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Costa H, Espírito-Santo M, Bispo J, Guedes J, Mimoso J, Palmeiro H, Baptista Gonçalves R, Vinhas H. Clinical outcomes of percutaneous coronary intervention in chronic total occlusion in patients with type 2 diabetes mellitus. Rev Port Cardiol 2024; 43:167-174. [PMID: 38141872 DOI: 10.1016/j.repc.2023.07.009] [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: 03/21/2023] [Revised: 06/07/2023] [Accepted: 07/17/2023] [Indexed: 12/25/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Coronary chronic total occlusions (CTOs) are relatively common findings in patients with type 2 diabetes mellitus (T2DM). However, the indication for percutaneous coronary intervention (PCI) and its clinical benefit in these patients remain controversial. METHODS A single-center retrospective cohort study with prospectively collected outcomes was carried out with CTO patients undergoing PCI in 2019 and 2020. Patients were divided into two groups according to previous T2DM diagnosis (T2DM and non-T2DM). The primary outcome was recurrence of angina and/or heart failure symptoms and secondary outcomes were myocardial infarction and all-cause mortality. RESULTS A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome (total symptom recurrence) occurred in 16.6% of the sample, with no difference between groups (non-T2DM 13.6% vs. T2DM 21.2%, p=0.194) in a two-year follow-up. Angina recurrence was significantly more frequent in T2DM patients (15.2%, p=0.043). The presence of T2DM was not an independent predictor of symptom recurrence (p=0.429, HR 1.37, 95% CI 0.62-2.98). Myocardial infarction and all-cause mortality were also not different between groups (T2DM 1.5%, p=0.786 and 4.5%, p=0.352, respectively, on survival analysis). Independent predictors of all-cause mortality were left ventricular function and creatine clearance (p=0.039, HR 0.92, 95% CI 0.85-0.99 and p=0.013, HR 0.96, 95% CI 0.93-0.99, respectively). CONCLUSIONS T2DM did not influence outcomes in CTO patients undergoing PCI, and its presence should not be a limiting factor in deciding on CTO revascularization.
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Affiliation(s)
- Hugo Costa
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal.
| | | | - João Bispo
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal
| | - João Guedes
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal
| | - Jorge Mimoso
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal
| | - Hugo Palmeiro
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal
| | | | - Hugo Vinhas
- Cardiology Department, Centro Hospitalar Universitário do Algarve, Portugal
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Lin XL, Li QY, Zhao DH, Liu JH, Fan Q. A high triglyceride-glucose index associated with adverse cardiovascular events in patients with type 2 diabetes mellitus and chronic total occlusion after percutaneous coronary intervention. J Investig Med 2023; 71:471-481. [PMID: 36727463 DOI: 10.1177/10815589231152823] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Triglyceride-glucose index (TyG index) is a reliable surrogate marker of insulin resistance, associated with morbidity and prognosis of cardiovascular disease. However, its predictive value for cardiovascular events in patients with type 2 diabetes mellitus (T2DM) and chronic total occlusion (CTO) after percutaneous coronary intervention (PCI) has not been studied. Here, we retrospectively enrolled 681 patients with T2DM and CTO after PCI. Patients were divided into two groups based on a median TyG index of 9.02. The TyG index was calculated as ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. The primary observational end point was the composite of overall death, nonfatal myocardial infarction, and unplanned revascularization. The Multivariate Cox hazards regression analysis showed that the TyG index was significantly correlated with the primary end point (hazard ratio = 1.699, 95% confidence interval 1.254-2.303, p = 0.001). The addition of TyG to a baseline risk model had an incremental effect on the predictive value for the primary end point (area under the curve: TyG index vs baseline model, 0.693 vs 0.663, comparison p = 0.040; integrated discrimination improvement = 0.049, p = 0.020). The TyG index might be a predictor of adverse cardiovascular events. Moreover, adding the TyG index into a baseline risk model had a cumulative effect on the predictive potential for the primary end point.
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Affiliation(s)
- Xiao Long Lin
- Center for Coronary Artery Disease, Beijing AnZhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Qiu Yu Li
- Center for Coronary Artery Disease, Beijing AnZhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Dong Hui Zhao
- Center for Coronary Artery Disease, Beijing AnZhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jing Hua Liu
- Center for Coronary Artery Disease, Beijing AnZhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Qian Fan
- Center for Coronary Artery Disease, Beijing AnZhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
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Kurup R, Wijeysundera HC, Bagur R, Ybarra LF. Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:86-92. [PMID: 36266152 DOI: 10.1016/j.carrev.2022.10.003] [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: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Multivessel coronary artery disease (CAD) is associated with worse outcomes across the spectrum of clinical presentations. The prognostic implications of completeness of revascularization in CAD patients, especially those with chronic coronary syndromes (CCS), remain highly debated. This is largely due to the use of non-standardized definitions for complete revascularization (CR) and incomplete revascularization (ICR) within previously published studies, lack of randomized clinical data, varying revascularization methods and heterogenous study populations. In particular, the utility and effectiveness of PCI-mediated CR for CCS remains unknown. In this review, we discuss the various definitions used for CR vs. ICR, highlight the rationale for pursuing CR and summarise the current literature regarding the effects of PCI-mediated CR on clinical outcomes in patients with CCS.
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Affiliation(s)
- Rahul Kurup
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Rodrigo Bagur
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luiz F Ybarra
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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Vásquez Loarte T, Piña Reyna Y, Peña Duque M, Ortiz Zegarra CA. [The SYNTAX Revascularization Index and major cardiovascular events in patients with multivessel coronary artery disease in the Instituto Nacional de Cardiología Ignacio Chávez - Mexico]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:7-12. [PMID: 37583449 PMCID: PMC10424548 DOI: 10.47487/apcyccv.v4i1.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/29/2023] [Indexed: 08/17/2023]
Abstract
Objective To evaluate the degree of incomplete revascularization in patients with multiarterial coronary artery disease who underwent percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) using the Syntax revascularization index (SRI) and its relationship to major cardiovascular events during follow-up. Materials and Methods Observational, retrospective study with 4-year follow-up of patients with multiarterial coronary artery disease who underwent surgical or percutaneous coronary revascularization, in whom the baseline Syntax score (SSb) and the residual Syntax score (SSr) were calculated. The Syntax Revascularization Index (SRI) was determined with the following formula: SRI = (1- [SSr/SSb]) x 100, and major cardiovascular events at 4-year follow-up were compared. Results Two hundred patients (100 in each group) were evaluated. Mean SSr in group 1 was 83.2%, and in group 2, 79.0% (p=0.88). Mean complete revascularization was 41% in the first group and 35% in the second. A cutoff point of ≤90% of IRS had the best accuracy for predicting major cardiovascular events (area under the curve of 0.60; 95% CI: 0.49-0.71, p<0.05). In multivariate analysis IRS was an independent predictor of major cardiovascular events (HR 2.6; 95%CI: 1.32-3.22, p= 0.043). Conclusions The Syntax Revascularization Index may be useful for measuring the degree of revascularization in patients with multiarterial coronary artery disease treated percutaneously or surgically. An SRI ³90% may be an acceptable target for revascularization.
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Affiliation(s)
- Tania Vásquez Loarte
- Universidad de San Martín de Porras, Lima, Perú. Universidad de San Martín de Porres Universidad de San Martín de Porras Lima Peru
| | - Yigal Piña Reyna
- Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Instituto Nacional de Cardiología «Ignacio Chávez Ciudad de México México
| | - Marco Peña Duque
- Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México. Instituto Nacional de Cardiología «Ignacio Chávez Ciudad de México México
| | - César Antonio Ortiz Zegarra
- Instituto Nacional Cardiovascular INCOR. EsSalud, Lima, Perú. Instituto Nacional Cardiovascular INCOR. EsSalud Lima Perú
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Mavromatis K, Boden WE, Maron DJ, Mancini GBJ, Weintraub WS, Gosselin G, Berman DS, Shaw LJ, Spertus JA, Hochman JS. Comparison of Outcomes of Invasive or Conservative Management of Chronic Coronary Disease in Four Randomized Controlled Trials. Am J Cardiol 2022; 185:18-28. [PMID: 36257844 DOI: 10.1016/j.amjcard.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/17/2022] [Accepted: 09/09/2022] [Indexed: 01/09/2023]
Abstract
Revascularization and medical therapy for chronic coronary disease have both evolved significantly over the last 50 years. A total of 4 contemporary randomized controlled trials- Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation (COURAGE), Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2), and International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)-have assessed the incremental benefit of revascularization when added to secondary prevention with intensive pharmacologic and lifestyle intervention. We reviewed these 4 seminal studies with the objective of marshaling evidence to better frame how these results should apply to clinical decision making. These studies differed in study design, end points, intensity of treatment, and revascularization techniques. Nevertheless, they all demonstrate similar rates of "hard" clinical events with invasive and conservative management, and varying degrees of benefit in angina-related quality of life with revascularization. In conclusion, although controversy persists concerning the role of revascularization because of differing interpretations of the clinical trial evidence, we contend that instead of being competing management strategies, invasive and conservative approaches are complementary.
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Affiliation(s)
- Kreton Mavromatis
- Division of Cardiology, Atlanta VA Health Care System, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - William E Boden
- Department of Medicine, VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - David J Maron
- Stanford Prevention Research Center, Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - G B John Mancini
- Department of Medicine, Division of Cardiology, Center for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - William S Weintraub
- MedStar Health and Department of Medicine, MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Gilbert Gosselin
- Department of Medicine, Montreal Heart Institute, Montreal, Québec, Canada
| | - Daniel S Berman
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Leslee J Shaw
- Icahn School of Medicine at Mt Sinai, New York, New York
| | - John A Spertus
- Department of Medicine, Saint Luke's Mid America Heart Institute, University of Missouri - Kansas City, Kansas City, Missouri
| | - Judith S Hochman
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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7
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Hwang D, Park J, Yang HM, Yang S, Kang J, Han JK, Park KW, Kang HJ, Koo BK, Kim HS. Angiographic complete revascularization versus incomplete revascularization in patients with diabetes mellitus. Cardiovasc Diabetol 2022; 21:56. [PMID: 35439958 PMCID: PMC9019985 DOI: 10.1186/s12933-022-01488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Considering the nature of diabetes mellitus (DM) in coronary artery disease, it is unclear whether complete revascularization is beneficial or not in patients with DM. We investigated the clinical impact of angiographic complete revascularization in patients with DM. Methods A total of 5516 consecutive patients (2003 patients with DM) who underwent coronary stenting with 2nd generation drug-eluting stent were analyzed. Angiographic complete revascularization was defined as a residual SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score of 0. The patient-oriented composite outcome (POCO, including all-cause death, any myocardial infarction, and any revascularization) and target lesion failure (TLF) at three years were analyzed. Results Complete revascularization was associated with a reduced risk of POCO in DM population [adjusted hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.52–0.93, p = 0.016], but not in non-DM population (adjusted HR 0.90, 95% CI 0.69–1.17, p = 0.423). The risk of TLF was comparable between the complete and incomplete revascularization groups in both DM (adjusted HR 0.75, 95% CI 0.49–1.16, p = 0.195) and non-DM populations (adjusted HR 1.11, 95% CI 0.75–1.63, p = 0.611). The independent predictors of POCO were incomplete revascularization, multivessel disease, left main disease and low ejection fraction in the DM population, and old age, peripheral vessel disease, and low ejection fraction in the non-DM population. Conclusions The clinical benefit of angiographic complete revascularization is more prominent in patients with DM than those without DM after three years of follow-up. Relieving residual disease might be more critical in the DM population than the non-DM population. Trial registration The Grand Drug-Eluting Stent registry NCT03507205. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01488-7.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea.
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
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Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy. Biomed Pharmacother 2022; 148:112772. [PMID: 35245735 DOI: 10.1016/j.biopha.2022.112772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 01/08/2023] Open
Abstract
Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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10
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 521] [Impact Index Per Article: 173.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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11
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What does complete revascularization mean in 2021? - Definitions, implications, and biases. Curr Opin Cardiol 2021; 36:748-754. [PMID: 34483299 DOI: 10.1097/hco.0000000000000920] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives. RECENT FINDINGS When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks. SUMMARY Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.
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Rate of Incomplete Revascularization Following Coronary Artery Bypass Grafting at a Single Institution Between 2007 and 2017. Am J Cardiol 2021; 144:33-36. [PMID: 33383011 DOI: 10.1016/j.amjcard.2020.12.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022]
Abstract
Incomplete revascularization following coronary artery bypass grafting (CABG) is associated with increased repeat revascularization, myocardial infarction and death. Whether the rate of incomplete revascularization is increasing over time has not been previously described. All patients with multivessel coronary artery disease who underwent isolated and elective CABG at our Institution in 2007 (n = 291) were compared to patients who underwent CABG in 2017 (n = 290). A Revascularization Index Score was created to compare rates of incomplete revascularization between the 2 years based on the coronary anatomy and degree of stenosis. Comparison of the 2 years disclose that the rate of incomplete revascularization increased from 17.9% in 2007 to 28.3% in 2017 (p = 0.003) and was accompanied by a decline in the Revascularization Index Score from 0.73 to 0.67 (p = 0.005). Left ventricular function improved in both groups following CABG. Two-year cardiovascular mortality was significantly higher in the 2017 cohort compared to the 2007 cohort. These differences may be attributable to patient factors including more severe coronary artery disease associated with older age, greater incidence of smoking and previous percutaneous coronary intervention. In conclusion, the rate of incomplete revascularization following CABG significantly increased in 2017 compared to 2007 and was associated with higher cardiovascular mortality.
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Burgess SN, Juergens CP, Nguyen T, Leung M, Robledo KP, Thomas L, Mussap C, Lo ST, French JK. Diabetes and Incomplete Revascularisation in ST Elevation Myocardial Infarction. Heart Lung Circ 2021; 30:471-480. [DOI: 10.1016/j.hlc.2020.09.928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 06/18/2020] [Accepted: 09/14/2020] [Indexed: 11/26/2022]
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Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, Federici M, Filippatos G, Grobbee DE, Hansen TB, Huikuri HV, Johansson I, Jüni P, Lettino M, Marx N, Mellbin LG, Östgren CJ, Rocca B, Roffi M, Sattar N, Seferović PM, Sousa-Uva M, Valensi P, Wheeler DC. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2021; 41:255-323. [PMID: 31497854 DOI: 10.1093/eurheartj/ehz486] [Citation(s) in RCA: 2319] [Impact Index Per Article: 773.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3903] [Impact Index Per Article: 975.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Guía ESC 2019 sobre diabetes, prediabetes y enfermedad cardiovascular, en colaboración con la European Association for the Study of Diabetes (EASD). Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gallo M, Blitzer D, Laforgia PL, Doulamis IP, Perrin N, Bortolussi G, Guariento A, Putzu A. Percutaneous coronary intervention versus coronary artery bypass graft for left main coronary artery disease: A meta-analysis. J Thorac Cardiovasc Surg 2020; 163:94-105.e15. [DOI: 10.1016/j.jtcvs.2020.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
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Moutakiallah Y, Boulahya A, Seghrouchni A, Mounir R, Atmani N, Drissi M, Hatim EGA, Lakhal Z, Asfalou I, El Bekkali Y, Abouqal R, Aithoussa M. Coronary artery bypass surgery in type 2 diabetic patients: predictors of mortality and morbidity. THE CARDIOTHORACIC SURGEON 2019. [DOI: 10.1186/s43057-019-0009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Coronary artery bypass grafting has been widely admitted in the therapeutic arsenal of coronary artery disease in diabetics with low morbi-mortality. However, it requires special management which may be challenging in low-volume centers especially in African countries. We aimed to analyze the outcome of coronary artery bypass graft in our diabetic population and define predictors of adverse events.
Patients and methods
We retrospectively enrolled 529 consecutive diabetic patients (type 2) who underwent on-pump coronary artery bypass grafting at our institution between January 2000 and June 2018. The mean age was 61.1 ± 8.3 years with 4.04 as sex ratio (M/F) and 2.95 as mean EuroSCORE II. History of acute myocardial infarction, left main coronary artery stenosis, and three-vessel disease was present in respectively 58%, 26.1%, and 72.2% of patients. The average number of bypass was 2.4 ± 0.8. Duration of cardiopulmonary bypass and aortic cross-clamping were respectively 124.8 ± 43.5 and 79.7 ± 32.9 min.
Results
In-hospital mortality was 5.9% (n = 31) and the late mortality was 6.9% (n = 32). Duration of artificial ventilation, ICU stay, and postoperative stay were respectively 7 h, 44 h, and 13 days. Postoperative complications were myocardial infarction, superficial wound infection, mediastinitis, and low cardiac output syndrome in respectively 9.1%, 25.5%, 3.8%, and 12.7% of patients. Multivariable logistic regression analysis revealed that left ventricular ejection fraction < 40% (OR = 1.88; 95% CI 1.30–2.47; p = 0.03), poor perioperative glycemic control (OR = 1.53; 95% CI 1.12–2.38; p = 0.014), intra-aortic balloon pump insertion (OR = 2.29; 95% CI 1.47–3.10; p < 0.001), and postoperative cardiac complications (OR = 2.01; 95% CI 1.23–2.78; p < 0.001) were predictors of in-hospital mortality. Predictors of mediastinitis were obesity (OR = 5.86; 95% CI 1.43–23.95; p = 0.014), inotropic drugs use (OR = 8.14; 95% CI 1.57–42.34; p = 0.013), chest reopening for bleeding (OR = 4.01; 95% CI 0.62–25.85; p = 0.014), and blood transfusion (OR = 7.56; 95% CI 1.09–52.76; p = 0.041). Follow-up was 86.1% complete, with a mean follow-up of 63.5 ± 48.3 months (1–192 months), and cumulative survival at 5, 10, and 15 years was respectively 95.5 ± 1.1%, 86.3 ± 2.9%, and 76.9 ± 6.9%.
Conclusion
Even in low-volume centers in developing areas, coronary artery bypass surgery is an effective therapy for coronary artery disease in diabetic patients despite a relative high morbidity and mortality.
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Hannan EL, Zhong Y, Berger PB, Jacobs AK, Walford G, Ling FSK, Venditti FJ, King SB. Association of Coronary Vessel Characteristics With Outcome in Patients With Percutaneous Coronary Interventions With Incomplete Revascularization. JAMA Cardiol 2019; 3:123-130. [PMID: 29282471 DOI: 10.1001/jamacardio.2017.4787] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Many studies have compared outcomes for incomplete revascularization (IR) among patients undergoing percutaneous coronary interventions (PCI), but little is known about whether outcomes are related to the nature of the IR. Objective To determine whether some coronary vessel characteristics are associated with worse outcomes in patients with PCI with IR. Design, Setting, and Participants New York's PCI registry was used to examine mortality (median follow-up, 3.4 years) as a function of the number of vessels that were incompletely revascularized, the stenosis in those vessels, and whether the proximal left anterior descending artery was incompletely revascularized after controlling for other factors associated with mortality for patients with and without ST-elevation myocardial infarction (STEMI). This was a multicenter study (all nonfederal PCI hospitals in New York State) that included 41 639 New York residents with multivessel coronary artery disease undergoing PCI in New York State between January 1, 2010, and December 31, 2012. Exposures Percutaneous coronary interventions, with complete and incomplete revascularization. Main Outcomes and Measures Medium-term mortality. Results For patients with STEMI, the mean age was 62.8 years; 26.2% were women, 11.9% were Hispanic, and 81.5% were white. For other patients, the mean age was 66.6 years, 29.1% were women, 11.3% were Hispanic, and 79.1% were white. Incomplete revascularization was very common (78% among patients with STEMI and 71% among other patients). Patients with IR in a vessel with at least 90% stenosis were at higher risk than other patients with IR. This was not significant among patients with STEMI (17.18% vs 12.86%; adjusted hazard ratio [AHR], 1.16; 95% CI, 0.99-1.37) and significant among patients without STEMI (17.71% vs 12.96%; AHR, 1.15; 95% CI, 1.07-1.24). Similarly, patients with IR in 2 or more vessels had higher mortality than patients with completely revascularization and higher mortality than other patients with IR among patients with STEMI (20.37% vs 14.39%; AHR, 1.35; 95% CI, 1.15-1.59) and among patients without STEMI (20.10% vs 12.86%; AHR, 1.17; 95% CI, 1.09-1.59). Patients with proximal left anterior descending artery vessel IR had higher mortality than other patients with IR (20.09% vs 14.67%; AHR, 1.31; 95% CI, 1.04-1.64 for patients with STEMI and 20.78% vs 15.62%; AHR, 1.11; 95% CI, 1.01-1.23 for patients without STEMI). More than 20% of all PCI patients had IR of 2 or more vessels and more than 30% had IR with more than 90% stenosis. Conclusions and Relevance Patients with IR are at higher risk of mortality if they have IR with at least 90% stenosis, IR in 2 or more vessels, or proximal left anterior descending IR.
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Affiliation(s)
- Edward L Hannan
- University at Albany, State University of New York, Rensselaer
| | - Ye Zhong
- University at Albany, State University of New York, Rensselaer
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Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox. Curr Cardiol Rep 2019; 21:9. [PMID: 30790113 DOI: 10.1007/s11886-019-1091-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. RECENT FINDINGS Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 310] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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22
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Roffi M, Iglesias JF. CTO PCI in Patients With Diabetes Mellitus: Sweet Perspectives. JACC Cardiovasc Interv 2019; 10:2182-2184. [PMID: 29122131 DOI: 10.1016/j.jcin.2017.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Marco Roffi
- Cardiology Division, Geneva University Hospital, Geneva, Switzerland.
| | - Juan F Iglesias
- Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
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Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
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Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
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Schwann TA, Yammine MB, El-Hage-Sleiman AKM, Engoren MC, Bonnell MR, Habib RH. The effect of completeness of revascularization during CABG with single versus multiple arterial grafts. J Card Surg 2018; 33:620-628. [PMID: 30216551 DOI: 10.1111/jocs.13810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). METHODS We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. RESULTS Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). CONCLUSIONS Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.
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Affiliation(s)
- Thomas A Schwann
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio.,Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Maroun B Yammine
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon
| | - Abdul-Karim M El-Hage-Sleiman
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon
| | - Milo C Engoren
- Mercy Saint Vincent Medical Center, Toledo, Ohio.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Mark R Bonnell
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio
| | - Robert H Habib
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon.,Society of Thoracic Surgery Research Center, Chicago, Illinois
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Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2018; 55:4-90. [PMID: 30165632 DOI: 10.1093/ejcts/ezy289] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Qiu Z, Auchoybur Merveesh L, Xu Y, Jiang Y, Wang L, Xu M, Xiang F, Chen X. The midterm results of coronary endarterectomy in patients with diffuse coronary artery disease. J Cardiothorac Surg 2018; 13:90. [PMID: 30041678 PMCID: PMC6057028 DOI: 10.1186/s13019-018-0776-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diffuse coronary artery disease is a challenge for both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Coronary artery endarterectomy (CE) coupled with CABG is an alternative method to achieve complete revascularization. The mid- and long-term results of CE are largely questionable. The aim is to evaluate the early and mid-term graft patency of concomitant coronary artery endarterectomy and CABG. METHODS A total of 304 patients who had undergone concomitant CE and CABG for diffuse coronary artery disease were identified from our database. A total of 238 patients (1) with complete operative records, (2) with good graft flow during surgery, (3) who were discharged, (4) with a one-year/ three-year follow-up were included in our study. The follow-up information was obtained directly from our out-patient department and by telephone contact. The categorical and continuous values were analyzed by Chi Square test and student's test respectively. RESULTS CE was performed on 238 patients who represented a total of 269 target coronary vessels. The mean age of the patients was 67.8 ± 6.8 years old; male to female patient ratio was 170:68. The mean intensive care unit stay was 1.7 ± 8 days, and mean post-operative length of hospital stay was 11 ± 3 days. The average follow up time was 41.8 ± 21.4 months. At follow-up, the overall graft patency was 78.4% at one year and 69.8% at three years. The left coronary graft patency rate was significantly higher than the right coronary graft patency rate (87.4% vs 73.1% at one-year and 78.2% vs 64.8% at three years). There was no significant difference in graft patency rates between the on-pump CE + CABG vs off-pump CE + CABG groups at one year (80.0% vs 76.9%) and at three years (92.3% vs 91.7%). At the one-year follow up, 92.3% of grafts showed grade A patency in the on-pump group versus 91.7% in the off-pump group; 7.7% of grafts showed grade B patency in the on-pump group versus 8.3% in the off-pump group. At the three-year follow up, 80.6% of grafts showed grade A patency in the on-pump group versus 77.4% in the off-pump group; 19.4% of grafts showed grade B patency in the on-pump group versus 22.6% in the off -pump group. The Predictors of better graft patency are use of LIMA graft, CE on LAD, and intra-operative graft flow meter and PI. CONCLUSIONS In patients with diffuse coronary disease, CE is a safe and feasible technique for a select group of patients with excellent mid-term survival rates and graft patency rates. CE produces better overall results when performed on the LAD, and grafted over with the LIMA. Similar outcomes are obtained with both on-pump and off-pump surgery. For a select group of patients, coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and complete coronary revascularization.
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Affiliation(s)
- Zhibing Qiu
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - L Auchoybur Merveesh
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Yueyue Xu
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Yinshuo Jiang
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Liming Wang
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Ming Xu
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery. Nanjing First Hospital, Nanjing Medical University, Changle Rd 68, Nanjing, 210006, Jiangsu, China. .,Department of Cardiothoracic and vascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China.
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Auchoybur ML, Chen X. Complete revascularization reduces adverse outcomes in patients with multivessel coronary artery disease. World J Meta-Anal 2017; 5:167-176. [DOI: 10.13105/wjma.v5.i6.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/13/2017] [Accepted: 10/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the influence of complete and incomplete revascularization (ICR) in patients with multivessel coronary artery disease undergoing coronary artery bypass or percutaneous coronary intervention.
METHODS We searched PubMed using the keywords “complete revascularization”, “incomplete revascularization”, “coronary artery bypass”, and “percutaneous coronary intervention”. We selected randomized controlled studies (RCT) and observational studies only for review. The main outcomes of interest were mortality, myocardial infarction (MI) and repeat revascularization. We identified further studies by hand searching relevant publications and included those that met with the inclusion criteria in our final analysis and performed a systematic review.
RESULTS Ten studies were identified, including 13327 patients of whom, 8053 received complete revascularization and 5274 received ICR. Relative to ICR, CR was associated with lower mortality (RR: 0.755, 95%CI: 0.66 to 0.864, P = 0.765, I2 = 0.0%), lower rates of MI (RR: 0.759, 95%CI: 0.615 to 0.937, P = 0.091, I2 = 45.1%), lower rates of MACCE (RR: 0.731, 95%CI: 0.668 to 0.8, P = 0.453, I2 = 0.0%) and reduced rates of repeat coronary revascularization (RR: 0.691, 95%CI: 0.541 to 0.883, P = 0.0, I2 = 88.3%).
CONCLUSION CR is associated with lower rates of adverse outcomes. CR can be used as a standard in the choice of any particular revascularization strategy.
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Affiliation(s)
- Merveesh L Auchoybur
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
| | - Xin Chen
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
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Schwann TA. The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem. Surg Clin North Am 2017; 97:835-865. [PMID: 28728719 DOI: 10.1016/j.suc.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine & Life Sciences, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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Percutaneous coronary intervention vs. cardiac surgery in diabetic patients. Where are we now and where should we be going? Hellenic J Cardiol 2017; 58:178-189. [DOI: 10.1016/j.hjc.2017.01.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/09/2017] [Accepted: 01/20/2017] [Indexed: 11/22/2022] Open
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Kennedy MW, Fabris E, Suryapranata H, Kedhi E. Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients? Cardiovasc Diabetol 2017; 16:51. [PMID: 28427383 PMCID: PMC5397766 DOI: 10.1186/s12933-017-0533-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/08/2017] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.
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Affiliation(s)
- Mark W Kennedy
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Enrico Fabris
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Harry Suryapranata
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Elvin Kedhi
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.
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Hannan EL, Zhong Y, Jacobs AK, Ling FSK, Berger PB, Walford G, Venditti FJ, King SB. Incomplete revascularization for percutaneous coronary interventions: Variation among operators, and association with operator and hospital characteristics. Am Heart J 2017; 186:118-126. [PMID: 28454825 DOI: 10.1016/j.ahj.2017.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/21/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many studies have compared outcomes for incomplete revascularization (IR) among patients undergoing percutaneous coronary interventions (PCIs), but little is known about the correlates of IR, the extent to which complete revascularization (CR) was attempted unsuccessfully, and the variation across operators in the use of IR. METHODS New York's PCI registry was used to examine medium-term mortality for IR, the variables associated with the use of IR, and the variation across operators in the utilization of IR after controlling for patient factors. RESULTS Incomplete revascularization occurred for 63% of all patients and was significantly associated with higher 3-year mortality (adjusted hazard ratio1.35, 95% CI 1.23-1.48) than for CR. A total of 96% of all attempted CRs were successful. Operators with 15 or fewer years in practice (the lowest half) used IR significantly more (65% vs 61%, adjusted odds ratio [AOR] 1.17, 95% CI 1.00-1.37) than other operators, and operators with annual volumes of 171 or lower (the lowest 3 quartiles) used IR more than other operators (68% vs 60%, AOR 1.35, 95% CI 1.14-1.59). Also, hospitals with annual volumes of 645 and lower (the lowest 50% of hospitals) used IR more (67% vs 62%, AOR 1.46, 95% CI 1.07-1.99) than other hospitals. CONCLUSIONS Percutaneous coronary intervention patients without myocardial infarction who undergo IR continue to have higher medium-term (3-year) risk-adjusted mortality rates. There is a large amount of variability among operators in the frequency with which IR occurs. Operators who have been in practice longer, and higher-volume operators and hospitals have lower rates of IR. Failed attempts at CR occur very infrequently.
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Affiliation(s)
- Edward L Hannan
- State University of New York, University at Albany, Albany, NY.
| | - Ye Zhong
- State University of New York, University at Albany, Albany, NY
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Mejía OAV, Lisboa LAF, Dallan LAO, Jatene FB. Bilateral Internal Thoracic Artery and Optimal Revascularization Strategy in Insulin-Dependent Diabetic Patients. Braz J Cardiovasc Surg 2016; 30:III-IV. [PMID: 26735608 PMCID: PMC4690654 DOI: 10.5935/1678-9741.20150062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Fabio Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Pineda AM, Chandra R, Gowani SA, Santana O, Mihos CG, Kirtane AJ, Stone GW, Kurlansky P, Smith CR, Beohar N. Completeness of revascularization and its impact on the outcomes of a staged approach of percutaneous coronary intervention followed by minimally invasive valve surgery for patients with concomitant coronary artery and valvular heart disease. Catheter Cardiovasc Interv 2015; 88:329-37. [PMID: 26526421 DOI: 10.1002/ccd.26294] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 10/02/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND A staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) is an alternative to the conventional combined coronary artery bypass and valve surgery for patients with concomitant coronary artery and valve disease. Limited data exist on degree of the completeness of revascularization achieved with this approach and its impact on outcomes. METHODS A total of 138 patients, who underwent a staged approach between January 2009 and June 2013, were retrospectively evaluated. Coronary angiograms were reviewed by two cardiologists blinded to outcomes and were then categorized into two groups: complete or incomplete revascularization, which was defined as ≥1 major epicardial coronary arteries of at least 2.0 mm diameter with ≥70% untreated obstruction after the index PCI and before MIVS. RESULTS Complete and incomplete revascularization was achieved in 105 (76%) and 33 (24%) patients, respectively. The patients with incomplete revascularization had a lower ejection fraction, a higher STS score, and more prior myocardial infarctions and multi-vessel coronary artery disease. There were no differences in the post-operative complications, 30-day mortality, or 3-year survival (84 vs. 83%, P = 0.68). After a median follow-up of 29 months, incompletely revascularized patients had a higher incidence of acute coronary syndrome (2.9 vs. 12.9%, P = 0.05). CONCLUSIONS In patients undergoing a staged approach of PCI followed by MIVS, incomplete revascularization did not significantly impact the short or mid-term survival, but was associated with an increased incidence of acute coronary syndrome at follow-up. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Andrés M Pineda
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida
| | - Ramesh Chandra
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida
| | - Saqib A Gowani
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida
| | - Orlando Santana
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida
| | - Christos G Mihos
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida
| | | | - Gregg W Stone
- Columbia University Medical Center, New York, New York
| | | | - Craig R Smith
- Columbia University Medical Center, New York, New York
| | - Nirat Beohar
- Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida.
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Jiménez-Navarro MF, López-Jiménez F, Barsness G, Lennon RJ, Sandhu GS, Prasad A. Long-term prognosis of complete percutaneous coronary revascularisation in patients with diabetes with multivessel disease. Heart 2015; 101:1233-9. [DOI: 10.1136/heartjnl-2014-307143] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 03/18/2015] [Indexed: 01/17/2023] Open
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Schwann TA, Hashim SW, Badour S, Obeid M, Engoren M, Tranbaugh RF, Bonnell MR, Habib RH. Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery-based coronary artery bypass graft surgery: a multi-institutional study†. Eur J Cardiothorac Surg 2015; 49:188-95. [PMID: 25762396 DOI: 10.1093/ejcts/ezv093] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 02/03/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG. METHODS Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.
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Affiliation(s)
- Thomas A Schwann
- University of Toledo Medical Center, Toledo, OH, USA Mercy St. Vincent Medical Center, Toledo, OH, USA
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Nicolini F, Agostinelli A, Vezzani A, Benassi F, Gherli T. CABG versus PCI in the treatment of diabetic patients affected by coronary artery disease. Int Heart J 2014; 55:469-73. [PMID: 25297505 DOI: 10.1536/ihj.14-061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical coronary revascularization and percutaneous coronary intervention were demonstrated to be effective treatments for coronary artery disease. However, the optimal revascularization strategy remains unclear in certain patient subsets. The recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial is a randomized study evaluating the use of CABG versus PCI in diabetic patients with multivessel coronary disease. The purpose of this study was to review the available literature based on randomized trials and observational studies in order to allow clinicians to make evidence-based decisions when treating diabetic patients with multivessel coronary disease. The current evidence suggests that CABG should remain the standard of care for this patient population.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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Raza S, Sabik JF, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2014; 148:1257-1264; discussion 1264-6. [PMID: 25260269 DOI: 10.1016/j.jtcvs.2014.06.058] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/17/2014] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG). METHODS From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n=938; 7.9%) versus single ITA (SITA) grafting, off-pump (n=602; 5.0%) versus on-pump CABG, and incomplete (n=2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality. RESULTS After adjusting for patient characteristics, BITA versus SITA grafting was associated with a 21% lower late mortality (68% confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality from DSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80% increased risk), higher body mass index (7% increased risk per kg/m2), medically treated diabetes (73% increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%). CONCLUSIONS BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden-those at greatest risk of developing these infections.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Khalil Masabni
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ponnuthurai Ainkaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Isolated coronary artery bypass grafting in extracorporeal circulation in patients over 65 years old - does age still matter? KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2014; 11:191-9. [PMID: 26336419 PMCID: PMC4283853 DOI: 10.5114/kitp.2014.43849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 11/26/2013] [Accepted: 04/22/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) is conducted more and more commonly in patients in advanced age. AIM OF THE STUDY To analyze the influence of age and concurrent risk factors on the complications and early mortality after CABG. MATERIAL AND METHODS Medical records of 2194 patients were analyzed retrospectively. A group of 1303 patients who had undergone isolated CABG was selected. 106 (4.8%) patients were excluded due to missing data in their medical records. The remaining 1197 patients were divided into two subgroups by age: 1(st) group < 65 years (n = 662; 55.3%); 2(nd) group ≥ 65 years (n = 535; 44.7%). RESULTS The total 30-day mortality was 3.93% and was six times higher in the older group (1.21 vs. 7.29%; p < 0.001). Complications were observed in 176 (14.70%) patients, more often in the older group (10.42% vs. 20.0%; p < 0.001). In this group all kinds of complications were noted more often and in particular: postoperative myocardial infarction (1.96% vs. 5.42%; p = 0.001), respiratory dysfunction (1.36% vs. 4.11%; p = 0.005), neurological complications (1.81% vs. 3.74%; p = 0.04) and multi-organ dysfunction syndrome (0.30% vs. 1.68%, p = 0.03). The older patients required longer time under mechanical ventilation (24.0 ± 27.9 vs. 37.0 ± 74.1 hours; p = 0.004) and stayed longer in the intensive care unit: 2.5 ± 3.0 vs. 4.1 ± 7.84 days; p < 0.001. Independent predictors of death were: female sex [OR (95% CI) = 2.4 (1.2-4.5)], age ≥ 65 years [OR = 4.9 (2.1-11.1)], eGFR < 60 mL/min/1.73 m(2) [OR = 2.2 (1.0-4.7)], time at extracorporeal circulation > 72 minutes [OR = 5.5 (2.7-10.9)] and left main stem stenosis (> 50%) [OR = 2.4 (1.3-4.6)]. CONCLUSIONS Age still significantly influences postoperative complications and mortality after isolated CABG.
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Zimarino M, Curzen N, Cicchitti V, De Caterina R. The adequacy of myocardial revascularization in patients with multivessel coronary artery disease. Int J Cardiol 2013; 168:1748-57. [DOI: 10.1016/j.ijcard.2013.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 04/04/2013] [Accepted: 05/03/2013] [Indexed: 02/04/2023]
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Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts. J Thorac Cardiovasc Surg 2013; 147:75-83. [PMID: 24084283 DOI: 10.1016/j.jtcvs.2013.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/02/2013] [Accepted: 08/09/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting. METHODS In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities. RESULTS In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients. CONCLUSIONS This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR.
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Wu C, Dyer AM, Walford G, Holmes DR, King SB, Stamato NJ, Sharma S, Jacobs AK, Venditti FJ, Hannan EL. Incomplete revascularization is associated with greater risk of long-term mortality after stenting in the era of first generation drug-eluting stents. Am J Cardiol 2013; 112:775-81. [PMID: 23756548 DOI: 10.1016/j.amjcard.2013.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 12/19/2022]
Abstract
The association between incomplete revascularization (IR) and long-term mortality after stenting in the era of drug-eluting stents is not well understood. In the present study, we test the hypothesis that IR is associated with a greater risk of long-term (5-year) mortality after stenting for multivessel coronary disease. Using data from the Percutaneous Coronary Intervention Reporting System of New York State, 21,767 patients with multivessel disease who underwent stenting during October 2003 to December 2005 were identified. Complete revascularization (CR) was achieved in 6,844 patients (31.4%), and 14,923 patients (68.6%) were incompletely revascularized. The CR and IR patients were propensity matched on a 1:1 ratio on the number of diseased vessels, the presence of total occlusion, type of stents, and the probability of achieving CR estimated using a logistic model with established risk factors as independent variables. Patients were followed for vital status until December 31, 2008 using the National Death Index. Differences in survival between the matched CR and IR patients were compared. Among the 6,511 pairs of propensity-matched patients, the 5-year survival rate for IR was lower compared with CR (79.3% vs 81.4%, p = 0.004), and the risk of death during follow-up was 16% greater for IR compared with CR (hazard ratio 1.16, 95% confidence interval 1.06 to 1.27, p = 0.001). In addition, subgroup analyses demonstrated that the association between IR and long-term mortality was not dependent on major patient risk factors. In conclusion, IR is associated with an increased risk of long-term mortality after stenting for multivessel disease in the era of drug-eluting stents.
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Affiliation(s)
- Chuntao Wu
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, USA
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Hakeem A, Garg N, Bhatti S, Rajpurohit N, Ahmed Z, Uretsky BF. Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data. J Am Heart Assoc 2013; 2:e000354. [PMID: 23926119 PMCID: PMC3828792 DOI: 10.1161/jaha.113.000354] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [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 Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). Coronary artery bypass grafting (CABG) has been compared with percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) in recent randomized controlled trials (RCTs). Methods and Results RCTs comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD42013003693). Primary end point (major adverse cardiac events) was a composite of death, myocardial infarction, and stroke at a mean follow‐up of 4 years. Analyses were performed for each outcome by using risk ratio (RR) by fixed‐ and random‐effects models. Four RCTS with 3052 patients met inclusion criteria (1539 PCI versus 1513 CABG). Incidence of major adverse cardiac events was 22.5% for PCI and 16.8% for CABG (RR 1.34, 95% CI 1.16 to 1.54, P<0.0001). Similar results were obtained for death (14% versus 9.7%, RR 1.51, 95% CI 1.09 to 2.10, P=0.01), and MI (10.3% versus 5.9%, RR 1.44, 95% CI 0.79 to 2.6, P=0.23). Stroke risk was significantly lower with DES (2.3% versus 3.8%, RR 0.59, 95% CI 0.39 to 0.90, P=0.01) and subsequent revascularization was several‐fold higher (17.4% versus 8.0%, RR 1.85, 95% CI 1.0 to 3.40, P=0.05). Conclusions These data demonstrate that CABG in diabetic patients with MVD at low to intermediate surgical risk (defined as EUROSCORE <5) is superior to MVD PCI with DES. CABG decreased overall death, nonfatal myocardial infarction, and repeat revascularization at the expense of an increase in stroke risk.
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Affiliation(s)
- Abdul Hakeem
- Division of Cardiovascular Diseases, Department of Medicine, University of Arkansas for Medical Sciences
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Farooq V, Serruys PW, Bourantas CV, Zhang Y, Muramatsu T, Feldman T, Holmes DR, Mack M, Morice MC, Ståhle E, Colombo A, de Vries T, Morel MA, Dawkins KD, Kappetein AP, Mohr FW. Quantification of Incomplete Revascularization and its Association With Five-Year Mortality in the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) Trial Validation of the Residual SYNTAX Score. Circulation 2013; 128:141-51. [DOI: 10.1161/circulationaha.113.001803] [Citation(s) in RCA: 274] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background—
The residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) Score is an objective measure of the degree and complexity of residual stenosis after percutaneous coronary intervention (PCI).
Methods and Results—
In the randomized PCI cohort of the SYNTAX Trial (n=903), the baseline and residual SYNTAX Scores were calculated. Subjects with a residual SYNTAX Score of 0 were defined as having undergone complete revascularization (CR), and a residual SYNTAX Score >0 as incomplete revascularization (ICR). Five-year clinical outcomes were stratified by CR and ICR (tertiles of the residual SYNTAX Score: >0–4, >4–8, and >8). In the PCI cohort, the mean baseline and residual SYNTAX Scores were 28.4±11.5 and 4.5±6.9, respectively. The mean Δ SYNTAX Score (representative of the burden of disease removed by PCI) was 23.8±10.9. The residual SYNTAX Score was distributed as follows: CR, 0 (n=386, 42.7%); ICR, >0 to 4 (n=184, 20.4%), >4 to 8 (n=167, 18.5%), >8 (n=153, 16.9%). A progressively higher residual SYNTAX Score was shown to be a surrogate marker of increasing clinical comorbidity and anatomic complexity. Subjects with CR or residual SYNTAX Scores ≤8 had comparable 5-year mortality (CR, 8.5%; residual SYNTAX Score >0–4, 8.7%; >4–8, 11.4%;
P
=0.60). A residual SYNTAX Score >8 was associated with 35.3% all-cause mortality at 5-years (
P
<0.001). Stratified analyses in the predefined medical treated diabetic and left main subgroups yielded similar results.
Conclusions—
The residual SYNTAX Score was shown to be a powerful indicator of 5-year mortality in the SYNTAX Trial. The residual SYNTAX Score may aid in determining a reasonable level of revascularization.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00114972.
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Affiliation(s)
- Vasim Farooq
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Patrick W. Serruys
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Christos V. Bourantas
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Yaojun Zhang
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Takashi Muramatsu
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Ted Feldman
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - David R. Holmes
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Michael Mack
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Marie Claude Morice
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Elisabeth Ståhle
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Antonio Colombo
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Ton de Vries
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Marie-angèle Morel
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Keith D. Dawkins
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Arie-Pieter Kappetein
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
| | - Friedrich W. Mohr
- From the Department of Interventional Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands (V.F., P.W.S., C.V.B., Y.Z., T.M.); Evanston Hospital, Evanston, IL (T.F.); The Mayo Clinic, Rochester, MN (D.R.H.); Medical City Dallas Hospital, Dallas, TX (M.M.); Institut Jacques Cartier, Massy, France (M.C.M.); University Hospital Uppsala, Uppsala, Sweden (E.S.); San Raffaele Scientific Institute, Milano, Italy (A.C.); Cardialysis BV, Rotterdam, The Netherlands (T.d.V.,
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Liistro F, Angioli P, Grotti S, Brandini R, Porto I, Ricci L, Tacconi D, Ducci K, Falsini G, Bellandi G, Bolognese L. Impact of critical limb ischemia on long-term cardiac mortality in diabetic patients undergoing percutaneous coronary revascularization. Diabetes Care 2013; 36:1495-500. [PMID: 23340882 PMCID: PMC3661812 DOI: 10.2337/dc12-1603] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Development of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD). RESEARCH DESIGN AND METHODS We designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study. RESULTS Among the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89-3.85]; P = 0.1). CONCLUSIONS The development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD.
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Affiliation(s)
- Francesco Liistro
- Cardiovascular and Neurologic Department, San Donato Hospital, Arezzo, Italy.
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Abstract
The incidence of both type 1 and type 2 diabetes is increasing globally, most likely explained by environmental changes, such as changing exposures to foods, viruses, and toxins, and by increasing obesity. While cardiovascular disease (CVD) mortality has been declining recently, this global epidemic of diabetes threatens to stall this trend. CVD is the leading cause of death in both type 1 and type 2 diabetes, with at least a two- to fourfold increased risk in patients with diabetes. In this review, the risk factors for CVD are discussed in the context of type 1 and type 2 diabetes. While traditional risk factors such as dyslipidemia, hypertension, and obesity are greater in type 2 patients than in type 1 diabetes, they explain only about half of the increased CVD risk. The role for diabetes-specific risk factors, including hyperglycemia and kidney complications, is discussed in the context of new study findings.
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Affiliation(s)
- Lindsey Duca
- Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, 13001 E 17th Place, B119, Bldg 500, 3rd Floor, Aurora, CO 80045, USA.
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Shirani J. Is ischemia the most powerful indicator of myocardial viability? Curr Cardiol Rep 2013; 15:354. [PMID: 23512623 DOI: 10.1007/s11886-013-0354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic symptomatic ischemic heart failure remains a major cause of morbidity and mortality in the adult. Recently, the utility of coronary revascularization in early management of patients with stable ischemic heart failure has come into question by several randomized clinical trials. Some of these studies have also challenged the notion that determination of the predominant state of the dysfunctional left ventricular myocardium (viable or scarred) may facilitate identification of patients who would benefit the most from revascularization. These prospective, randomized, multi-center trials have also exposed many of the practical impediments to conducting an ideal clinical investigation particularly in the context of increasingly recognized need for goal-directed and personalized approaches to management of ischemic heart disease. This review summarizes the present evidence for an ischemia-guided approach to evaluation and treatment of chronic ischemic heart disease with left ventricular systolic dysfunction.
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Affiliation(s)
- Jamshid Shirani
- Department of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
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49
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The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol 2012; 61:282-94. [PMID: 23265332 DOI: 10.1016/j.jacc.2012.10.017] [Citation(s) in RCA: 213] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 10/16/2012] [Accepted: 10/30/2012] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The study sought to evaluate the clinical impact of angiographic complete (CR) and incomplete (ICR) revascularization and its association with the presence of total occlusions (TO), after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery in the "all-comers" SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. BACKGROUND In patients with complex coronary artery disease undergoing PCI or CABG, the long-term prognostic implications of CR versus ICR is unsettled. METHODS In this post hoc study, consisting of randomized (n = 1,800) and nested PCI (n = 198) and CABG (n = 649) registries, 4-year clinical outcomes were compared in groups, with and without angiographic CR, in the PCI and CABG arms. Clinical outcomes were analyzed with Kaplan-Meier estimates, log-rank comparisons, and Cox regression analyses. Multivariate predictors of ICR were determined. Similar analyses were undertaken in the TO and non-TO treated groups of both study arms. RESULTS Angiographic CR was achieved in 52.8% of the PCI arm and 66.9% of the CABG arm. Within the PCI and CABG arms, ICR (compared with CR) seemed to be a surrogate marker of a greater burden of anatomical coronary complexity and clinical comorbidity and was associated with significantly higher frequencies of 4-year mortality, all-cause revascularization, stent thrombosis (PCI arm), and major adverse cardiac and cerebrovascular events. The presence of a TO was the strongest independent predictor of ICR after PCI (hazard ratio: 2.70, 95% confidence interval: 1.98 to 3.67, p < 0.001). Eight hundred and forty patients (PCI: 26.3%, CABG: 36.4%, p < 0.001) were identified to have 1,007 TOs, with 68.1% of TOs located in the proximal-mid coronary vasculature. The findings associating ICR (compared with CR) with higher frequencies of 4-year mortality and major adverse cardiac and cerebrovascular events remained consistent in the TO-treated groups in the PCI and CABG arms. CONCLUSIONS Within the PCI and CABG arms of the all-comers SYNTAX trial, angiographically determined ICR has a detrimental impact on long-term clinical outcomes, including mortality. This effect remained consistent in patients with and without TOs.
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Bacaksiz A, Kayrak M, Vatankulu MA, Ayhan SS, Sonmez O, Akilli H, Aribas A, Ari H, Ozdemir K. The Effect of Smoking on Myocardial Performance Index in Middle-Aged Males after First Acute Myocardial Infarction. Echocardiography 2012; 30:155-63. [DOI: 10.1111/echo.12029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ahmet Bacaksiz
- Department of Cardiology; BezmiÂlem Foundation University; Istanbul; Turkey
| | - Mehmet Kayrak
- Department of Cardiology; Meram School of Medicine; Selcuk University; Konya; Turkey
| | | | - Selim S. Ayhan
- Department of Cardiology; Abant Izzet Baysal University; Bolu; Turkey
| | - Osman Sonmez
- Department of Cardiology; BezmiÂlem Foundation University; Istanbul; Turkey
| | - Hakan Akilli
- Department of Cardiology; Meram School of Medicine; Selcuk University; Konya; Turkey
| | - Alpay Aribas
- Department of Cardiology; Meram School of Medicine; Selcuk University; Konya; Turkey
| | - Hatem Ari
- Department of Cardiology; Meram School of Medicine; Selcuk University; Konya; Turkey
| | - Kurtulus Ozdemir
- Department of Cardiology; Meram School of Medicine; Selcuk University; Konya; Turkey
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