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Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol 2017; 14:317-320. [PMID: 28630609 PMCID: PMC5466936 DOI: 10.11909/j.issn.1671-5411.2017.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Caldwell B Esselstyn
- Cleveland Clinic Wellness Institute, 1950 Richmond Road, Lyndhurst, Ohio 44124, USA. E-mail:
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2
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Alster KB, Radwin LE. The Deserved Care Framework for Evaluating Health Care Quality. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2016. [DOI: 10.1177/1084822304264604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Excessively narrow definitions of health care quality do not identify certain important components of health care for clinicians, providers, or patients. Excessively broad definitions drive up health care costs and encourage unjustified interventions. This article proposes a framework for examining health care quality that distinguishes between what patients need, want, and deserve, and it advances the idea that deserved care is the relevant concept of care to inform health policy debates.
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Affiliation(s)
| | - Laurel E. Radwin
- Department of Nursing in the College of Nursing and Health Sciences, University of Massachusetts, Boston
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3
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Hong YJ, Ahn Y, Jeong MH. Role of Intravascular Ultrasound in Patients with Acute Myocardial Infarction. Korean Circ J 2015; 45:259-65. [PMID: 26240578 PMCID: PMC4521102 DOI: 10.4070/kcj.2015.45.4.259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/09/2015] [Accepted: 04/14/2015] [Indexed: 11/11/2022] Open
Abstract
Rupture of a vulnerable plaque and subsequent thrombus formation are important mechanisms leading to the development of an acute myocardial infarction (AMI). Typical intravascular ultrasound (IVUS) features of AMI include plaque rupture, thrombus, positive remodeling, attenuated plaque, spotty calcification, and thin-cap fibroatheroma. No-reflow phenomenon was attributable to the embolization of thrombus and plaque debris that results from mechanical fragmentation of the vulnerable plaque by percutaneous coronary intervention (PCI). Several grayscale IVUS features including plaque rupture, thrombus, positive remodeling, greater plaque burden, decreased post-PCI plaque volume, and tissue prolapse, and virtual histology-IVUS features such as large necrotic corecontaining lesion and thin-cap fibroatheroma were the independent predictors of no-reflow phenomenon in AMI patients. Non-culprit lesions associated with recurrent events were more likely than those not associated with recurrent events to be characterized by a plaque burden of ≥70%, a minimal luminal area of ≤4.0 mm(2), or to be classified as thin-cap fibroatheromas.
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Affiliation(s)
- Young Joon Hong
- Division of Cardiology of Chonnam National University Hospital, Heart Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Youngkeun Ahn
- Division of Cardiology of Chonnam National University Hospital, Heart Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology of Chonnam National University Hospital, Heart Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
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Vandermolen S, Abbott J, De Silva K. What's Age Got to do with it? A Review of Contemporary Revascularization in the Elderly. Curr Cardiol Rev 2015; 11:199-208. [PMID: 25329923 PMCID: PMC4558351 DOI: 10.2174/1573403x10666141020110122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 09/10/2014] [Accepted: 10/12/2014] [Indexed: 01/05/2023] Open
Abstract
Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.
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Affiliation(s)
| | | | - Kalpa De Silva
- Specialist Registrar in Cardiology, St. Peter's Hospital, Surrey, UK.
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Barsoum EA, Azab B, Shah N, Patel N, Shariff MA, Lafferty J, Nabagiez JP, McGinn JT. Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients). Eur J Cardiothorac Surg 2014; 47:862-7. [PMID: 24994756 DOI: 10.1093/ejcts/ezu267] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 05/21/2014] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD. METHODS This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index. RESULTS Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses. CONCLUSIONS The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.
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Affiliation(s)
- Emad A Barsoum
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Basem Azab
- Department of Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - Neeraj Shah
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Nileshkumar Patel
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Masood A Shariff
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - James Lafferty
- Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA
| | - John P Nabagiez
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - Joseph T McGinn
- Department of Surgery, Staten Island University Hospital, Staten Island, NY, USA Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
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6
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Pyxaras SA, Mangiacapra F, Wijns W, Di Serafino L, De Vroey F, Toth G, Sinagra G, De Bruyne B, Heyndrickx GR, Barbato E. ACEF and clinical SYNTAX score in the risk stratification of patients with heavily calcified coronary stenosis undergoing rotational atherectomy with stent implantation. Catheter Cardiovasc Interv 2014; 83:1067-73. [DOI: 10.1002/ccd.25360] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 11/11/2013] [Accepted: 12/21/2013] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - William Wijns
- Cardiovascular Center Aalst; OLV Clinic Aalst Belgium
| | | | | | - Gabor Toth
- Cardiovascular Center Aalst; OLV Clinic Aalst Belgium
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7
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Gao L, Hu X, Liu YQ, Xue Q, Wang Y. Comparison of coronary DES and BMS in octogenarians: A systematic review and meta-analysis. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2014; 10:336-43. [PMID: 24454326 PMCID: PMC3888915 DOI: 10.3969/j.issn.1671-5411.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/07/2013] [Accepted: 11/11/2013] [Indexed: 12/01/2022]
Abstract
Objective Uncertainty exists regarding the relative performance of drug-eluting stents (DES) versus bare-metal stents (BMS) in octogenarians undergoing percutaneous coronary intervention (PCI). We undertook a meta-analysis to assess outcomes for DES and BMS in octogenarians undergoing PCI. Methods Electronic data bases of PubMed, Cochrane, and EMBASE were searched. We included randomized, controlled clinical trials (RCT) and observational studies comparing DES and BMS in octogenarians receiving PCI. The methodological qualities of eligible trials were assessed using a “risk of bias” tool. The endpoints included all-cause death, major adverse cardiac events (MACE), myocardial infarction (MI), target vessel revascularization (TVR), major bleeding, and stent thrombosis (ST). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for each endpoint. Results A total of one RCT and six observational studies were included and analyzed in this meta-analysis. All trials were of acceptable quality. At 30 days, compared with DES-treated patients, BMS-treated patients had a higher incidence of mortality (OR: 3.91, 95% CI: 1.10–13.91; P = 0.03). The OR for MACE (1.52, 95% CI: 0.56–4.17; P = 0.13), MI (0.81, 95% CI: 0.37–2.17; P = 0.23), TVR (0.75, 95% CI: 0.17–3.41; P = 0.41), major bleeding (0.77, 95% CI: 0.35–1.68; P = 0.43), and ST (1.44, 95% CI: 0.32–6.45; P = 0.33) did not reach statistical significance. At one year follow-up, the OR did not favor BMS over MACE (MACE, defined as the composite of death, myocardial infarction, and TVR) (1.87; 95% CI: 1.22–2.87; P < 0.01), MI (1.91, 95% CI: 1.22–2.99; P < 0.01), TVR (3.08, 95% CI: 1.80–5.26; P < 0.01) and ST (3.37, 95% CI: 1.12–10.13; P < 0.01). The OR for mortality (1.51; 95% CI: 0.92–2.47; P = 0.10) and major bleeding (0.85, 95% CI: 0.47–1.55; P = 0.60) did not reach statistical significance. At > 1 year follow-up, the OR for all endpoints, including mortality, MACE, MI, TVR, major bleeding, and ST, did not reach statistical significance. Conclusions Our meta-analysis suggests that DES is associated with favorable outcomes as compared with BMS in octogenarians receiving PCI.
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Affiliation(s)
- Lei Gao
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Xin Hu
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Yu-Qi Liu
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Qiao Xue
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Yu Wang
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
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8
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Safety and effectiveness of drug-eluting stents versus bare-metal stents in elderly patients with small coronary vessel disease. Arch Cardiovasc Dis 2013; 106:554-61. [DOI: 10.1016/j.acvd.2013.06.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/23/2013] [Accepted: 06/25/2013] [Indexed: 11/21/2022]
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9
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Baig K, Harling L, Papanikitas J, Attaran S, Ashrafian H, Casula R, Athanasiou T. Does coronary artery bypass grafting improve quality of life in elderly patients? Interact Cardiovasc Thorac Surg 2013; 17:542-53. [PMID: 23711736 PMCID: PMC3745137 DOI: 10.1093/icvts/ivt220] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 04/03/2013] [Accepted: 04/16/2013] [Indexed: 01/13/2023] Open
Abstract
Traditional outcome measures such as long-term mortality may be of less value than symptomatic improvement in elderly patients undergoing coronary artery bypass grafting (CABG). In this systematic review, we analyse health-related quality of life (HRQOL) as a marker of outcome after CABG. We aimed to assess the role of HRQOL tools in making recommendations for elderly patients undergoing surgery, where symptomatic and quality-of-life improvement may often be the key indications for intervention. Twenty-three studies, encompassing 4793 patients were included. Overall, elderly patients underwent CABG at reasonably low risk. Our findings, therefore, support the conclusion that performing CABG in the elderly may be associated with significant improvements in HRQOL. In order to overcome previous methodological limitations, future work must clearly define and stringently follow-up this elderly population, to develop a more robust, sensitive and specialty-specific HRQOL tool.
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Affiliation(s)
| | | | | | | | | | | | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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10
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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12
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1227] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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14
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Antonsen L, Jensen LO, Thayssen P, Christiansen EH, Junker A, Tilsted HH, Terkelsen CJ, Kaltoft A, Maeng M, Hansen KN, Ravkilde J, Lassen JF, Madsen M, Sørensen HT, Thuesen L. Comparison of outcomes of patients ≥ 80 years of age having percutaneous coronary intervention according to presentation (stable vs unstable angina pectoris/non-ST-segment elevation myocardial infarction vs ST-segment elevation myocardial infarction). Am J Cardiol 2011; 108:1395-400. [PMID: 21890087 DOI: 10.1016/j.amjcard.2011.06.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/19/2022]
Abstract
Patients ≥ 80 years old with coronary artery disease constitute a particular risk group in relation to percutaneous coronary intervention (PCI). From 2002 through 2008 we examined the annual proportion of patients ≥ 80 years old undergoing PCI in western Denmark, their indications for PCI, and prognosis. From 2002 through 2009 all elderly patients treated with PCI were identified in a population of 3.0 million based on the Western Denmark Heart Registry. Cox regression analysis was used to compare mortality rates according to clinical indications controlling for potential confounding. In total 3,792 elderly patients (≥ 80 years old) were treated with PCI and the annual proportion increased from 224 (5.4%) in 2002 to 588 (10.2%) in 2009. The clinical indication was stable angina pectoris (SAP) in 30.2%, ST-segment elevation myocardial infarction (STEMI) in 35.0%, UAP/non-STEMI in 29.7%, and "ventricular arrhythmia or congestive heart failure" in 5.1%. Overall 30-day and 1-year mortality rates were 9.2% and 18.1%, respectively. Compared to patients with SAP the adjusted 1-year mortality risk was significantly higher for patients presenting with STEMI (hazard ratio 3.86, 95% confidence interval 3.08 to 4.85), UAP/non-STEMI (hazard ratio 1.95, 95% confidence interval 1.53 to 2.50), and ventricular arrhythmia or congestive heart failure (hazard ratio 2.75, 95% confidence interval 1.92 to 3.92). In patients with SAP target vessel revascularization decreased from 7.1% in 2002 to 2.5% in 2008. In conclusion, the proportion of patients ≥ 80 years old treated with PCI increased significantly over an 8-year period. Patients with SAP had the lowest mortality rates and rates of clinically driven target vessel revascularization decreased over time.
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MESH Headings
- Aged, 80 and over
- Angina, Stable/mortality
- Angina, Stable/therapy
- Angina, Unstable/mortality
- Angina, Unstable/therapy
- Angioplasty, Balloon, Coronary/statistics & numerical data
- Angioplasty, Balloon, Coronary/trends
- Arrhythmias, Cardiac/mortality
- Cohort Studies
- Comorbidity
- Coronary Artery Disease/mortality
- Coronary Artery Disease/therapy
- Denmark/epidemiology
- Female
- Follow-Up Studies
- Heart Failure/mortality
- Humans
- Male
- Myocardial Infarction/mortality
- Myocardial Infarction/therapy
- Registries
- Regression Analysis
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Affiliation(s)
- Lisbeth Antonsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Hsieh TH, Wang JD, Tsai LM. Improving in-hospital mortality in elderly patients after acute coronary syndrome--a nationwide analysis of 97,220 patients in Taiwan during 2004-2008. Int J Cardiol 2011; 155:149-54. [PMID: 22062897 DOI: 10.1016/j.ijcard.2011.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/19/2011] [Accepted: 10/16/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Elderly patients seem to have especially poor outcomes after acquiring acute coronary syndrome (ACS). We conducted this study to examine the in-hospital mortality by utilization of invasive coronary therapies and age in a nationwide population in Taiwan. METHODS This observational study was conducted on a retrospective cohort from January 2004 to December 2008. Epidemiological features, including incidence rate and clinical characteristics of ACS in a Chinese population were investigated. Risk factors of in-hospital mortality, including myocardial infarction, shock, previous history of stroke, chronic kidney disease, diabetes mellitus, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, dementia, peripheral arterial occlusive disease, septicemia and the use of invasive coronary procedures, were explored using a logistic regression model. RESULTS A total of 97,220 patients were enrolled, and 53.6% of them were elderly. A significant decrease in the utilization rate of invasive coronary therapies (diagnostic coronary angiography and PCI) and increased in-hospital mortality (p<0.001) were observed as patient age increased. Adjusted multivariate logistic regression analysis revealed that the impact of PCI in reducing in-hospital mortality is consistent across age groups, including those older than 75 years old. CONCLUSIONS Our nationwide study provides evidence that PCI is associated with significant improvement of in-hospital mortality in patients with ACS. Even the very elderly patients could benefit from PCI. However, currently the utilization rate of PCI in the aging population still does not present enough. A prospective study is indicated to corroborate the findings of this study.
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Affiliation(s)
- Tung-Han Hsieh
- Division of Cardiology, Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan, Taiwan.
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16
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Hong YJ, Jeong MH, Abizaid A, Banning A, Bartorelli A, Dzavik V, Ellis SG, Gao R, Holmes DR, Legrand V, Neumann FJ, Spaulding C, Worthley S, Urban P. Sirolimus-Eluting Coronary Stents in Octogenarians. JACC Cardiovasc Interv 2011; 4:982-91. [DOI: 10.1016/j.jcin.2011.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 01/16/2023]
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17
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57:e215-367. [PMID: 21545940 DOI: 10.1016/j.jacc.2011.02.011] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Thomas MP, Moscucci M, Smith DE, Aronow H, Share D, Kraft P, Gurm HS. Outcome of contemporary percutaneous coronary intervention in the elderly and the very elderly: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Clin Cardiol 2011; 34:549-54. [PMID: 21717474 DOI: 10.1002/clc.20926] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND There is a paucity of data on the outcome of contemporary percutaneous coronary intervention (PCI) in the elderly. Accordingly, we assessed the impact of age on outcome of a large cohort of patients undergoing PCI in a regional collaborative registry. HYPOTHESIS Increasing age is associated with a higher incidence of procedural-related complications. METHODS We evaluated the outcome of 152,373 patients who underwent PCI from 2003 to 2008 in the 31 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. The procedural outcomes of the cohort were compared by dividing patients into < 70 years of age, 70 to 79 years, 80 to 84 years, 85 to 89 years, and ≥ 90 years. RESULTS Of the cohort, 64.64% were <70 years of age, 23.83% were 70 to 79 years, 7.85% were 80 to 84 years, 3.09% were 85 to 89 years, and 0.58% were 90 years or older. Increasing age was associated with an increase in all-cause in-hospital mortality, contrast-induced nephropathy, transfusion, stroke/transient ischemic attack, and vascular complications. The overall in-hospital mortality rate was 1.09% and increased from 0.67% in those younger than 70 years up to 5.44% in those 90 years old or greater. The mortality rate in patients over 80 years approached 12% to 15% for those with ST-segment myocardial infarction and 39% in cardiogenic shock patients. CONCLUSIONS The proportion of elderly patients referred for PCI is increasing. Procedural complications increase with age, and patients presenting with unstable symptoms are at the highest risk.
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Affiliation(s)
- Michael P Thomas
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109-5853, USA
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123:e426-579. [PMID: 21444888 DOI: 10.1161/cir.0b013e318212bb8b] [Citation(s) in RCA: 349] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Liu SW, Xu B, Chen J, Hu FH, Wu YJ, Li JJ, Yang YJ, Chen JL, Gao RL, Qiao SB. Trends in in-hospital outcome after percutaneous coronary intervention in the drug-eluting stents era. Clin Cardiol 2010; 33:516-21. [PMID: 20734450 DOI: 10.1002/clc.20786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The introduction of drug-eluting stents (DES) dramatically changed the practice of percutaneous coronary intervention (PCI) in the 2000s. Little is known about trends in in-hospital outcome after PCI in the DES era. HYPOTHESIS The in-hospital outcomes after PCI might be continuously improved over time. METHODS We analyzed in-hospital outcomes of 21,667 patients who underwent PCI at Fu Wai Hospital in the past 5 years. The patients were divided into 5 groups according to the time of their intervention: group 1 (June 2004 to May 2005), group 2 (June 2005 to May 2006), group 3 (June 2006 to May 2007), group 4 (June 2007 to May 2008), and group 5 (June 2008 to May 2009). RESULTS Procedural success rates for the 5 groups were 93.6%, 95%, 94.4%, 94.2%, and 94.3%, respectively (P = 0.39). Significant reduction in in-hospital major adverse cardiac events (3.1%, 3.4%, 2.8%, 1.6%, and 1.0%, P < 0.001) and need for target-vessel revascularization (2.0%, 2.2%, 1.5%, 0.4%, and 0.2%, P < 0.001) was noted over time, which was associated with a significant increase in use of DES (from 56.6% to 97.0%, P < 0.001). On multivariate analysis, use of DES, dissection during procedure, left main lesion, prior myocardial infarction, and age > or = 65 years were independent predictors of major adverse cardiovascular events. CONCLUSIONS There were substantial reductions in in-hospital major adverse cardiac events and target-vessel revascularization over the past 5 years. This reduction was associated with the concurrent increased use of DES.
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Affiliation(s)
- Sheng Wen Liu
- Department of Cardiology, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Kind AJH, Bartels C, Mell MW, Mullahy J, Smith M. For-profit hospital status and rehospitalizations at different hospitals: an analysis of Medicare data. Ann Intern Med 2010; 153:718-27. [PMID: 21135295 PMCID: PMC3058683 DOI: 10.7326/0003-4819-153-11-201012070-00005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown. OBJECTIVE To describe and examine predictors of and payments for rehospitalization at a different hospital among Medicare patients rehospitalized within 30 days at for-profit and nonprofit or public hospitals. DESIGN Cohort study of patients discharged and rehospitalized from January 2005 to November 2006. SETTING Medicare fee-for-service hospitals throughout the United States. PARTICIPANTS A 5% random national sample of Medicare patients with acute care rehospitalizations within 30 days of discharge (n = 74,564). MEASUREMENTS 30-day rehospitalizations at different hospitals and total payments or mortality over the subsequent 30 days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; patient sociodemographic characteristics, disability status, and comorbid conditions; and a measure of risk adjustment. RESULTS 16 622 patients (22%) in the sample were rehospitalized at a different hospital. Factors associated with increased risk for rehospitalization at a different hospital included index hospitalization at a for-profit, major medical school-affiliated, or low-volume hospital and having a Medicare-defined disability. Compared with patients rehospitalized at the same hospital, patients rehospitalized at different hospitals had higher adjusted 30-day total payments (median additional cost, $1308 per patient; P < 0.001) but no statistically significant differences in 30-day mortality, regardless of index hospital for-profit status. LIMITATION The database lacked detailed clinical information about patients and did not include information about specific provider practice motivations or the role of patient choice in hospitalization venues. CONCLUSION Rehospitalizations at different hospitals are common among Medicare patients, are more likely among those initially hospitalized at a for-profit hospital, and are related to increased overall payments without improved mortality. PRIMARY FUNDING SOURCE University of Wisconsin Hartford Center of Excellence in Geriatrics, National Institutes of Health.
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Affiliation(s)
- Amy J H Kind
- University of Wisconsin School of Medicine and Public Health and William S. Middleton Veterans Affairs Hospital-Geriatric Research Education and Clinical Center, Madison, Wisconsin, USA.
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Comparison of five-year outcome of octogenarians undergoing percutaneous coronary intervention with drug-eluting versus bare-metal stents (from the RESEARCH and T-SEARCH Registries). Am J Cardiol 2010; 106:1376-81. [PMID: 21059424 DOI: 10.1016/j.amjcard.2010.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 07/12/2010] [Accepted: 07/12/2010] [Indexed: 11/22/2022]
Abstract
Although octogenarians are increasingly referred for percutaneous coronary intervention (PCI), data are lacking on long-term safety and efficacy of drug-eluting stents in this high-risk subpopulation. The aim of this study was to evaluate 5-year clinical outcome of octogenarians who underwent PCI using sirolimus-eluting stents (SESs) or paclitaxel-eluting stents (PESs) compared to bare-metal stents (BMSs). From January 2000 to December 2005, 319 consecutive octogenarian patients who underwent PCI with BMSs (n = 93, January 2000 to April 2002), SESs (n = 52, April 2002 to February 2003), or PESs (n = 174, February 2003 to December 2005) were included prospectively. Primary study end points were all-cause mortality and major adverse cardiac events (MACEs), defined as all-cause death, any myocardial infarction, or any revascularization. Mean age of the study population was 83 ± 2 years and 51% of patients were men. Median follow-up duration was 5.4 years (range 3 to 9). Five-year mortality rates in the BMS, SES, and PES cohorts were similar (41%, 42%, and 41%, respectively). Cumulative 5-year MACE-free survival in the BMS, SES, and PES cohorts were 44%, 52%, and 48%, respectively. Compared to the BMS cohort, adjusted hazard ratios for MACEs in the SES and PES cohorts were 0.5 (95% confidence interval [CI] 0.3 to 0.9, p <0.05) and 0.5 (95% CI 0.2 to 1.4, p = 0.2), respectively. Overall, use of drug-eluting stents was associated with fewer MACEs (adjusted hazard ratio 0.5, 95% CI 0.3 to 0.9, p <0.05) and a trend toward less target vessel revascularization (adjusted hazard ratio 0.5, 95% CI 0.2 to 1.2, p = 0.1). In conclusion, PCI with drug-eluting stents in octogenarians was found to be safe and more effective compared to PCI with BMSs.
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Hong YJ, Jeong MH, Choi YH, Ma EH, Ko JS, Lee MG, Park KH, Sim DS, Yoon NS, Youn HJ, Kim KH, Park HW, Kim JH, Ahn Y, Cho JG, Park JC, Kang JC. Age-related differences in virtual histology-intravascular ultrasound findings in patients with coronary artery disease. J Cardiol 2010; 55:224-31. [DOI: 10.1016/j.jjcc.2009.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 10/31/2009] [Accepted: 11/04/2009] [Indexed: 10/20/2022]
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Jasti H, Hanusa BH, Switzer GE, Granieri R, Elnicki M. Residents' perceptions of a night float system. BMC MEDICAL EDUCATION 2009; 9:52. [PMID: 19650924 PMCID: PMC2728710 DOI: 10.1186/1472-6920-9-52] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2009] [Accepted: 08/03/2009] [Indexed: 05/28/2023]
Abstract
BACKGROUND A Night Float (NF) system has been implemented by many institutions to address increasing concerns about residents' work hours. The purpose of our study was to examine the perceptions of residents towards a NF system. METHODS A 115-item questionnaire was developed to assess residents' perceptions of the NF rotation as compared with a regular call month. The categories included patient care, education, medical errors, and overall satisfaction. Internal Medicine housestaff (post-graduate years 1-3) from three hospital settings at the University of Pittsburgh completed the questionnaire. RESULTS The response rate was 90% (n = 149). Of these, 74 had completed the NF rotation. The housestaff felt that the quality of patient care was improved because of NF (41% agreed and 18% disagreed). A majority also felt that better care was provided by a rested physician in spite of being less familiar with the patient (46% agreed and 21% disagreed). Most felt that there was less emphasis on education (65%) and more emphasis on service (52%) during NF. Overall, the residents felt more rested during their call months (83%) and strongly supported the 80-hour workweek requirement (77%). CONCLUSION Housestaff felt that the overall quality of patient care was improved by a NF system. The perceived improved quality of care by a rested physician coupled with a perceived decrease in the emphasis on education may have significant implications in housestaff training.
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Affiliation(s)
- Harish Jasti
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara H Hanusa
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System and Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Galen E Switzer
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System and Departments of Psychiatry and Medicine and the Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rosanne Granieri
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Elnicki
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Teplitsky I, Assali A, Golovchiner G, Shor N, Weiss A, Battler A, Kornowski R. Acute and intermediate‐term results of percutaneous coronary stenting in octogenarian patients. ACTA ACUST UNITED AC 2009; 5:195-9. [PMID: 14630562 DOI: 10.1080/14628840310018167] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) in octogenarian patients has been associated with increased cardiovascular morbidity and mortality. This study aimed to assess acute and intermediate-term clinical outcomes among octogenarians undergoing PCI. METHODS The authors identified 97 consecutive patients aged > or =80 years who underwent PCI using stents between November 2000 and February 2002 at their institution. The patients were divided into three groups according to clinical presentation: (1) acute myocardial infarction (AMI, n = 31); (2) unstable angina pectoris (UAP, n = 28); and (3) stable angina pectoris (SAP, n = 38). Procedural data, and in-hospital and six-month clinical outcomes were obtained and adjudicated for all patients. RESULTS Overall mean age was 84 +/- 3 years, 67% of patients were males and 73% had multivessel coronary disease. In-hospital outcomes varied according to clinical presentation: procedural success was 78% in AMI patients (including shock patients), 93% in UAP, and 95% in SAP patients. Likewise, hospital mortality was 26% in AMI, 3.6% in UAP, and 0% in SAP patients (p = 0.0003). Among AMI patients, hospital mortality was extremely high in patients with cardiogenic shock (67% versus 4.6% in AMI without shock, p < 0.0001). Cumulative event rate at six months also varied according to clinical presentation: mortality/MI and target vessel revascularization (TVR) rates were 29%, 3.6%, and 0% in AMI, 7.1%, 7.4%, and 11% in UAP and 0%, 5.3%, and 7.9% in SAP patients. Multivariate analysis identified cardiogenic shock as the most powerful risk factor for predicting mortality (odds ratio = 42, p = 0.03). CONCLUSIONS These results show that clinically stable octogenarian patients undergoing PCI have favorable procedural and intermediate-term prognosis. In contrast, cardiogenic shock has a profound negative prognostic impact on octogenarians despite 'aggressive' PCI attempts.
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Affiliation(s)
- Igal Teplitsky
- Cardiology Department, Rabin Medical Center, Petch-Tivka, Israel
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Dohmen P, Gabbieri D, Weymann A, Linneweber J, Konertz W. Reduction in surgical site infection in patients treated with microbial sealant prior to coronary artery bypass graft surgery: a case–control study. J Hosp Infect 2009; 72:119-26. [DOI: 10.1016/j.jhin.2009.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 02/04/2009] [Indexed: 12/01/2022]
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Radial artery achieves better flowmetric results than saphenous vein in the elderly. Heart Vessels 2009; 24:108-15. [DOI: 10.1007/s00380-008-1095-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 07/17/2008] [Indexed: 10/20/2022]
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Morrison DA. It is never too late for PCI: To relieve medically refractory myocardial ischemia. Catheter Cardiovasc Interv 2009; 73:455-6. [PMID: 19235234 DOI: 10.1002/ccd.22004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Motomura N, Miyata H, Tsukihara H, Takamoto S. Risk Model of Thoracic Aortic Surgery in 4707 Cases From a Nationwide Single-Race Population Through a Web-Based Data Entry System. Circulation 2008; 118:S153-9. [DOI: 10.1161/circulationaha.107.756684] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery.
Methods and Results—
The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%
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ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively.
Conclusion—
This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.
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Affiliation(s)
- Noboru Motomura
- From the. Departments of Cardiothoracic Surgery (N.M., S.T.) and Healthcare Quality Assessment (N.M., H.M., H.T.), Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- From the. Departments of Cardiothoracic Surgery (N.M., S.T.) and Healthcare Quality Assessment (N.M., H.M., H.T.), Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroyuki Tsukihara
- From the. Departments of Cardiothoracic Surgery (N.M., S.T.) and Healthcare Quality Assessment (N.M., H.M., H.T.), Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Shinichi Takamoto
- From the. Departments of Cardiothoracic Surgery (N.M., S.T.) and Healthcare Quality Assessment (N.M., H.M., H.T.), Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Onorati F, Santarpino G, Lerose MA, Impiombato B, Mastroroberto P, Renzulli A. Intraoperative behavior of arterial grafts in the elderly and the young: a flowmetric systematic analysis. Heart Vessels 2008; 23:316-24. [PMID: 18810580 DOI: 10.1007/s00380-008-1055-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Accepted: 03/07/2008] [Indexed: 10/21/2022]
Abstract
Extensive arterial grafting (Art-CABG) in the elderly is still questioned due to the reduced life expectancy and the supposed higher periprocedural risk. Reports further demonstrated accelerated atherosclerosis of arterial grafts in the elderly, with hampered short-term and long-term results. We reviewed our experience of patients undergoing Art-CABG between January 2003 and January 2007, divided into two groups: the elderly (238 patients > or = 70 years; Group A) and the young (195 patients < or = 60 years; Group B). Transit time flowmetric (TTF) maximum and mean flow, pulsatility index (PI), and graft flow reserve (GFR) were compared. Hospital outcome was analyzed. Hospital mortality, need for intra-aortic balloon pump, troponin I, and echocardiographic segmental kinetics were comparable between the two groups (P = not significant [NS]). Stratifying patients for target vessels and type of arterial CABG, no differences in TTF results were recorded between the two groups either on-pump (P = NS) and off-pump (P = NS), both for the two internal mammary arteries (P = NS irrespective of the target vessel) and the radial artery conduits (P = NS irrespective of the target vessel). Although graft flow reserve was significantly recruited in all patients (P < 0.05 in young and elderly, either on-pump and off-pump, irrespective of the arterial conduit and the grafted vessel), GFR of all arterial grafts was comparable between elderly and young patients, either on-pump (P = NS) or off-pump (P = NS). Art-CABG showed similar TTF results in elderly and young patients, regardless of the arterial conduit, target vessel, or surgical technique employed. These functional results supported the reported survival benefit of arterial revascularization in the elderly.
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Affiliation(s)
- Francesco Onorati
- Cardiac Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy.
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Kagal DR, Salehian O. Time to Medical Management in Patients Presenting with Non-ST Elevation Myocardial Infarction: A Retrospective Analysis of Two Teaching Hospitals. Clin Med Cardiol 2008. [DOI: 10.4137/cmc.s1056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Omid Salehian
- Division of Cardiology, McMaster University, Hamilton, Canada
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Siminoff LA, Hausmann LRM, Ibrahim S. Barriers to obtaining diagnostic testing for coronary artery disease among veterans. Am J Public Health 2008; 98:2207-13. [PMID: 18381987 DOI: 10.2105/ajph.2007.123224] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to identify factors associated with appointment nonattendance for diagnostic testing of coronary artery disease among veterans. For patients with possible heart disease, appointment nonattendance may seriously compromise short- and long-term outcomes. Understanding factors associated with nonattendance may help improve care while reducing inefficiency in service delivery. METHODS We surveyed patients who attended (n = 240) or did not attend (n = 139) a scheduled cardiac appointment at a midwestern Veterans Administration medical center. Multivariable regression models were used to assess factors associated with nonattendance. RESULTS Younger age, lower income, unemployment, and longer wait times for appointments were predictive of nonattendance. Nonattenders reported fewer cardiac symptoms and were more likely to attribute their symptoms to something other than heart disease. Nonattendance was also associated with a coping style characterized by avoidance of aversive information. Logistical issues, fear of diagnostic procedures, disbelief that one had heart disease, and medical mistrust were some of the reasons given for missed appointments. CONCLUSIONS Appointment nonattendance among veterans scheduled for cardiology evaluation was associated with several important cognitive factors. These factors should be considered when one is designing clinical systems to reduce patient nonattendance.
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Affiliation(s)
- Laura A Siminoff
- Department of Social and Behavioral Health, Virginia Commonwealth University, Richmond, VA 23298, USA.
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Hong YJ, Jeong MH, Ahn Y, Sim DS, Chung JW, Cho JS, Yoon NS, Yoon HJ, Moon JY, Kim KH, Park HW, Kim JH, Cho JG, Park JC, Kang JC. Age-Related Differences in Intravascular Ultrasound Findings in 1,009 Coronary Artery Disease Patients. Circ J 2008; 72:1270-5. [DOI: 10.1253/circj.72.1270] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital
| | - Youngkeun Ahn
- The Heart Center of Chonnam National University Hospital
| | - Doo Sun Sim
- The Heart Center of Chonnam National University Hospital
| | - Jong Won Chung
- The Heart Center of Chonnam National University Hospital
| | - Jung Sun Cho
- The Heart Center of Chonnam National University Hospital
| | - Nam Sik Yoon
- The Heart Center of Chonnam National University Hospital
| | - Hyun Ju Yoon
- The Heart Center of Chonnam National University Hospital
| | - Jae Youn Moon
- The Heart Center of Chonnam National University Hospital
| | - Kye Hun Kim
- The Heart Center of Chonnam National University Hospital
| | | | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital
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Onorati F, Pezzo F, Comi MC, Impiombato B, Esposito A, Polistina M, Renzulli A. Radial artery graft function is not affected by age. J Thorac Cardiovasc Surg 2007; 134:1112-20. [DOI: 10.1016/j.jtcvs.2007.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 05/16/2007] [Accepted: 06/05/2007] [Indexed: 11/29/2022]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1-e157. [PMID: 17692738 DOI: 10.1016/j.jacc.2007.02.013] [Citation(s) in RCA: 1285] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: Executive Summary. Circulation 2007. [DOI: 10.1161/circulationaha.107.185752] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116:e148-304. [PMID: 17679616 DOI: 10.1161/circulationaha.107.181940] [Citation(s) in RCA: 813] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary. J Am Coll Cardiol 2007. [DOI: 10.1016/j.jacc.2007.02.028] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Sardella G, De Luca L, De Persio G, Colantonio R, Petrolini A, Conti G, Fedele F. Benefits on coronary restenosis from elective paclitaxel-eluting stent implantation in patients aged 75 years and older. J Cardiovasc Med (Hagerstown) 2007; 8:494-8. [PMID: 17568281 DOI: 10.2459/01.jcm.0000278442.81741.d2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Elderly patients are increasingly referred for revascularisation yet have been underrepresented in some large clinical trials. Although the advent of drug-eluting stents has dramatically reduced clinical events related to restenosis, older age remains one of the most important correlates of adverse outcome, even after an elective percutaneous coronary intervention (PCI). We sought to evaluate the impact of paclitaxel-eluting stents on coronary restenosis in elderly patients undergoing elective PCI. METHODS Patients undergoing successful elective PCI with stenting of de novo coronary artery lesions were identified and screened for participation in this study. All patients included in our analysis were divided into two cohort groups: patients aged <75 years (younger cohort) and patients aged >or=75 years (elderly cohort). We evaluated the six-month incidence of target lesion revascularisation (TLR) and major adverse cardiac events, which included TLR, death and myocardial infarction. RESULTS A total of 171 (58 aged >or=75 years) consecutive patients were enrolled in the study. At six months, TLR rate was similar in both groups [1.77 vs. 1.72%, odds ratio (OR) 0.97, 95% confidence interval (CI) 0.08-10.9, P = 0.98, in the younger and elderly group, respectively]. Even the rate of major adverse cardiac events was comparable between the two groups (7.96 vs. 8.62%, OR 1.09, 95% CI 0.34-3.41, P = 0.88, in the younger and elderly group, respectively). Also the angiographic restenosis rates were comparable between patients <75 or >or=75 years (4.42 vs. 3.46%, P = 0.76). CONCLUSIONS After elective paclitaxel-eluting stent implantation, there is no difference in coronary restenosis in younger and elderly patients, suggesting an age-independent efficacy.
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Affiliation(s)
- Gennaro Sardella
- Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy.
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Pritisanac A, Gulbins H, Rosendahl U, Ennker J. Outcome of heart surgery procedures in octogenarians: is age really not an issue? Expert Rev Cardiovasc Ther 2007; 5:243-50. [PMID: 17338669 DOI: 10.1586/14779072.5.2.243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Survival rates are a well-known marker for quality performance of a cardiac surgery department, as well as standard of procedures, freedom of reoperation, postoperative complications, length of hospital stay, improvement in New York Heart Association classification and quality of life after surgery. Until recently there has not been any great interest of surgeons in topics concerning the costs of postoperative care, as long as the results were successful. However, satisfactory results after cardiac surgery in aged people require successful procedures, as well as meticulous perioperative care. The expenses of healthcare are constantly growing and approaches to optimize costs in all departments of medicine have a high priority. Exact evaluation of comorbidities and prevention of complications in aged people, as well as attentive strategies concerning expenses, may help to reduce mortality, postoperative complications and costs.
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Affiliation(s)
- Anita Pritisanac
- Heart Institute Lahr/Baden, Department of Cardio-Thoracic and Vascular Surgery, Hohbergweg 2, 77933 Lahr, Germany.
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Harpaz D, Rozenman Y, Behar S, Boyko V, Mandelzweig L, Gottlieb S. Coronary angiography in the elderly with acute myocardial infarction. Int J Cardiol 2007; 116:249-56. [PMID: 16839633 DOI: 10.1016/j.ijcard.2006.03.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Revised: 03/04/2006] [Accepted: 03/11/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the high mortality rate in elderly patients with acute myocardial infarction (AMI), the value of coronary angiography (CA) in the elderly has been questioned due to a less favorable outcome. The aim of the study was to determine the prognostic significance of CA on mortality of elderly patients AMI in "real world" practice. METHODS The study cohort comprised 1009 elderly (age > or = 75 years) patients with AMI who were derived from three prospective national surveys between 1996 and 2000 in all 25 CCUs operating in Israel. Baseline characteristics, hospital course, management and outcome of 274 (27%) elderly patients who underwent CA during the index hospitalization were compared with 735 (73%) counterpart patients who did not. RESULTS Patients who underwent CA were on average 2.2 years younger, and were more often with hyperlipidemia (p<0.0001 for each) and with a history of previous percutaneous coronary intervention (p<0.03) than the control group. They had a more favorable clinical presentation: a higher systolic blood pressure (p<0.04), a better Killip class (p<0.03) and an increased frequency of non-Q wave MI (p<0.03). They developed more often recurrent MI (p=0.002) and re-ischemia (p<0.0001). Variables associated with CA use during the index hospitalization were re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a catheterization laboratory in the hospital, while a higher age and fibrinolytic therapy decreased the likelihood of CA use. Of the patients who underwent CA, 67% underwent coronary revascularization (either PCI and/or CABG). Crude and adjusted mortality rates at 1 year were significantly lower in patients who underwent CA, as compared to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio=0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted in a wide range of subgroups analyzed. CONCLUSIONS In "real world" practice, elderly patients with AMI who undergo CA during hospitalization have a better prognosis at 1 year. Age alone should not be a deterrent to performing CA in elderly patients with AMI. Further large randomized trials are needed to confirm that an invasive approach is beneficial in high-risk elderly patients with AMI. CONDENSED ABSTRACT To determine the prognostic significance of coronary angiography (CA) during the course of acute myocardial infarction (AMI) in "real world" practice on mortality of elderly patients, 1009 such patients were studied. Re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a Cath. Lab. were variables which increased the likelihood of undergoing CA, while a higher age and fibrinolytic therapy decreased this likelihood. The crude and covariate adjusted mortality rates at 1 year were significantly lower in patients who underwent CA in comparison to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio 0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted across a wide range of subgroups analyzed.
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Affiliation(s)
- David Harpaz
- The Heart Institute, E. Wolfson Medical Center, Holon, 58-100, Israel.
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Bridgewater B, Grayson AD, Brooks N, Grotte G, Fabri BM, Au J, Hooper T, Jones M, Keogh B. Has the publication of cardiac surgery outcome data been associated with changes in practice in northwest England: an analysis of 25,730 patients undergoing CABG surgery under 30 surgeons over eight years. Heart 2007; 93:744-8. [PMID: 17237128 PMCID: PMC1955202 DOI: 10.1136/hrt.2006.106393] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To study changes in coronary artery surgery practice in the years spanning publication of cardiac surgery mortality data in the UK. METHODS A retrospective analysis of prospectively collected data from all National Health Service centres undertaking adult cardiac surgery in northwest England was carried out. Patients undergoing coronary artery surgery for the first time between April 1997 and March 2005 were included. Changes in observed, predicted and risk adjusted mortality (EuroSCORE) were studied. Evidence of risk-averse behaviour was looked for by examining the number of patients at low risk (EuroSCORE 0-5), high risk (6-10), and very high risk (11 or more), before and after public disclosure. RESULTS 25,730 patients underwent coronary artery surgery during the study period. The observed mortality decreased from 2.4% in 1997-8 to 1.8% in 2004-5 (p = 0.014). The expected mortality (EuroSCORE) increased from 3.0 to 3.5 (p<0.001). The observed to expected mortality ratio decreased from 0.8 to 0.51 (p<0.05). The total number and percentage of patients who were at low risk, high risk and very high risk was 2694 (84.6%), 449 (14.1%) and 41 (1.3%) before and 2654 (81.7%), 547 (16.8%) and 47 (1.4%) after public disclosure, respectively, demonstrating a significant increase in the number and proportion of high risk patients undergoing surgery (p<0.001). CONCLUSIONS Publication of cardiac surgery mortality data in the UK has been associated with decreased risk adjusted mortality on retrospective analysis of a large patient database. There is no evidence that fewer high risk patients are undergoing surgery because mortality rates are published.
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Wiviott SD, Giugliano RP. Non ST-Elevation Acute Coronary Syndromes. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50016-4] [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: 10/20/2022] Open
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Rossi ML, Belli G, Parenti DZ, Scatturin M, Pagnotta P, Gasparini G, Presbitero P. "Do Least Harm" Philosophy May Suffice for Percutaneous Coronary Intervention in Octogenarians. J Interv Cardiol 2006; 19:313-8. [PMID: 16881977 DOI: 10.1111/j.1540-8183.2006.00152.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Octogenarians represent one of the most rapidly expanding segments of the population and an ever growing number are undergoing percutaneous coronary intervention (PCI). A simplified approach with incomplete or "culprit-lesion" only PCI may be an option even in multivessel disease, to minimize periprocedural complications while still allowing a meaningful clinical recovery in patients with inherent functional limitations related to age itself. We tried to determine the effects of either complete or partial PCI on procedural and long-term outcome in a consecutive series of octogenarians. METHODS In-hospital and 1-year clinical outcomes were collected in elderly patients treated with PCI between January 1998 and March 2004 in our institution. RESULTS In a total of 165 octogenarians, 73 elderly patients (44%) underwent complete (COM) and 92 (56%) incomplete (INC) revascularization. Major in-hospital cardiac events were similar in the two subgroups. At 1-year follow-up 65% of patients in the COM and 68% in the INC group (P = ns) referred improvement in angina status and quality of life. Clinically driven repeat PCI was necessary in 16% of COM and 15% of INC patients. Recurrent PCI was mostly required to treat a restenotic index lesion in both groups, while only five patients in the INC group (5.4%) required PCI of a different lesion. CONCLUSIONS Current PCI coronary techniques are safe and effective in octogenarians. Restenosis remains the main cause for recurrent events after bare metal stents. Percutaneous revascularization limited to the culprit lesion may suffice in most patients, with favorable clinical outcome at 1 year.
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Affiliation(s)
- Marco L Rossi
- Division of Cardiology, Unità Operativa di Emodinamica e Cardiologia Invasiva, Istituto Clinico Humanitas, Milan, Italy.
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García-Pinilla JM, Jiménez-Navarro MF, Gómez Doblas JJ, Alonso JH, Hernández García JM, de Teresa Galván E. [Therapeutic attitude after coronariography in elderly patients with ischemic heart disease]. Rev Clin Esp 2006; 205:595-600. [PMID: 16527181 DOI: 10.1016/s0014-2565(05)72652-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The incidence of ischemic heart disease in the elderly is high. These patients are increasing referred for coronariography. OBJECTIVES Identify factors associated with coronary revascularization in elderly patients. MATERIAL AND METHODS Retrospective study of 473 patients > or = 75 years who underwent coronariography in relationship with ischemic heart disease. Their clinical-epidemiological characteristics and treatment adopted were analyzed. A multivariate analysis model was used to identify factors associated with revascularization. RESULTS Mean age was 77.6 +/- 2.8 years; 70.4% were men. A total of 36% smoked, 53% were hypertensive, 33% diabetics and 30% dislipidemic. Thirty one % had multivessel disease and 11% involvement of left coronary trunk. There was evidence of anterior descending artery in 68%. Medical treatment was done in 48.4%, percutaneous revascularization in 41.5% and surgical in 10.1%. Patients with lesions of the anterior descending artery were revascularized in greater proportion: 67.7% vs 32.3%; p. 0.001. A logistic regression model was used to identify revascularization predictors, obtaining a direct relationship with the involvement of the anterior descending artery (OR: 4.87; 95% CI: 2.98-7.94; (p < 0.001) and inverse on with the previous revascularization (OR: 0.47; 95% CI: 0.26-0.85; p < 0.02), left ventricular dysfunction (OR: 0.58; 95% CI: 0.39-0.88; p = 0.01) and presence of multivessel disease (OR: 0.51; 95% CI: 0.31-0.84; p < 0.01). CONCLUSIONS The elderly subjects with ischemic heart disease who underwent coronariography received revascularizing treatment in somewhat more than 50% of the cases. A direct relationship was found between involvement of the anterior descending artery and performance of revascularizing treatment and an inverse on between previous revascularization, left ventricular dysfunction and presence of multivessel disease.
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Affiliation(s)
- J M García-Pinilla
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Victoria, Málaga.
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Kozower BD, Moon MR, Barner HB, Moazami N, Lawton JS, Pasque MK, Damiano RJ. Impact of Complete Revascularization on Long-Term Survival After Coronary Artery Bypass Grafting in Octogenarians. Ann Thorac Surg 2005; 80:112-6; discussion 116-7. [PMID: 15975351 DOI: 10.1016/j.athoracsur.2005.02.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2004] [Revised: 02/02/2005] [Accepted: 02/03/2005] [Indexed: 11/13/2022]
Abstract
BACKGROUND Complete revascularization is important in young patients undergoing coronary artery bypass grafting, but this principle remains less absolute in elderly patients. The purpose of this study was to determine how complete revascularization influenced long-term survival after coronary artery bypass grafting in octogenarians. METHODS From 1986 to 2003, 500 consecutive patients 80 to 94 years of age underwent coronary artery bypass grafting. Complete revascularization was defined as placement of at least one graft to each of the three major vascular regions that included a 50% diameter lesion. Revascularization was complete in 400 (80%) patients and incomplete in 100 (20%) patients. Mean (+/- standard deviation) follow-up was 51 +/- 41 months and was 99% complete (2,102 total patient-years). RESULTS Operative mortality was 8% +/- 2% (+/-95% confidence interval) and was statistically lower with complete (7% +/- 3%) versus incomplete (13% +/- 7%) revascularization (p < 0.05). Of 459 operative survivors, there were 261 late deaths. Multivariate regression analysis identified six independent predictors of late death: earlier operative year, male sex, peripheral or cerebrovascular disease, congestive heart failure, and incomplete revascularization (p < 0.03 for all). Excluding operative deaths, mean survival (Kaplan-Meier) was 82 months with complete revascularization compared with 65 months with incomplete revascularization (p < 0.008). Survival was 62% +/- 3% with complete versus 45% +/- 6% with incomplete revascularization at 5 years and 39% +/- 3% with complete versus 25% +/- 6% with incomplete revascularization at 8 years (p < 0.008). CONCLUSIONS In octogenarians undergoing coronary artery bypass grafting, complete revascularization correlated with improved long-term survival, increasing mean survival by almost 25% compared with incomplete revascularization.
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Affiliation(s)
- Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1013, USA
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García Fuster R, Montero JA, Gil O, Hornero F, Cánovas S, Bueno M, Buendía J, Rodríguez I. Tendencias en cirugía coronaria: cambios en el perfil del paciente quirúrgico. Rev Esp Cardiol 2005; 58:512-22. [PMID: 15899197 DOI: 10.1157/13074845] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES In the last few years, the percentage of high-risk patients proceeding to coronary artery bypass surgery has increased. The most common risk factors are older age and the presence of comorbid complaints. We carried out a retrospective study to confirm this new risk profile and to evaluate its impact on surgical results. PATIENTS AND METHOD We analyzed the changing risk profile of 1360 patients who underwent coronary artery bypass surgery in our hospital between 1993 and 2001, divided into three historical cohorts: 1993-1996, 1997-1999 and 2000-2001. The main factors associated with morbidity and mortality were analyzed by logistic regression analysis. The introduction of new operative techniques, such as off-pump surgery and arterial grafting, was also evaluated. RESULTS The patients' risk profile worsened over time: patients were older, comorbid complaints were more common, and ventricular function was poorer. EuroSCORE figures reflected this trend: estimated mortality in the three historical cohorts was 2.0%, 4.0% and 4.2%, respectively (P<.001). However, risk-adjusted mortality, at 3.7%, 2.7% and 1.5%, respectively, decreased (P<.05), and combined overall morbidity and mortality remained stable, at 16.7%, 16.4% and 13.8%, respectively, (P<.39). There was a non-significant tendency for arterial grafting and off-pump surgery to reduce in-hospital morbidity and mortality. CONCLUSIONS The risk profile of patients undergoing surgery has worsened as their mean age has increased and as comorbid complaints have become more prevalent. However, there has been no simultaneous increase in risk-adjusted mortality. The potential benefits of new surgical advances such as off-pump surgery and multiple arterial grafting must be corroborated by future studies.
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Affiliation(s)
- Rafael García Fuster
- Servicio de Cirugía Cardíaca, Hospital General Universitario de Valencia, Valencia, España.
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Kressin NR, Chang BH, Whittle J, Peterson ED, Clark JA, Rosen AK, Orner M, Collins TC, Alley LG, Petersen LA. Racial differences in cardiac catheterization as a function of patients' beliefs. Am J Public Health 2004; 94:2091-7. [PMID: 15569959 PMCID: PMC1448597 DOI: 10.2105/ajph.94.12.2091] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2004] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined racial differences in cardiac catheterization rates and reviewed whether patients' beliefs or other variables were associated with observed disparities. METHODS We did a prospective observational cohort study of 1045 White and African American patients at 5 Veterans Affairs (VA) medical centers whose nuclear imaging studies indicated reversible cardiac ischemia. RESULTS There were few demographic differences between White and African American patients in our sample. African Americans were less likely than Whites to undergo cardiac catheterization. African Americans were more likely than Whites to indicate a strong reliance on religion and to report racial and social class discrimination and were less likely to indicate a generalized trust in people but did not differ from White patients on numerous other attitudes about health and health care. Neither sociodemographic or clinical characteristics nor patients' beliefs explained the observed disparities, but physicians' assessments of the procedure's importance and patients' likelihood of coronary disease seemed to account for differences not otherwise explained. CONCLUSIONS Patients' preferences are not the likely source of racial disparities in the use of cardiac catheterization among veterans using VA care, but physicians' assessments warrant further attention.
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Affiliation(s)
- Nancy R Kressin
- Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, MA 01730, USA.
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Kuster GM, Pfisterer ME. Care of elderly patients with chronic symptomatic coronary artery disease: is it TIME to be more offensive? ACTA ACUST UNITED AC 2004; 19:102-6. [PMID: 15249770 DOI: 10.1111/j.0889-7204.2004.02602.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Young patients with coronary artery disease usually benefit from revascularization in terms of symptom relief and outcome. There are no prospective data available, however, for patients older than age 75 years, for whom quality of life might be more of an issue than quantity of life and for whom risk profiles and comorbidities make treating physicians more reluctant to prescribe an invasive procedure. The recently published Trial of Invasive vs. Medical therapy in Elderly patients (TIME) was the first to address patients > or =75 years of age with chronic angina despite standard medical therapy. The authors discuss the benefits and risks of interventional vs. medical management of chronic, symptomatic coronary artery disease in elderly patients in view of the TIME results and their clinical implications.
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