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Mehaffey JH, Hayanga JWA, Kawsara M, Sakhuja A, Mascio C, Rankin JS, Badhwar V. Contemporary Coronary Artery Bypass Grafting vs Multivessel Percutaneous Coronary Intervention. Ann Thorac Surg 2023; 116:1213-1220. [PMID: 37353103 PMCID: PMC10739562 DOI: 10.1016/j.athoracsur.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/03/2023] [Accepted: 05/13/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Interpretation of recent alterations to the guideline priority of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease contests historical data and practice. To reevaluate contemporary outcomes, a large contemporary analysis was conducted comparing CABG with multivessel PCI among Medicare beneficiaries. METHODS The United States Centers for Medicare and Medicaid Services database was evaluated all beneficiaries with acute coronary syndrome undergoing isolated CABG or multivessel PCI (2018-2020). Risk adjustment was performed using multilevel regression analysis, Cox proportional hazards time to event models, and inverse probability of treatment weighting propensity scores. RESULTS A total of 104,127 beneficiaries were identified undergoing CABG (n = 51,389) or multivessel PCI (n = 52,738). Before risk adjustment, compared with PCI, CABG patients were associated with younger age (72.9 vs 75.2 years, P < .001), higher Elixhauser Comorbidity Index (5.0 vs 4.2, P < .001), more diabetes (48.5% vs 42.2%, P < .001), higher cost ($54,154 vs $33,484, P < .001), and longer length of stay (11.9 vs 5.8 days, P < .001). After inverse probability of treatment weighting propensity score adjustment, compared with PCI, CABG was associated with lower hospital mortality (odds ratio, 0.74; P < .001), fewer hospital readmissions at 3 years (odds ratio, 0.85; P < .001), fewer coronary reinterventions (hazard ratio, 0.37; P < .001), and improved 3-year survival (hazard ratio, 0.51; P < .001). CONCLUSIONS Contemporary real-world data from Medicare patients with multivessel disease reveal that CABG outcomes were superior to PCI, providing important longitudinal data to guide patient care and policy development.
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Affiliation(s)
- J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia.
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Mohammad Kawsara
- Division of Cardiology, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Christopher Mascio
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - J Scott Rankin
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
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Kumar A, Lutsey PL, St. Peter WL, Schommer JC, Van’t Hof JR, Rajpurohit A, Farley JF. Prescription patterns of P2Y12 inhibitors following revascularization in the United States: 2013-2018. Clin Transl Sci 2023; 16:1886-1897. [PMID: 37466284 PMCID: PMC10582679 DOI: 10.1111/cts.13596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/01/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023] Open
Abstract
P2Y12 inhibitors (i.e., clopidogrel, prasugrel, or ticagrelor) are effective at reducing adverse cardiovascular outcomes post-revascularization in coronary artery disease (CAD). However, the choice of a specific P2Y12 inhibitor may vary according to the patient's characteristics, and trends in the use of different P2Y12 inhibitors are not well studied in real-world settings. The objective of this study is to determine trends in the prescription patterns of P2Y12 inhibitors in patients with CAD. We studied 137,073 patients with CAD cross-sectionally using the IBM MarketScan database (2013-2018). Patients with CAD prescribed P2Y12 inhibitors within 14 days of index revascularization were included to compare the utilization of P2Y12 inhibitors based on age and clinical characteristics. There were differences in prescription patterns by age. Among patients aged less than or equal to 65 years (N = 92,734), a continuously increased utilization of ticagrelor was observed from 13.7% to 45.6% replacing clopidogrel as the most prescribed medication by 2018. Similarly, ticagrelor was the choice of drug among patients undergoing percutaneous coronary intervention. Among the patients at high bleeding risk, clopidogrel remained the most prescribed medication with use in 50.6% of patients in 2018 in patients aged less than or equal to 65 years. Contrarily, among the older adults with age 65 or above (N = 44,339), although ticagrelor use increased with time, clopidogrel remained the most utilized drug and was used by 66.2% of patients in 2018. Additionally, clopidogrel was the preferred medication among patients with stroke history. With the increasing use of ticagrelor in real-world practice, further research is needed to observe its impact on cardiovascular outcomes.
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Affiliation(s)
- Arun Kumar
- Department of Pharmacy Practice and Administrative Sciences, James L. Winkle College of PharmacyUniversity of CincinnatiCincinnatiOhioUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthUniversity of Minnesota, School of Public HealthMinneapolisMinnesotaUSA
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care and Health SystemsUniversity of Minnesota, College of PharmacyMinneapolisMinnesotaUSA
| | - Jon C. Schommer
- Department of Pharmaceutical Care and Health SystemsUniversity of Minnesota, College of PharmacyMinneapolisMinnesotaUSA
| | - Jeremy R. Van’t Hof
- Cardiovascular Division, Lillehei Heart InstituteUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care and Health SystemsUniversity of Minnesota, College of PharmacyMinneapolisMinnesotaUSA
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health SystemsUniversity of Minnesota, College of PharmacyMinneapolisMinnesotaUSA
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Rodriguez AE, Fernandez-Pereira C, Mieres JR, Rodriguez-Granillo AM. High Non-Cardiac Death Incidence Should Be a Limitation of Drug-Eluting Stents Implantation? Insights from Recent Randomized Data. Diagnostics (Basel) 2023; 13:diagnostics13071321. [PMID: 37046540 PMCID: PMC10093159 DOI: 10.3390/diagnostics13071321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/16/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Despite the introduction of drug-eluting stents (DES) significantly improved the efficacy and safety of percutaneous coronary interventions (PCI), particularly in a high-risk group of patients, the gap between PCI with his competitor’s coronary artery bypass surgery (CABG) and/or optimal medical treatment alone was not reduced. In this revision, we highlighted the fact that in recent years landmark randomized studies reported at mid and long-term follow-ups a high incidence of non-cardiac death, cancer incidence, or both in the DES group of patients. The overall incidence of non-cardiac death was significantly higher in the DES vs. the comparator arm: 5.5% and 3.8%, respectively, p = 0.000018, and non-cardiac death appears to be more divergent between DES vs. the comparator at the extended follow-up to expenses of the last one. One of these trials reported five times greater cancer incidence in the DES arm at late follow-up, 5% vs. 0.7% p < 0.0018. We review the potential reason for these unexpected findings, although we can discard that DES biology could be involved in it. Until all these issues are resolved, we propose that DES implantation should be tailored accorded patient age, life expectancy, and lesion complexity.
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Affiliation(s)
- Alfredo E. Rodriguez
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Carlos Fernandez-Pereira
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Juan Ramon Mieres
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Alfredo Matias Rodriguez-Granillo
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
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4
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Kakar H, Groenland FTW, Elscot JJ, Rinaldi R, Scoccia A, Kardys I, Nuis RJ, Wilschut J, Dekker WKD, Daemen J, Zijlstra F, Van Mieghem NM, Diletti R. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Non-ST-Elevation Coronary Syndromes and Multivessel Disease: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 195:70-76. [PMID: 37011556 DOI: 10.1016/j.amjcard.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/17/2023] [Accepted: 03/06/2023] [Indexed: 04/05/2023]
Abstract
There is lack of evidence regarding the optimal revascularization strategy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). This systematic review and meta-analysis compares the clinical impact of percutaneous coronary intervention (PCI) with that of coronary artery bypass graft surgery (CABG) in this subset of patients. EMBASE, MEDLINE, and Web of Knowledge were searched for studies including patients with NSTE-ACS and MVD who underwent PCI or CABG up to September 1, 2021. The primary end point of the meta-analysis was all-cause mortality at 1 year. The secondary end points were myocardial infarction (MI), stroke, or repeat revascularization at 1 year. The analysis was conducted using the Mantel-Haenszel random-effects model to calculate the odds ratio (OR) with 95% confidence interval (CI). Four prospective observational studies met the inclusion criteria, including 1,542 patients who underwent CABG and 1,630 patients who underwent PCI. No significant differences were found in terms of all-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) between PCI and CABG. Repeat revascularization was significantly lower in the CABG group (OR 0.21, 95% CI 0.13 to 0.34, p <0.00001). In patients presenting with NSTE-ACS and MVD, 1-year mortality, MI, and stroke were similar between patients treated with either PCI or CABG, but the repeat revascularization rate was higher after PCI.
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Affiliation(s)
- Hala Kakar
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederik T W Groenland
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jacob J Elscot
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rutger Jan Nuis
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wijnand K Den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
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5
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Hemelrijk KI, Faria D, Salinas P, Escaned J. A Travel Through Time: Percutaneous Management of Degenerated Coronary Saphenous Vein Grafts. JACC Case Rep 2023; 10:101746. [PMID: 36974054 PMCID: PMC10039387 DOI: 10.1016/j.jaccas.2023.101746] [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: 10/15/2022] [Accepted: 10/21/2022] [Indexed: 03/17/2023]
Abstract
Managing coronary saphenous vein graft failure has remained an unmet need since the inception of interventional cardiology. The present case constitutes an opportunity to revisit percutaneous strategies to treat saphenous vein graft failure, providing a travel though interventional strategies and showing a contemporary approach to this problem. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Kimberley Iris Hemelrijk
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria San Carlos, Complutense University of Madrid, Madrid, Spain
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Daniel Faria
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Pablo Salinas
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Javier Escaned
- Hospital Clínico San Carlos Instituto de Investigación Sanitaria San Carlos, Complutense University of Madrid, Madrid, Spain
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Hou B, Chen M, Li Q, Huang W, Wang L. Comparative efficacy of eight therapeutic methods in the treatment of left main coronary artery disease: a Bayesian network meta-analysis protocol. BMJ Open 2022; 12:e058886. [PMID: 36691134 PMCID: PMC9453992 DOI: 10.1136/bmjopen-2021-058886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 08/19/2022] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION As for coronary artery bypass grafting, although there are many direct comparative studies on different minimally invasive methods and traditional thoracotomy (off-pump/on-pump), there is still a lack of further ranking and summary of the efficacy of all surgical methods for left main coronary artery (LMCA) lesions. Combined with the current controversial views, this study aims to introduce a planned network meta-analysis (NMA) in detail, with a view to comparing the long-term efficacy and safety of multiple therapeutic methods in the treatment of patients with LMCA disease, and finally providing some reference bases for the best selection of clinical schemes. METHOD AND ANALYSIS PubMed, Embase, Web of Science and The Cochrane Library databases will be collected from inception to June 2022 to compare the efficacy of different surgical methods in randomised controlled trials (RCTs) for LMCA disease. Main outcome endpoints: major adverse cardiovascular events, including mortality, myocardial infarction, stroke and revascularisation. Secondary outcome endpoints: (1) operation-related time, (2) the amount of blood transfusion, (3) complications including secondary thoracotomy, postoperative new atrial fibrillation, wound infection, (4) physiological score and psychological score, (5) time return to work and (6) total hospitalisation costs. The methodological quality of included RCTs will be assessed according to the Cochrane bias risk table. The Bayesian NMA will be conducted by STATA V.16.0. ETHICS AND DISSEMINATION The essence of this study is to summarise and analyse the original data without the approval of the ethics committee. Our research does not involve ethical issues, and the results will be published in peer-review journals. PROSPERO REGISTRATION NUMBER CRD42021274712.
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Affiliation(s)
- Biao Hou
- Inner Mongolia Medical University, Hohhot, China
| | | | - Qin Li
- Inner Mongolia Medical University, Hohhot, China
| | - Weimin Huang
- Inner Mongolia Medical University, Hohhot, China
| | - Liang Wang
- Inner Mongolia Medical University, Hohhot, China
- Cardiothoracic surgery department, Inner Mongolia Baotou City Central Hospital, Baotou, Inner Mongolia, China
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7
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Martinez-Sanchez FD, Medina-Urrutia AX, Jorge-Galarza E, Martínez-Alvarado MDR, Reyes-Barrera J, Osorio-Alonso H, Arellano-Buendía AS, Del Carmen González-Salazar M, Posadas-Sánchez R, Vargas-Alarcón G, Posadas-Romero C, Juárez-Rojas JG. Effect of metabolic control on recurrent major adverse cardiovascular events and cardiovascular mortality in patients with premature coronary artery disease: Results of the Genetics of Atherosclerotic Disease study. Nutr Metab Cardiovasc Dis 2022; 32:2227-2237. [PMID: 35843799 DOI: 10.1016/j.numecd.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/30/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Coronary artery disease (CAD) is the leading cause of death around the world, and its rate of presentation is increasing at young ages. Despite the evidence that secondary prevention in CAD reduces the risk of recurrent major adverse cardiovascular events (MACE), no studies have analyzed the composite control of blood pressure, lipids, and glucose control in premature CAD. METHODS AND RESULTS This was a real-world prospective cohort study of patients with premature CAD. The composite control in blood pressure <140/80 mmHg, LDL-C <70 mg/dL, non-HDL-C <100 mg/dL, and Hemoglobin A1c <8% was considered as metabolic control. The primary endpoint was the occurrence of non-fatal and fatal MACE. The data included 1042 patients with premature CAD. The mean age of the patients was 54.1 ± 8.1 years, 18.5% were women, and had a median follow-up of 59.1 ± 11.8 months. Of them, 7% had non-fatal MACE, and 4% had a fatal MACE. Overall, 21.3% achieved metabolic control, and 3.0% did not achieve any target. Cox regression analysis showed that percutaneous coronary intervention (Hazzard ratio = 1.883 [95% CI, 1.131-3.136]), C-reactive protein (1.046 [1.020-1.073]), blood pressure >140/90 mmHg (2.686 [1.506-4.791]), fibrates (2.032 [1.160-3.562]), calcium channel blockers (2.082 [1.158-3.744]) had greater risk to present a recurrent non-fatal MACE; whereas familial history of premature CAD (2.419 [1.240-4.721]), heart failure (2.139 [1.032-4.433]), LDL-C >70 mg/dL (4.594 [1.401-15.069]), and diuretics (3.328 [1.677-6.605]) were associated with cardiovascular mortality. CONCLUSIONS The composite goal achievement in lipids, blood pressure and glucose, reduced the risk for recurrent MACE in 80%.
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Affiliation(s)
- F D Martinez-Sanchez
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - A X Medina-Urrutia
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - E Jorge-Galarza
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | | | - J Reyes-Barrera
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - H Osorio-Alonso
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - A S Arellano-Buendía
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | | | - R Posadas-Sánchez
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - G Vargas-Alarcón
- Department of Molecular Biology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - C Posadas-Romero
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
| | - J G Juárez-Rojas
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
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8
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Meta-Analysis of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Narrowing. Am J Cardiol 2022; 173:39-47. [PMID: 35393084 DOI: 10.1016/j.amjcard.2022.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022]
Abstract
Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results. We performed a systematic review up to May 23, 2021, and 1-stage reconstructed individual patient data meta-analysis (IPDMA) to compare outcomes between both groups. The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, and unplanned revascularization at 5 years. We performed individual patient data meta-analysis using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups. Of 583 articles retrieved, 5 RCTs were included. A total of 4,595 patients from these 5 RCTs were randomly assigned to PCI (n = 2,297) or CABG (n = 2,298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6%, respectively (hazard ratio [HR] 1.093, 95% confidence interval [CI] 0.925 to 1.292; p = 0.296). PCI conferred similar time-to-MI (restricted mean survival time ratio 1.006, 95% CI 0.992 to 1.021, p=0.391) and stroke (restricted mean survival time ratio 1.005, 95% CI 0.998 to 1.013, p = 0.133) at 5 years. Unplanned revascularization was more frequent after PCI than CABG (HR 1.807, 95% CI 1.524 to 2.144, p <0.001) at 5 years. This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.
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9
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Duggan JP, Peters AS, Trachiotis GD, Antevil JL. Epidemiology of Coronary Artery Disease. Surg Clin North Am 2022; 102:499-516. [PMID: 35671770 DOI: 10.1016/j.suc.2022.01.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady.
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Affiliation(s)
- John P Duggan
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - Alex S Peters
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - Gregory D Trachiotis
- Division of Cardiology, Cardiothoracic Surgery and Heart Center, Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA; Department of Surgery, George Washington University Hospital, 2300 I Street NW, Washington, DC 20052, USA
| | - Jared L Antevil
- Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA.
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10
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Chew NWS, Koh JH, Ng CH, Tan DJH, Yong JN, Lin C, Lim OZH, Chin YH, Lim DMW, Chan KH, Loh PH, Low A, Lee CH, Tan HC, Chan M. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease: A One-Stage Meta-Analysis. Front Cardiovasc Med 2022; 9:822228. [PMID: 35402572 PMCID: PMC8990308 DOI: 10.3389/fcvm.2022.822228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease. Methods Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints. Results We screened 1,496 studies and included six randomized controlled trials with 7,181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118-1.469, p < 0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822-1.479, p = 0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122-1.858, p < 0.001; HR: 1.856, 1.380-2.497, p < 0.001, respectively). Conclusion This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.
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Affiliation(s)
- Nicholas W. S. Chew
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Jin Hean Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chaoxing Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Oliver Zi-Hern Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Denzel Ming Wei Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Koo Hui Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Poay-Huan Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Adrian Low
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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11
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Azaza N, Baslaib FO, Al Rishani A, Ahmed M, Al-Zainal J, Aboalela M, Gargousa M, Abdalla G, Shah N. Predictors of the Development of Major Adverse Cardiac Events following Percutaneous Coronary Intervention. DUBAI MEDICAL JOURNAL 2022. [DOI: 10.1159/000522481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Coronary artery disease remains the greatest cause of morbidity and mortality worldwide despite the growing access to percutaneous coronary intervention (PCI). Data regarding the factors predicting the development of major adverse cardiac events (MACE) in patients undergoing PCI are, however, lacking in the gulf region. In this study, we analyze demographics and risk profile of all patients undergoing PCI in a tertiary cardiovascular center located in Dubai – UAE. In our study, we aimed to analyze the risk profile of all patients undergoing PCI and determine the independent predictors of MACE. <b><i>Methods:</i></b> Data were collected prospectively on all patients who underwent PCI in our hospital between September 2017 and September 2018. Patients aged 18 years and above were included in the study and there were no exclusion criteria. The definition of MACE was a composite of death, in-hospital recurrent myocardial infarction (MI), in-hospital target vessel revascularization (TVR), and stroke. The patients’ characteristics, risk factor, and demographics were analyzed to identify the predictors of MACE using logistic regression model which is presented in odds ratio. <b><i>Results:</i></b> Data were available for 789 patients. Of these, 741 (94%) were male. The mean age was 52 ± 11 years. Twenty-two (3%) patients died, 7 (1%) had an in-hospital recurrent MI, 6 (1%) had in-hospital TVR, and 1 (0.1%) had a stroke. Of the patients who died, 16 (73%) patients presented with cardiogenic shock. Major adverse cardiovascular events occurred in 29 (3.7%) patients. In the multivariable regression model, only cardiogenic shock (odds ratio [OR] = 32.43) and the presence of diabetes mellitus (OR = 3.36) were predictors of MACE. <b><i>Conclusion:</i></b> Our study showed that cardiogenic shock and diabetes mellitus are the independent predictors of MACE in patients undergoing PCI.
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12
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Ohno T. The magnitude of the survival benefit of internal thoracic artery grafting: Absolute risk reduction. JTCVS OPEN 2022; 9:106-111. [PMID: 36003479 PMCID: PMC9390134 DOI: 10.1016/j.xjon.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Takayuki Ohno
- Address for reprints: Takayuki Ohno, MD, PhD, Department of Cardiovascular Surgery and Intensive Care Unit, Mitsui Memorial Hospital, 1 Kanda Izumicho, Chyoda-ku, Tokyo 101-8643, Japan.
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13
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Revascularization Strategies for Multivessel Coronary Artery Disease in the Elderly Population. J Surg Res 2021; 270:444-454. [PMID: 34798427 DOI: 10.1016/j.jss.2021.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 09/23/2021] [Accepted: 10/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prospective trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary disease (MVCAD) have included mostly younger patients. We compared treatment strategies in the elderly population. MATERIALS AND METHODS We performed a propensity-score-matched comparison of patients ≥75 y who underwent isolated CABG or PCI for MVCAD between 2011 and 2018, excluding those with prior cardiac surgery and/or significant left main disease. The primary outcome was 5-year Kaplan Meier survival, and secondary outcomes included readmissions and major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS Propensity-matching yielded 536 patients (266 PCI and 266 CABG). Rates of complete revascularization of all stenotic lesions were higher in the CABG arm (86.8% versus 21.8%; P < 0.001). Thirty-d mortality was similar between cohorts, though PCI recipients had shorter hospital stay and greater likelihood of discharge to home. Unadjusted one- (89.1% versus 88.4%) and 5-year (73.8% versus 60.1%) survival were both higher in patients who underwent CABG (P = 0.0332). Patients undergoing CABG had reduced, but nonsignificant cumulative incidence of all-cause hospital readmission and MACCE at 5 y. Subgroup analysis of patients 80 y or older revealed similar late survival benefit with CABG when compared to PCI. Among patients undergoing CABG, there did not appear to be any 5-year benefits from multi-arterial grafting. CONCLUSIONS Despite longer hospitalization and higher rate of nonhome discharge, CABG was associated with improved late survival over PCI in the elderly population. Cardiac surgeons should be included in the multidisciplinary evaluation of older patients with MVCAD.
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Glenn IC, Iacona GM, Mangi AA. Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease. Int J Angiol 2021; 30:221-227. [PMID: 34776822 PMCID: PMC8580606 DOI: 10.1055/s-0041-1735238] [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: 10/20/2022] Open
Abstract
The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.
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Affiliation(s)
- Ian C. Glenn
- Department of Thoracic and Cardiovascular Surgery; Heart, Vascular, and Thoracic Institute; Cleveland Clinic; Cleveland, Ohio
| | - Gabriele M. Iacona
- Medstar Health Cardiac Surgery, Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, District of Columbia
| | - Abeel A. Mangi
- Medstar Health Cardiac Surgery, Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, District of Columbia
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15
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Rodríguez-Granillo AM, Fernández-Pereira C, Rodríguez AE. Drug-Eluting vs Bare-Metal Stents for Percutaneous Coronary Intervention. JAMA Intern Med 2021; 181:1012-1013. [PMID: 33720301 DOI: 10.1001/jamainternmed.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alfredo M Rodríguez-Granillo
- Cardiology Department, Sanatorio Otamendi, Buenos Aires, Argentina.,Centro de Estudios en Cardiología Intervencionista, Buenos Aires, Argentina
| | - Carlos Fernández-Pereira
- Cardiology Department, Sanatorio Otamendi, Buenos Aires, Argentina.,Centro de Estudios en Cardiología Intervencionista, Buenos Aires, Argentina
| | - Alfredo E Rodríguez
- Cardiology Department, Sanatorio Otamendi, Buenos Aires, Argentina.,Centro de Estudios en Cardiología Intervencionista, Buenos Aires, Argentina
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16
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Yuan D, Jia S, Zhang C, Jiang L, Xu L, Zhang Y, Xu J, Liu R, Xu B, Hui R, Gao R, Gao Z, Song L, Yuan J. Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease. BMC Cardiovasc Disord 2021; 21:316. [PMID: 34187370 PMCID: PMC8243749 DOI: 10.1186/s12872-021-02067-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background There are relatively limited data regarding real-world outcomes in very old patients with three-vessel disease (3VD) receiving different therapeutic strategies. This study aimed to perform analysis of long-term clinical outcomes of medical therapy (MT), coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) in this population. Methods We included 711 patients aged ≥ 75 years from a prospective cohort of patients with 3VD. Consecutive enrollment of these patients began from April 2004 to February 2011 at Fu Wai Hospital. Patients were categorized into three groups (MT, n = 296; CABG, n = 129; PCI, n = 286) on the basis of different treatment strategies. Results During a median follow-up of 7.25 years, 262 deaths and 354 major adverse cardiac and cerebrovascular events (MACCE) occurred. Multivariate Cox analysis showed that the risk of cardiac death was significantly lower for CABG compared with PCI (adjusted hazard ratio [HR] = 0.475, 95% confidence interval [CI] 0.232–0.974, P = 0.042). Additionally, MACCE appeared to show a trend towards a better outcome for CABG (adjusted HR = 0.759, 95% CI 0.536–1.074, P = 0.119). Furthermore, CABG was significantly superior in terms of unplanned revascularization (adjusted HR = 0.279, 95% CI 0.079–0.982, P = 0.047) and myocardial infarction (adjusted HR = 0.196, 95% CI 0.043–0.892, P = 0.035). No significant difference in all-cause death between CABG and PCI was observed. MT had a higher risk of cardiac death than PCI (adjusted HR = 1.636, 95% CI 1.092–2.449, P = 0.017). Subgroup analysis showed that there was a significant interaction between treatment strategy (PCI vs. CABG) and sex for MACCE (P = 0.026), with a lower risk in men for CABG compared with that of PCI, but not in women. Conclusions CABG can be performed with reasonable results in very old patients with 3VD. Sex should be taken into consideration in therapeutic decision-making in this population. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02067-6.
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Affiliation(s)
- Deshan Yuan
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Sida Jia
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Ce Zhang
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Lin Jiang
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Lianjun Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Yin Zhang
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Jingjing Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Ru Liu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Rutai Hui
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Runlin Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Zhan Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Lei Song
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China.
| | - Jinqing Yuan
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China.
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Xie Q, Huang J, Zhu K, Chen Q. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis. Clin Cardiol 2021; 44:899-906. [PMID: 34089266 PMCID: PMC8259162 DOI: 10.1002/clc.23613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/07/2021] [Accepted: 04/16/2021] [Indexed: 01/19/2023] Open
Abstract
Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.
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Affiliation(s)
- Qiuping Xie
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Jianguo Huang
- Department of Cardiology, Liling Traditional Chinese Medicine Hospital, Zhuzhou, China
| | - Ke Zhu
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Qing Chen
- Department of Cardiology, Zhuzhou Central Hospital, Zhuzhou, China
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18
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Thuijs DJFM, Head SJ, Stone GW, Puskas JD, Taggart DP, Serruys PW, Dressler O, Crowley A, Brown WM, Horkay F, Boonstra PW, Bogáts G, Noiseux N, Sabik JF, Kappetein AP. Outcomes following surgical revascularization with single versus bilateral internal thoracic arterial grafts in patients with left main coronary artery disease undergoing coronary artery bypass grafting: insights from the EXCEL trial†. Eur J Cardiothorac Surg 2020; 55:501-510. [PMID: 30165487 DOI: 10.1093/ejcts/ezy291] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/05/2018] [Accepted: 07/22/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)-a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020), were less likely female (24.3% vs 14.3%, P = 0.002) and diabetic (28.8% vs 15.2%, P < 0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71-1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60-3.12; P = 0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93-1.74; P = 0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99). CONCLUSIONS In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
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Affiliation(s)
- Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Gregg W Stone
- Department of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - David P Taggart
- Department of Cardiovascular Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | | | - Aaron Crowley
- Cardiovascular Research Foundation, New York, NY, USA
| | - W Morris Brown
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, GA, USA
| | - Ferenc Horkay
- Department of Cardiology, National Institute of Cardiology, Budapest, Hungary
| | - Piet W Boonstra
- Department of Cardiothoracic Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Gabor Bogáts
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Nicolas Noiseux
- Department of Surgery, Faculté de Médecine, Université de Montréal, Montreal, QC, Canada
| | - Joseph F Sabik
- Department of Cardiovascular Surgery, University Hospitals, Cleveland, OH, USA
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
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19
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Lee HJ, Wong JB, Jia B, Qi X, DeLong ER. Empirical use of causal inference methods to evaluate survival differences in a real-world registry vs those found in randomized clinical trials. Stat Med 2020; 39:3003-3021. [PMID: 32643219 PMCID: PMC9813951 DOI: 10.1002/sim.8581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/11/2023]
Abstract
With heighted interest in causal inference based on real-world evidence, this empirical study sought to understand differences between the results of observational analyses and long-term randomized clinical trials. We hypothesized that patients deemed "eligible" for clinical trials would follow a different survival trajectory from those deemed "ineligible" and that this factor could partially explain results. In a large observational registry dataset, we estimated separate survival trajectories for hypothetically trial-eligible vs ineligible patients under both coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI). We also explored whether results would depend on the causal inference method (inverse probability of treatment weighting vs optimal full propensity matching) or the approach to combine propensity scores from multiple imputations (the "across" vs "within" approaches). We found that, in this registry population of PCI/CABG multivessel patients, 32.5% would have been eligible for contemporaneous RCTs, suggesting that RCTs enroll selected populations. Additionally, we found treatment selection bias with different distributions of propensity scores between PCI and CABG patients. The different methodological approaches did not result in different conclusions. Overall, trial-eligible patients appeared to demonstrate at least marginally better survival than ineligible patients. Treatment comparisons by eligibility depended on disease severity. Among trial-eligible three-vessel diseased and trial-ineligible two-vessel diseased patients, CABG appeared to have at least a slight advantage with no treatment difference otherwise. In conclusion, our analyses suggest that RCTs enroll highly selected populations, and our findings are generally consistent with RCTs but less pronounced than major registry findings.
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Affiliation(s)
- Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - John B Wong
- Tufts Medical Center, Division of Clinical Decision Making, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Beilin Jia
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Xinyue Qi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Elizabeth R DeLong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Mieres J, Alfredo E Rodríguez, Fernández-Pereira C, Ascarrunz-Cattoretti D. Increased incidence of serious late adverse events with drug-eluting stents when compared with coronary artery bypass surgery: a cause of concern. Future Cardiol 2020; 16:711-723. [PMID: 32643395 DOI: 10.2217/fca-2020-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in pre-drug-eluting stents (DESs) era, randomized trials and meta-analysis showed that the extension of coronary artery disease was not associated with a better survival with CABG, and only diabetic patients had an inferior survival with PCI. After the introduction of DES, we would expect a substantial improvement in PCI results compared with CABG, narrowing the gap between both revascularization strategies, However, on the contrary, most randomized studies between DES and CABG showed that rate of recurrences remained and there is an unexpected increased of late serious adverse events including spontaneous myocardial infarction and death. In this review, we try to described each of these problems and find out explanations for these new findings searching for potential solutions.
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Affiliation(s)
- Juan Mieres
- Cardiac Unit Otamendi Hospital Cardiovascular Research Center (CECI) Azcuenaga 870, Buenos Aires, Argentina
| | - Alfredo E Rodríguez
- Cardiac Unit Otamendi Hospital Cardiovascular Research Center (CECI) Azcuenaga 870, Buenos Aires, Argentina
| | - Carlos Fernández-Pereira
- Cardiac Unit Otamendi Hospital Cardiovascular Research Center (CECI) Azcuenaga 870, Buenos Aires, Argentina
| | - Diego Ascarrunz-Cattoretti
- Cardiac Unit Otamendi Hospital Cardiovascular Research Center (CECI) Azcuenaga 870, Buenos Aires, Argentina
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21
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Thuijs DJFM, Habib RH, Head SJ, Puskas JD, Taggart DP, Stone GW, Zhang Z, Serruys PW, Sabik JF, Kappetein AP. Prognostic performance of the Society of Thoracic Surgeons risk score in patients with left main coronary artery disease undergoing revascularisation: a post hoc analysis of the EXCEL trial. EUROINTERVENTION 2020; 16:36-43. [PMID: 31422924 DOI: 10.4244/eij-d-19-00417] [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] [Indexed: 11/23/2022]
Abstract
AIMS Accurate risk prediction in patients undergoing revascularisation is essential. We aimed to assess the predictive performance of Society of Thoracic Surgeons (STS) risk models in patients with left main coronary artery disease (LMCAD) undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention with everolimus-eluting stents (PCI-EES). METHODS AND RESULTS The predictive performance of STS risk models for perioperative mortality, stroke and renal failure was evaluated for their discriminative ability (C statistic) and calibration (Hosmer-Lemeshow goodness-of-fit-test; χ2 and p-values) among patients with LMCAD undergoing PCI-EES (n=935) and CABG (n=923) from the randomised EXCEL trial. STS risk scores, in CABG patients, showed good discrimination for 30-day mortality and average discrimination for stroke (C statistic 0.730 and 0.629, respectively) with average calibration. For PCI, STS risk scores had no discrimination for mortality (C statistic 0.507), yet good discrimination (C statistic 0.751) and calibration for stroke. The predictive performance for renal failure was good for CABG (C statistic 0.82), yet poor for PCI (C statistic 0.59). CONCLUSIONS In selected patients with LMCAD from the EXCEL trial, STS risk models showed good predictive performance for CABG yet lacked predictive performance for PCI for perioperative mortality and renal failure. The STS stroke risk model was surprisingly more discriminating in PCI compared to CABG. Improved and procedure-specific risk prediction instruments are needed to accurately estimate adverse events after LMCAD revascularisation by CABG and PCI. ClinicalTrials.gov Identifier: NCT01205776.
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Affiliation(s)
- Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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23
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Shafi AMA, Dhanji ARAA, Habib AM, Kennon SRO, Awad WI. Coronary artery bypass vs percutaneous coronary intervention in under 50s. J Card Surg 2019; 35:320-327. [PMID: 31803987 DOI: 10.1111/jocs.14370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Young patients with coronary artery disease are undergoing percutaneous coronary intervention (PCI) primarily, with a view to deferring coronary artery bypass grafting (CABG). We investigated the validity of this approach, by comparing outcomes in patients ≤50 years undergoing CABG or PCI. METHODS One hundred consecutive patients undergoing PCI and 100 undergoing CABG in 2004 were retrospectively studied to allow for 5 and 12 years follow-up. The two groups were compared for the primary endpoints of major adverse cardiac or cerebrovascular event (MACCE). RESULTS Diabetes, peripheral vascular disease, and left ventricular ejection fraction <50% were higher in the CABG group. At 5 years, rates of myocardial infarction (MI) (9% vs 1%, P = .02), repeat revascularization (31% vs 7%, P < .01), and MACCE (34 vs 12, P < .01) were greater in the PCI vs the CABG group. Similarly, at 12 years, rates of MI (27.4% vs 19.4%, P = .19), repeat revascularization (41.1% vs 20.4%, P < .01), and MACCE (51 vs 40, P = .07) were greater in the PCI group. There were no differences in major outcomes in patients with 1 or 2VD, at 5 or 12 years. Rates of MI, revascularization, and MACCE were higher in patients with 3VD undergoing PCI (n = 21; MI, 47.6%; revascularization, 66.7%; and MACCE, 19 events) vs CABG (n = 78; MI, 19.2%; revascularization, 20.5%; and MACCE, 31 events); P < .01, for all end points. CONCLUSIONS MACCE was lower in young patients undergoing CABG vs PCI at both 5 and 12 years follow-up, primarily as a consequence of patients with 3VD undergoing PCI having more MI and repeat revascularization. CABG should remain the preferred method of revascularization in young patients with 3VD.
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Affiliation(s)
- Ahmed M A Shafi
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Al-Rehan A A Dhanji
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ahmed M Habib
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Simon R O Kennon
- Department of Cardiology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Dual-probe molecular MRI for the in vivo characterization of atherosclerosis in a mouse model: Simultaneous assessment of plaque inflammation and extracellular-matrix remodeling. Sci Rep 2019; 9:13827. [PMID: 31554825 PMCID: PMC6761132 DOI: 10.1038/s41598-019-50100-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/03/2019] [Indexed: 01/07/2023] Open
Abstract
Molecular MRI is a promising in-vivo modality to detect and quantify morphological and molecular vessel-wall changes in atherosclerosis. The combination of different molecular biomarkers may improve the risk stratification of patients. This study aimed to investigate the feasibility of simultaneous visualization and quantification of plaque-burden and inflammatory activity by dual-probe molecular MRI in a mouse-model of progressive atherosclerosis and in response-to-therapy. Homozygous apolipoprotein E knockout mice (ApoE−/−) were fed a high-fat-diet (HFD) for up to four-months prior to MRI of the brachiocephalic-artery. To assess response-to-therapy, a statin was administered for the same duration. MR imaging was performed before and after administration of an elastin-specific gadolinium-based and a macrophage-specific iron-oxide-based probe. Following in-vivo MRI, samples were analyzed using histology, immunohistochemistry, inductively-coupled-mass-spectrometry and laser-inductively-coupled-mass-spectrometry. In atherosclerotic-plaques, intraplaque expression of elastic-fibers and inflammatory activity were not directly linked. While the elastin-specific probe demonstrated the highest accumulation in advanced atherosclerotic-plaques after four-months of HFD, the iron-oxide-based probe showed highest accumulation in early atherosclerotic-plaques after two-months of HFD. In-vivo measurements for the elastin and iron-oxide-probe were in good agreement with ex-vivo histopathology (Elastica-van-Giesson stain: y = 298.2 + 5.8, R2 = 0.83, p < 0.05; Perls‘ Prussian-blue-stain: y = 834.1 + 0.67, R2 = 0.88, p < 0.05). Contrast-to-noise-ratio (CNR) measurements of the elastin probe were in good agreement with ICP-MS (y = 0.11x-11.3, R² = 0.73, p < 0.05). Late stage atherosclerotic-plaques displayed the strongest increase in both CNR and gadolinium concentration (p < 0.05). The gadolinium probe did not affect the visualization of the iron-oxide-probe and vice versa. This study demonstrates the feasibility of simultaneous assessment of plaque-burden and inflammatory activity by dual-probe molecular MRI of progressive atherosclerosis. The in-vivo detection and quantification of different MR biomarkers in a single scan could be useful to improve characterization of atherosclerotic-lesions.
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Mulukutla SR, Gleason TG, Sharbaugh M, Sultan I, Marroquin OC, Thoma F, Smith C, Toma C, Lee JS, Kilic A. Coronary Bypass Versus Percutaneous Revascularization in Multivessel Coronary Artery Disease. Ann Thorac Surg 2019; 108:474-480. [PMID: 31056197 DOI: 10.1016/j.athoracsur.2019.02.064] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/21/2018] [Accepted: 02/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study focused on contemporary outcomes after coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (MVCAD). METHODS This was a propensity-matched retrospective, observational analysis. Patients with MVCAD who underwent CABG or PCI between 2010 and 2018 and for whom data were available through the National Cardiovascular Data Registry or The Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. The primary outcome was overall survival. Secondary outcomes included freedom from inpatient readmission and freedom from repeat revascularization. RESULTS Of the initial 6,163 patients with MVCAD, the propensity-matched cohort included 844 in each group. The estimated 1-year mortality was 11.5% and 7.2% (p < 0.001) in the PCI and CABG groups, respectively, with an overall hazard ratio for mortality of PCI versus CABG of 1.64 (95% confidence interval [CI], 1.29 to 2.10; p < 0.001). The overall hazard ratio for readmission for PCI versus CABG was 1.42 (95% CI, 1.23 to 1.64; p < 0.001). The overall hazard ratio for repeat revascularization for PCI versus CABG was 4.06 (95% CI, 2.39 to 6.91; p < 0.001). Overall major adverse cardiovascular events and individual outcomes of mortality, readmission, and repeat revascularization all favored CABG across virtually all major clinical subgroups. CONCLUSIONS This contemporary propensity-matched analysis of patients undergoing coronary revascularization for MVCAD demonstrates a significant mortality benefit with CABG over PCI, and this benefit is consistent across virtually all major patient subgroups. Futures studies are needed reflecting routine practice to assess how best to approach shared decision making and informed consent when it comes to revascularization decisions in any patient with MVCAD.
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Affiliation(s)
- Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Thomas G Gleason
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Sharbaugh
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Cuminetti G, Bonadei I, Vizzardi E, Sciatti E, Lorusso R. On-Pump Coronary Artery Bypass Graft: The State of the Art. Rev Recent Clin Trials 2019; 14:106-115. [PMID: 30836924 DOI: 10.2174/1574887114666190301142114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/21/2017] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) remains the standard of care for patients with coronary artery disease (CAD). Debate exists concerning several factors, which include percutaneous coronary intervention (PCI) vs. CABG, single vs. bilateral mammary artery grafts, radial artery vs. saphenous vein grafts, right internal mammary artery vs. radial artery grafts, endoscopic vs. open vein-graft harvesting, and on-pump vs. off- pump surgery. Moreover, challenging is the management of diabetic patients with CAD undergoing CABG. This review reports current indications, practice patterns, and outcomes of CABG. METHODS Randomized controlled trials comparing CABG to other therapeutical strategies for CAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS Large multicenter randomized and observational studies (SYNTAX, BEST, PRECOMBAT, ASCERT) have reported excellent outcomes in CABG patients, with always fewer rates of operative mortality and major morbidity, than PCI. The 10-year follow-up of ARTS II trial showed no difference between single and bilateral mammary artery. BARI 2D, MASS II, CARDia, FREEDOM trials showed that CABG is the best choice for diabetic patients. CONCLUSION CABG still represents one of the most widespread major surgeries, with well-known benefits on symptoms and prognosis in patients with CAD. However, further studies and follow-up data are needed to validate these evidences.
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Affiliation(s)
- Giovanni Cuminetti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Ivano Bonadei
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Edoardo Sciatti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
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Fernandez-Pereira C, Mieres J, Rodriguez AE. Long-Term Mortality After Coronary Revascularization in Nondiabetic Patients With Multivessel Disease. J Am Coll Cardiol 2018; 69:116-117. [PMID: 28057243 DOI: 10.1016/j.jacc.2016.07.792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
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Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, Domanski MJ, Farkouh ME, Flather M, Fuster V, Hlatky MA, Holm NR, Hueb WA, Kamalesh M, Kim YH, Mäkikallio T, Mohr FW, Papageorgiou G, Park SJ, Rodriguez AE, Sabik JF, Stables RH, Stone GW, Serruys PW, Kappetein AP. Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization. J Am Coll Cardiol 2018; 72:386-398. [DOI: 10.1016/j.jacc.2018.04.071] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 04/23/2018] [Indexed: 11/24/2022]
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Quality of life after coronary artery bypass graft surgery versus percutaneous coronary intervention: what do the trials tell us? Curr Opin Cardiol 2018; 32:707-714. [PMID: 28834794 DOI: 10.1097/hco.0000000000000458] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With an ever-aging population, the treatment of multi-vessel coronary artery disease (CAD) has increasingly become focused not only on mortality, but on symptom relief and improving quality of life (QOL). The purpose of this review is to present a summary on the subject of QOL after percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), highlighting the latest comparative trials in the field. RECENT FINDINGS About 1 month after revascularization, patients recovering from either PCI or CABG report improvements in angina frequency. However, at 6 months and in the years that follow, angina relief is significantly better after CABG compared with PCI. Correspondingly, the use of antiangina medication is significantly higher following PCI, even in recent years with the use of drug-eluting stents. Regarding general health status, at the 1-month time point, PCI patients have recovered faster than those who have had surgery, reporting fewer physical limitations, less bodily pain, and greater QOL and treatment satisfaction. Nevertheless, these differences disappear by 6 months, and in the years thereafter, CABG patients report fewer physical limitations compared with those who have undergone PCI. About 5 years after revascularization, significant benefits remain favoring CABG in term of physical, emotional, and mental health. SUMMARY Patients with multivessel coronary artery disease attain important QOL benefits following revascularization with either PCI or CABG. Percutaneous treatments lead to a more rapid recovery and improved short-term health status compared with CABG at 1 month. However, surgery results in greater angina relief and improved QOL compared with PCI 6 months after revascularization and beyond.
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Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, Domanski MJ, Farkouh ME, Flather M, Fuster V, Hlatky MA, Holm NR, Hueb WA, Kamalesh M, Kim YH, Mäkikallio T, Mohr FW, Papageorgiou G, Park SJ, Rodriguez AE, Sabik JF, Stables RH, Stone GW, Serruys PW, Kappetein AP. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018; 391:939-948. [PMID: 29478841 DOI: 10.1016/s0140-6736(18)30423-9] [Citation(s) in RCA: 458] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/18/2017] [Accepted: 12/07/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. METHODS We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. FINDINGS We included 11 randomised trials involving 11 518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR] 1·20, 95% CI 1·06-1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09-1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19-1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86-1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87-1·33; p=0·52), regardless of diabetes status and SYNTAX score. INTERPRETATION CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease. Longer follow-up is needed to better define mortality differences between the revascularisation strategies. FUNDING None.
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jung-Min Ahn
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Michael J Domanski
- Icahn School of Medicine at Mount Sinai, New York, NY, USA; Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, ON, Canada
| | - Michael E Farkouh
- Icahn School of Medicine at Mount Sinai, New York, NY, USA; Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, ON, Canada
| | - Marcus Flather
- Norwich Medical School University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Whady A Hueb
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Masoor Kamalesh
- Richard L Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Young-Hak Kim
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Timo Mäkikallio
- Department of Cardiology, Oulu University Hospital, Oulu, Finland
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Seung-Jung Park
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | | | - Joseph F Sabik
- Department Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rodney H Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregg W Stone
- Columbia University Medical Center and the Center for Clinical Trials, Cardiovascular Research Foundation, New York, NY, USA
| | | | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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Masdjedi K, Daemen J, Diletti R, Wilschut J, Utens E, de Jaegere PP, Lemmert ME, Kappetein AP, Zijlstra F, van Domburg R, Van Mieghem NM. A case-vignette based assessment of patient's perspective on coronary revascularization strategies, the OPINION study. J Cardiol 2018; 72:149-154. [PMID: 29478878 DOI: 10.1016/j.jjcc.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/02/2018] [Accepted: 01/11/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND AIMS Significant left main (LM) stem disease is potentially life-threatening and mandates revascularization. This study aimed to assess how patients rate the importance of particular features of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), how this determines their preference for a particular treatment strategy, and whether particular personality characteristics influence this preference. METHODS AND RESULTS In total, 1145 patients who visited the outpatient clinic of the Erasmus Medical Center for stable coronary artery disease were asked to complete a case vignette-questionnaire on a hypothetical significant LM stenosis amenable to PCI or CABG. To assess the individual's personality disposition and general distress level, each patient had to complete a set of 3 standardized, validated questionnaires with satisfactory psychometric properties. Overall 89% of patients preferred PCI to CABG. PCI was the preferred strategy despite a higher risk for repeat revascularization and need for more medication. Remarkably, the fact that a risk for repeat revascularization is more common in the PCI group is less important for the patients who opt for PCI. Risk for stroke and bleeding were the most important arguments to opt for PCI over CABG. Type D personality, depression, and anxiety were all associated with a relatively higher preference for CABG as revascularization strategy. CONCLUSION Overall, when given the choice patients seem to have a clear preference for PCI over CABG and consider stroke and bleeding important procedure-related complications. Patients with Type D personality, depression, or anxiety favor CABG.
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Affiliation(s)
- Kaneshka Masdjedi
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Elisabeth Utens
- Departments of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Rotterdam Medical Center, Rotterdam, The Netherlands; Research Institute of Child Development and Education, University of Amsterdam, Amsterdam/De Bascule, The Netherlands
| | - Peter P de Jaegere
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arie-Pieter Kappetein
- Department of Cardio-Thoracic Surgery, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron van Domburg
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW In spite of the benefits of drug eluting (DES), these advantages were not translated to better outcome when percutaneous coronary interventions (PCI) were compared with coronary artery bypass surgery. PCI strategy allowing stent deployment in all intermediate lesions including small vessels together with DES design may be the reasons of these findings. RECENT FINDINGS Recently randomized and observational studies demonstrated using functional flow reserve analysis, residual Syntax score risk, or residual ERACI score after PCI that a reasonably incomplete revascularization was associated with good long-term outcome and low events rate at follow-up. In the ERACI IV study, which included patients with multiple vessel disease and left main, all intermediate lesions and severe lesions in small vessels were excluded from the revascularization strategy, and the 3-year follow-up results showed a remarkable low incidence of death/MI and stroke. Intermediate stenosis or severe lesions in small vessels should not be incorporated in the PCI strategy in order to define patient clinical cardiac prognosis or completeness of revascularization.
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Khan MR, Kayani WT, Ahmad W, Hira RS, Virani SS, Hamzeh I, Jneid H, Lakkis N, Alam M. Meta-Analysis of Comparison of 5-Year Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery in the Era of Drug-eluting Stents. Am J Cardiol 2017; 120:1514-1520. [PMID: 28886851 DOI: 10.1016/j.amjcard.2017.07.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 11/30/2022]
Abstract
Patients with unprotected left main coronary artery (ULMCA) disease are increasingly being treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but long-term outcomes comparing PCI with coronary artery bypass grafting (CABG) remain limited. We performed aggregate data meta-analyses of clinical outcomes (all-cause death, nonfatal myocardial infarction, stroke, repeat revascularization, cardiac death, and major adverse cardiac and cerebrovascular events) in studies comparing 5-year outcomes of PCI with DES versus CABG in patients with ULMCA disease. A comprehensive literature search (January 1, 2003 to December 10, 2016) identified 9 studies (6,637 patients). Effect size for individual clinical outcomes was estimated using odds ratio (OR) with 95% confidence intervals (CI) using a random effects model. At 5 years, PCI with DES was associated with equivalent cardiac (OR 0.95, 95% CI 0.62 to 1.46) and all-cause mortality (OR 0.98, 95% CI 0.72 to 1.33), lower rates of stroke (OR 0.50, 95% CI 0.30 to 0.84), and higher rates of repeat revascularization (OR 2.52, 95% CI 1.63 to 3.91); compared with CABG, major adverse cardiac and cerebrovascular events showed a trend favoring CABG but did not reach statistical significance (OR 1.19, 95% CI 0.93 to 1.54). In conclusion, for ULMCA disease, PCI can be considered as a comparably effective and yet less invasive alternative to CABG given the comparable long-term mortality and lower incidences of stroke.
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Affiliation(s)
- Mahin R Khan
- Resident Internal Medicine, McLaren Flint/Michigan State University, Flint, Michigan
| | - Waleed T Kayani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | | | - Ravi S Hira
- University of Washington, Seattle, Washington
| | - Salim S Virani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ihab Hamzeh
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Nasser Lakkis
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.
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Roy A, Chevalier B, Lefèvre T, Louvard Y, Segurado R, Sawaya F, Spaziano M, Neylon A, Serruys P, Dawkins K, Kappetein AP, Mohr FW, Colombo A, Feldman T, Morice MC. Does geographical variability influence five-year MACCE rates in the multicentre SYNTAX revascularisation trial? EUROINTERVENTION 2017; 13:828-834. [DOI: 10.4244/eij-d-16-00991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Berdajs D, Kolh P. Percutaneous coronary interventions with second-generation drug-eluting stent versus off-pump coronary artery bypass grafting: mid-term results. Eur J Cardiothorac Surg 2017; 52:469-470. [PMID: 28874026 DOI: 10.1093/ejcts/ezx243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Denis Berdajs
- Division of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liège, CHU Sart Tilman, Liège, Belgium
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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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Milojevic M, Head S, Andrinopoulou ER, Serruys P, Mohr F, Tijssen J, Kappetein AP. Hierarchical testing of composite endpoints: applying the win ratio to percutaneous coronary intervention versus coronary artery bypass grafting in the SYNTAX trial. EUROINTERVENTION 2017; 13:106-114. [DOI: 10.4244/eij-d-16-00745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Carmona García P, Mateo E, Hornero F, López Cantero M, Zarragoikoetxea I. Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years. ACTA ACUST UNITED AC 2017; 64:262-272. [PMID: 28258744 DOI: 10.1016/j.redar.2016.12.005] [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: 04/18/2016] [Revised: 12/10/2016] [Accepted: 12/13/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. MATERIAL AND METHOD From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. RESULTS We identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. CONCLUSION Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.
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Affiliation(s)
- P Carmona García
- Departamento de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - E Mateo
- Departamento de Anestesiología y Reanimación, Consorcio Hospital General de Valencia, Valencia, España
| | - F Hornero
- Departamento de Cirugía Cardiovascular, Consorcio Hospital General de Valencia, Valencia, España
| | - M López Cantero
- Departamento de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - I Zarragoikoetxea
- Departamento de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
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Koenig O, Nothdurft D, Perle N, Neumann B, Behring A, Degenkolbe I, Walker T, Schlensak C, Wendel HP, Nolte A. An Atelocollagen Coating for Efficient Local Gene Silencing by Using Small Interfering RNA. MOLECULAR THERAPY-NUCLEIC ACIDS 2017; 6:290-301. [PMID: 28325296 PMCID: PMC5363512 DOI: 10.1016/j.omtn.2017.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 01/13/2023]
Abstract
In the last decades, many efforts have been made to counteract adverse effects after stenting atherosclerotic coronary arteries. A breakthrough in better vascular wall regeneration was noted in the new era of drug-eluting stents. A novel personalized approach is the development of gene-eluting stents promising an alteration in gene expression involved in regeneration. We investigated a coating system consisting of the polymer atelocollagen (ATCOL) and a specific small interfering RNA (siRNA) for intercellular adhesion molecule-1 (ICAM-1) found on the surface of defective endothelial cells (ECs). We demonstrated very high cell viability, in which EA.hy926 grew on 0.008% or 0.032% ATCOL layers. Additionally, hemocompatibility assays proved the biocompatibility of this coating. The highest transfection efficiency with EA.hy926 was achieved with 5 μg siRNA immobilized in ATCOL after 2 days. The release of fluorescent-labeled siRNA was about 9 days. Long-term knockdown of ICAM-1 was analyzed by flow cytometry, revealing that the coating with 0.008% ATCOL and 5 μg siICAM-1 provoked gene silencing up to 8 days. 5′-RNA ligase-mediated rapid amplification of cDNA ends PCR (RLM-RACE-PCR) demonstrated the specificity of our established ATCOL gene-silencing coating, meaning that our coating is well suited for further investigations in in vivo studies. Herein, we would like to demonstrate that our ATCOL is well-suited for better artery wall regeneration after stent implantation.
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Affiliation(s)
- Olivia Koenig
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Dimitrios Nothdurft
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Nadja Perle
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Bernd Neumann
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Andreas Behring
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Ilka Degenkolbe
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Tobias Walker
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Christian Schlensak
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
| | - Hans Peter Wendel
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany.
| | - Andrea Nolte
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital Tuebingen, Tuebingen, 72076 Baden-Wuerttemberg, Germany
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Tsai IT, Wang CP, Lu YC, Hung WC, Wu CC, Lu LF, Chung FM, Hsu CC, Lee YJ, Yu TH. The burden of major adverse cardiac events in patients with coronary artery disease. BMC Cardiovasc Disord 2017; 17:1. [PMID: 28052754 PMCID: PMC5210314 DOI: 10.1186/s12872-016-0436-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/07/2016] [Indexed: 12/30/2022] Open
Abstract
Background Patients with a history of cardiovascular disease are at high risk of developing secondary major adverse cardiac events (MACE). This study aimed to identify independent predictors of MACE after hospital admission which could be used to identify of high-risk patients who may benefit from preventive strategies. Methods This study included 1,520 consecutive patients with coronary artery disease (CAD) (654 with acute coronary syndrome (ACS) and 866 with elective percutaneous coronary intervention (PCI) patients) who received PCI and/or stenting. MACE was defined as all-cause mortality or rehospitalization for a cardiovascular- related illness. Cardiovascular-related illnesses included heart failure, reinfarction (nonfatal), recurrence of angina pectoris and repeat PCI or coronary artery bypass graft. Results During a mean follow-up period of 32 months, 558 of the 1,520 patients developed at least one MACE. Cox regression analysis showed that the baseline clinical and biochemical variables which associated with MACE were age, being illiterate, a widow or widower, and/or economically dependent, having triple vessel disease, stent implantation, anemia, and/or diabetes mellitus, waist to hip ratio (WHR), diastolic blood pressure, fasting glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), creatinine, estimated glomerular filtration rate (eGFR), red blood cell count, hemoglobin, hematocrit, and mean corpuscular-hemoglobin concentration (MCHC) in ACS patients, and age, malnourished, and/or economically dependent, taking hypoglycemic medication, having triple vessel disease, stent implantation, anemia, diabetes mellitus, and/or hypertension, WHR, fasting glucose, HDL-C, uric acid, creatinine, eGFR, high-sensitivity C-reactive protein, mean corpuscular volume, and MCHC in elective PCI patients. Using multivariate Cox regression analysis, we found the MACE’s independent factors are triple vessel disease, stent implantation, hypertension, and eGFR in ACS patients, and having triple vessel disease, stent implantation, hypertension, and uric acid in elective PCI patients. Conclusions Having triple vessel disease, stent implantation, hypertension, and eGFR or uric acid independently predicted MACE in patients with CAD after long-term follow-up. Fortunately, these factors are modifiable and should be identified and monitored early.
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Affiliation(s)
- I-Ting Tsai
- Department of Emergency, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,Department of Nursing, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Chao-Ping Wang
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Yung-Chuan Lu
- Division of Endocrinology and Metabolism, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Wei-Chin Hung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Cheng-Ching Wu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Li-Fen Lu
- Division of Cardiac Surgery, Department of Surgery, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Fu-Mei Chung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Chia-Chang Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | | | - Teng-Hung Yu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.
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Reply: Long-Term Mortality After Coronary Revascularization in Nondiabetic Patients With Multivessel Disease. J Am Coll Cardiol 2017; 69:117-118. [PMID: 28057244 DOI: 10.1016/j.jacc.2016.09.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/19/2016] [Indexed: 11/23/2022]
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Hirshfeld JW, Fiorilli PN. Coronary Bypass Surgery Versus Percutaneous Coronary Intervention in Left Main and Multivessel Disease: Incremental Data-How Do We Apply It? JACC Cardiovasc Interv 2016; 9:2490-2492. [PMID: 28007200 DOI: 10.1016/j.jcin.2016.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/05/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
Affiliation(s)
- John W Hirshfeld
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Paul N Fiorilli
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Rodriguez AE, Pavlovsky H, Del Pozo JF. Understanding the Outcome of Randomized Trials with Drug-Eluting Stents and Coronary Artery Bypass Graft in Patients with Multivessel Disease: A Review of a 25-Year Journey. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:195-199. [PMID: 27980442 PMCID: PMC5145267 DOI: 10.4137/cmc.s40645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/21/2016] [Accepted: 10/09/2016] [Indexed: 12/15/2022]
Abstract
Randomized clinical trials (RCTs) with first- and second-generation drug-eluting stents (DESs) confirmed the superiority of coronary artery bypass surgery (CABG) in patients with multiple vessel disease. In spite of different DES designs, investigators in these trials used similar percutaneous coronary intervention (PCI) strategies hoping to achieve complete revascularization, meaning that all intermediate lesions would be stented. One of these studies also included small vessels in the revascularization policy. On this revision, authors searched for a potential explanation of these intriguing findings and also for solutions to this problem, not seen years ago when other RCTs compared CABG with PCI in the previous DES era. After they revised old and new scientific data, they concluded that improved DES design is not itself enough to narrow the gap between PCI and CABG and that in the future RCTs we should institute more conservative strategies avoiding unnecessary multiple DES implantation.
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Affiliation(s)
- Alfredo E. Rodriguez
- Head, Cardiac Unit, Otamendi Hospital, Buenos Aires, Argentina
- Director and Founder, Cardiovascular Research Center (CECI), Buenos Aires, Argentina
| | - Hernán Pavlovsky
- Fellow, Cardiac Unit, Otamendi Hospital, Buenos Aires, Argentina
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Coronary Artery Bypass Surgery Versus Drug-Eluting Stent Implantation for Left Main or Multivessel Coronary Artery Disease. JACC Cardiovasc Interv 2016; 9:2481-2489. [DOI: 10.1016/j.jcin.2016.10.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/03/2016] [Accepted: 10/06/2016] [Indexed: 11/23/2022]
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Zhang M, Guddeti RR, Matsuzawa Y, Sara JDS, Kwon TG, Liu Z, Sun T, Lee SJ, Lennon RJ, Bell MR, Schaff HV, Daly RC, Lerman LO, Lerman A, Locker C. Left Internal Mammary Artery Versus Coronary Stents: Impact on Downstream Coronary Stenoses and Conduit Patency. J Am Heart Assoc 2016; 5:JAHA.116.003568. [PMID: 27664803 PMCID: PMC5079021 DOI: 10.1161/jaha.116.003568] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The study compared downstream coronary and conduit disease progression in the left anterior descending coronary artery treated with coronary artery bypass grafting using the left internal mammary artery (LIMA) versus percutaneous coronary intervention with bare metal stent (BMS) or drug eluting stent (DES). METHODS AND RESULTS A total of 12 301 consecutive patients underwent isolated primary coronary revascularization, of which 2386 met our inclusion criteria (Percutaneous coronary intervention, n=1450; coronary artery bypass grafting, n=936). Propensity score analysis matched 628 patients, of which 468 were treated to the left anterior descending with coronary artery bypass grafting with LIMA (n=314), percutaneous coronary intervention with BMS (n=94), and DES (n=60). Coronary angiograms were analyzed by quantitative coronary angiography (QCA; n=433). Cumulative downstream coronary and conduit disease progression were estimated by Kaplan-Meier method and effect of treatment type by Cox proportional hazard models. Patients treated with LIMA had significantly lower risk of downstream coronary disease progression at follow-up angiogram compared with BMS and DES (hazard ratio [HR] [95% CI], 0.34; [0.20-0.59]; P=0.0002; and HR [95% CI], 0.39; [0.20-0.79]; P=0.01, respectively). LIMA was associated with a lower risk of conduit disease progression compared to BMS and DES (HR [95% CI], 0.18; [0.12-0.28]; P<0.001; and HR [95% CI], 0.27; [0.16-0.46]; P<0.001, respectively). BMS was associated with higher HR for downstream coronary and conduit disease progression compared with DES, but the difference did not reach statistical significance (HR [95% CI], 1.13; [0.57-2.36]; P=0.73; and HR [95% CI], 1.46; [0.88-2.50]; P=0.14, respectively). CONCLUSIONS LIMA grafting to left anterior descending is associated with significantly lower risk of downstream coronary and conduit disease progression compared to percutaneous coronary intervention with BMS and DES.
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Affiliation(s)
- Ming Zhang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | | | | | - Taek-Geun Kwon
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Zhi Liu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Tao Sun
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Seung-Jin Lee
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo College of Medicine, Rochester, MN
| | - Malcolm R Bell
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Chaim Locker
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
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Medical Treatment and Revascularization Options in Patients With Type 2 Diabetes and Coronary Disease. J Am Coll Cardiol 2016; 68:985-95. [DOI: 10.1016/j.jacc.2016.06.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 05/03/2016] [Accepted: 06/05/2016] [Indexed: 12/22/2022]
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Hirshfeld JW, Saybolt MD. Coronary Revascularization: How Can Model-Derived Probabilities Inform Clinical Judgment? JACC Cardiovasc Interv 2016; 9:1573-5. [PMID: 27491606 DOI: 10.1016/j.jcin.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Affiliation(s)
- John W Hirshfeld
- Cardiovascular Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Matthew D Saybolt
- Cardiovascular Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Locker C, Schaff HV, Daly RC, Dearani JA, Bell MR, Frye RL, Greason KL, Stulak JM, Joyce LD, Pochettino A, Li Z, Lennon RJ, Lerman A. Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions. J Thorac Cardiovasc Surg 2016; 152:369-379.e4. [DOI: 10.1016/j.jtcvs.2016.03.089] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/01/2016] [Accepted: 03/15/2016] [Indexed: 12/26/2022]
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Zhang H, Hu X, Wu Q, Shi B. Impact of diabetes on bleeding events in ST-elevation myocardial infarction patients after urgent percutaneous coronary intervention: A retrospective cohort study. Medicine (Baltimore) 2016; 95:e4470. [PMID: 27537568 PMCID: PMC5370795 DOI: 10.1097/md.0000000000004470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with diabetes mellitus (DM) have more ischemic events and a decreased survival rate after percutaneous coronary intervention (PCI) than non-DM patients. However, it is unknown whether short-term or long-term bleeding events are associated with DM. We aimed to determine the impact of DM on mortality and bleeding events in ST-elevation myocardial infarction (STEMI) patients after urgent PCI.This retrospective cohort study included 435 STEMI patients who had undergone urgent PCI between 2010 and 2013, comprising 97 DM patients and 338 non-DM patients. The primary outcomes were the 30-day bleeding and 30-day mortality rates. The median follow-up period was 2 years. Data regarding patient demographics, peri-PCI medication, and invasive procedures were compared between DM and non-DM patients. Multivariate logistic regression was applied to estimate the association between DM and bleeding events. Kaplan-Meier curves were calculated to elucidate the survival rate.Compared with non-DM patients, DM patients with STEMI had a higher incidence of left ventricular ejection fraction <40% (17.6% vs 4.2%, P < 0.05), Killip class >II (11.3% vs 3.8%, P < 0.05), and smoking (44.3% vs 63.0%, P < 0.05). Similar peri-PCI medication and invasive procedures were administered in the 2 groups. The incidence of 30-day bleeding events was significantly higher for DM patients than non-DM patients (6.2% vs 0.9%, P < 0.05). A multivariate analysis showed that DM was strongly associated with 30-day bleeding events after adjusting for confounders. DM patients had significant increased mortality rates at both the 30-day and 2-year end points.DM was an independent predictor for an increased risk of 30-day bleeding events and correlated with increased 30-day and 2-year mortality rates in STEMI patients with PCI. Our study has significant clinical implications for risk stratification before the application of urgent PCI.
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Affiliation(s)
- Huairong Zhang
- Department of Endocrinology, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xiaowen Hu
- Division of Endocrinology and Metabolism, McGill University Health Center, Montreal General Hospital, Montreal, PQ, Canada
- Correspondence: Bingyin Shi, Department of Endocrinology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China (e-mail: ); Xiaowen Hu, Division of Endocrinology and Metabolism, McGIll University Health Center, Montreal General Hospital, 1650 avenue Cedar, room C6.240, Montreal, PQ, Canada H3G 1A4 (e-mail: )
| | - Qian Wu
- School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi, China
| | - Bingyin Shi
- Department of Endocrinology, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Correspondence: Bingyin Shi, Department of Endocrinology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China (e-mail: ); Xiaowen Hu, Division of Endocrinology and Metabolism, McGIll University Health Center, Montreal General Hospital, 1650 avenue Cedar, room C6.240, Montreal, PQ, Canada H3G 1A4 (e-mail: )
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Milojevic M, Head SJ, Parasca CA, Serruys PW, Mohr FW, Morice MC, Mack MJ, Ståhle E, Feldman TE, Dawkins KD, Colombo A, Kappetein AP, Holmes DR. Causes of Death Following PCI Versus CABG in Complex CAD: 5-Year Follow-Up of SYNTAX. J Am Coll Cardiol 2016; 67:42-55. [PMID: 26764065 DOI: 10.1016/j.jacc.2015.10.043] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/06/2015] [Accepted: 10/08/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are no data available on specific causes of death from randomized trials that have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI). OBJECTIVES The purpose of this study was to investigate specific causes of death, and its predictors, after revascularization for complex coronary disease in patients. METHODS An independent Clinical Events Committee consisting of expert physicians who were blinded to the study treatment subclassified causes of death as cardiovascular (cardiac and vascular), noncardiovascular, or undetermined according to the trial protocol. Cardiac deaths were classified as sudden cardiac, related to myocardial infarction (MI), and other cardiac deaths. RESULTS In the randomized cohort, there were 97 deaths after CABG and 123 deaths after PCI during a 5-year follow-up. After CABG, 49.4% of deaths were cardiovascular, with the greatest cause being heart failure, arrhythmia, or other causes (24.6%), whereas after PCI, the majority of deaths were cardiovascular (67.5%) and as a result of MI (29.3%). The cumulative incidence rates of all-cause death were not significantly different between CABG and PCI (11.4% vs. 13.9%, respectively; p = 0.10), whereas there were significant differences in terms of cardiovascular (5.8% vs. 9.6%, respectively; p = 0.008) and cardiac death (5.3% vs. 9.0%, respectively; p = 0.003), which were caused primarily by a reduction in MI-related death with CABG compared with PCI (0.4% vs. 4.1%, respectively; p <0.0001). Treatment with PCI versus CABG was an independent predictor of cardiac death (hazard ratio: 1.55; 95% confidence interval: 1.09 to 2.33; p = 0.045). The difference in MI-related death was seen largely in patients with diabetes, 3-vessel disease, or high SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) trial scores. CONCLUSIONS During a 5-year follow-up, CABG in comparison with PCI was associated with a significantly reduced rate of MI-related death, which was the leading cause of death after PCI. Treatments following PCI should target reducing post-revascularization spontaneous MI. Furthermore, secondary preventive medication remains essential in reducing events post-revascularization. (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).
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Affiliation(s)
- Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Catalina A Parasca
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Patrick W Serruys
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Friedrich W Mohr
- Department of Cardiovascular Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany
| | - Marie-Claude Morice
- Générale de Santé, Institut Cardiovasculaire Paris Sud, Hopital Privé Jacques Cartier, Massy, France
| | - Michael J Mack
- Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas
| | - Elisabeth Ståhle
- Department of Thoracic and Cardiovascular Surgery, University Hospital, Uppsala, Sweden
| | - Ted E Feldman
- Cardiology Division, Evanston Hospital, Evanston, Illinois
| | | | - Antonio Colombo
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, and Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - David R Holmes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota.
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