnóstico e Intervenção Cardiovascular, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Armando Teixeira-Pinto
- School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Luís Filipe Azevedo
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Freitas
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Cláudia Nisa
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Leonor Bacelar-Nicolau
- Institute of Preventive Medicine and Public Health and ISAMB - Institute of Environmental Health, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Francisco Nuno Rocha-Gonçalves
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Portuguese Institute of Oncology Porto (IPO-Porto), Porto, Portugal
| | - José Pereira-Miguel
- Institute of Preventive Medicine and Public Health and ISAMB - Institute of Environmental Health, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Altamiro Costa-Pereira
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Subbotin VM. Analysis of arterial intimal hyperplasia: review and hypothesis. Theor Biol Med Model 2007; 4:41. [PMID: 17974015 PMCID: PMC2169223 DOI: 10.1186/1742-4682-4-41] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2007] [Accepted: 10/31/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite a prodigious investment of funds, we cannot treat or prevent arteriosclerosis and restenosis, particularly its major pathology, arterial intimal hyperplasia. A cornerstone question lies behind all approaches to the disease: what causes the pathology? HYPOTHESIS I argue that the question itself is misplaced because it implies that intimal hyperplasia is a novel pathological phenomenon caused by new mechanisms. A simple inquiry into arterial morphology shows the opposite is true. The normal multi-layer cellular organization of the tunica intima is identical to that of diseased hyperplasia; it is the standard arterial system design in all placentals at least as large as rabbits, including humans. Formed initially as one-layer endothelium lining, this phenotype can either be maintained or differentiate into a normal multi-layer cellular lining, so striking in its resemblance to diseased hyperplasia that we have to name it "benign intimal hyperplasia". However, normal or "benign" intimal hyperplasia, although microscopically identical to pathology, is a controllable phenotype that rarely compromises blood supply. It is remarkable that each human heart has coronary arteries in which a single-layer endothelium differentiates early in life to form a multi-layer intimal hyperplasia and then continues to self-renew in a controlled manner throughout life, relatively rarely compromising the blood supply to the heart, causing complications requiring intervention only in a small fraction of the population, while all humans are carriers of benign hyperplasia. Unfortunately, this fundamental fact has not been widely appreciated in arteriosclerosis research and medical education, which continue to operate on the assumption that the normal arterial intima is always an "ideal" single-layer endothelium. As a result, the disease is perceived and studied as a new pathological event caused by new mechanisms. The discovery that normal coronary arteries are morphologically indistinguishable from deadly coronary arteriosclerosis continues to elicit surprise. CONCLUSION Two questions should inform the priorities of our research: (1) what controls switch the single cell-layer intimal phenotype into normal hyperplasia? (2) how is normal (benign) hyperplasia maintained? We would be hard-pressed to gain practical insights without scrutinizing our premises.
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Ruef J, Hofmann M, Störger H, Haase J. Four-year results after brachytherapy for diffuse coronary in-stent restenosis: will coronary radiation therapy survive? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:170-4. [PMID: 17765646 DOI: 10.1016/j.carrev.2006.09.005] [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] [Received: 07/28/2006] [Revised: 09/27/2006] [Accepted: 09/27/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prior to the introduction of drug-eluting stents (DES), diffuse coronary in-stent restenosis (ISR) was mainly treated by brachytherapy (BT), with good short-term and mid-term results. However, there exist limited data on the long-term effects of BT that justify its continuous use. MATERIALS AND METHODS Two hundred patients with diffuse ISR treated with intravascular BT were retrospectively followed over 4 years. Group A (n=134) was treated with the noncentered (90)Sr/Y BetaCath radiation system, whereas Group B (n=66) was treated with the centered 32P Galileo source wire system. Primary endpoints after 4 years were target lesion restenosis (TLS) and target lesion revascularization (TLR). Secondary endpoints were target vessel revascularization (TVR) and nontarget vessel revascularization (NTVR), as well as major adverse cardiac events (MACE). RESULTS Follow-up at 4 years yielded a TLS rate of 37.6% (Group A, 40.8%; Group B, 31.1%; P=.48). TLR was performed in 34.8% of patients (37.5% in Group A vs. 29.5% in Group B; P=.55). Ten percent of patients underwent coronary bypass surgery. Percutaneous coronary intervention was performed more often in Group A (27.5%) than in Group B (19.7%), while TVR was less frequent in Group A (10.0%) than in Group B (18.0%). NTVR was undertaken in 25.0% of Group A patients versus 21.3% of Group B patients, and MACE occurred in 1.7% of Group A patients versus 3.3% of Group B patients. These differences were not statistically significant (P>.05). CONCLUSIONS While excellent short-term and mid-term results after coronary BT are widely accepted, a high TLS rate can be observed after 4 years. The potential superiority of DES to BT will depend on the availability of long-term clinical data.
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Affiliation(s)
- Johannes Ruef
- Red Cross Hospital Cardiology Center, Frankfurt, Germany.
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Oliver LN, Buttner PG, Hobson H, Golledge J. A meta-analysis of randomised controlled trials assessing drug-eluting stents and vascular brachytherapy in the treatment of coronary artery in-stent restenosis. Int J Cardiol 2007; 126:216-23. [PMID: 17481749 PMCID: PMC2435504 DOI: 10.1016/j.ijcard.2007.03.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 02/17/2007] [Accepted: 03/30/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We undertook a meta-analysis of randomised trials assessing the outcome of vascular brachytherapy (VBT) or DES for the treatment of coronary artery ISR. METHODS AND RESULTS Studies utilising DES or VBT for ISR were identified by a systematic search. Data was pooled and combined overall effect measures were calculated for a random effect model in terms of deaths, myocardial infarctions, revascularisation, binary restenosis, mean late luminal loss and major adverse cardiac events (MACE). Fourteen eligible studies (3103 patients) were included. Neither therapy had any effect on mortality or myocardial infarction rate. VBT reduced the rate of revascularisation (RR 0.59, 95%CI 0.50-0.68), MACE (RR 0.58, 95%CI 0.51-0.67), binary restenosis (RR 0.51, 95%CI 0.44-0.59) and late loss (-0.73 mm, 95%CI -0.91 to -0.55 mm) compared to balloon angioplasty and selective bare metal stents (BMS) alone at intermediate follow-up and MACE (RR 0.72, 95%CI 0.61-0.85) at long-term follow-up. DES reduced the rate of revascularisation (OR 0.51, 95% CI 0.36-0.71), MACE (OR 0.55, 95% CI 0.39-0.79) and binary restenosis (OR 0.57, 95% CI 0.40-0.81) compared to VBT but follow-up was limited to 9 months. CONCLUSIONS VBT improves the long-term outcome of angioplasty compared with BMS alone in the treatment of ISR. DES appears to provide similar results to that of VBT during short-term follow-up.
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Affiliation(s)
- Lisa N Oliver
- The Vascular Biology Unit, James Cook University, Townsville, Queensland. 4811. Australia
| | - Petra G Buttner
- School of Public Health and Tropical Medicine James Cook University Townsville, Queensland. 4811. Australia
| | - Helen Hobson
- The Vascular Biology Unit, James Cook University, Townsville, Queensland. 4811. Australia
| | - Jonathan Golledge
- The Vascular Biology Unit, James Cook University, Townsville, Queensland. 4811. Australia
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Van Houtte P, Roelandts M, Devriendt D, Minsat M, Laharie H, Kantor G. La radiothérapie des affections bénignes : quelles indications huit ans plus tard ? Cancer Radiother 2005; 9:427-34. [PMID: 16219478 DOI: 10.1016/j.canrad.2005.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2005] [Indexed: 11/27/2022]
Abstract
The authors present an update version of the indications for radiotherapy in the management of benign diseases. This is based on available randomized trials and recent international meetings. Validated indications remain the prevention of resected heterotopic bone ossifications, keloïds scars and pterygium and also treatment of arteriovenous malformations; the place of radiotherapy for malignant exophtalmia is more and more restricted. Randomized trials have demonstrated the efficacy of endobrachytherapy in the prevention of restenosis after angioplasty but the use of embedded stent has replaced this indication. Macular degeneration is no more an indication of radiotherapy. Quality requirements for radiotherapy are identical for benign or malignant indications.
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Affiliation(s)
- P Van Houtte
- Département de radio-oncologie, institut Jules-Bordet, 121, boulevard de Waterloo, 1000 Bruxelles, Belgique.
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