Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature

Background

Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy.

Methods

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke.

Results

The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%.

Conclusion

Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

The impact of invasive treatment of superficial venous insufficiency of the lower extremities on cardiac functions

OBJECTIVE

The aim of the study was to investigate the effect of invasive treatment for chronic venous insufficiency (CVI) on cardiac hemodynamics.

METHODS

Fifty three patients diagnosed with saphenofemoral junction or great saphenous vein insufficiency in a level above C3 according to Clinical-Etiology-Anatomy-Pathophysiology classification were included in the study. All the patients underwent 2D echocardiography before and 3 months after the invasive treatment.

RESULTS

In postinvasive treatment echocardiographic assessment, significant decreases in right ventricular end-diastolic diameter (p = 0.006), TAPSE (p = 0.006), tricuspid E wave velocity (p = 0.004), tricuspid E/A ratio (p < 0.001), sPAB (p = 0.017), tricuspid lateral s' wave velocity (p = 0.004), and right ventricular free wall longitudinal strain rate (p = 0.011) were observed.

CONCLUSIONS

The invasive treatment of superficial venous insufficiency of the lower extremities may lead to reduction in the increased venous return in the supine position subclinically.

Predictors of Revascularization in Lower-Extremity Peripheral Artery Disease: Insights From the PORTRAIT Study

BACKGROUND

Peripheral artery disease (PAD) guidelines recommend revascularization only for patients with lifestyle-limiting claudication that is refractory to goal-directed medical therapy (class IIA, level of evidence A). However, real-world invasive treatment patterns and predictors of revascularization in patients with symptomatic lower-extremity PAD are still largely unknown.

AIM

We aimed to examine rates, patient-level predictors, and site variability of early revascularization in patients with new or worsening PAD symptoms.

METHODS

Among patients with new-onset or recent exacerbation of PAD in the 10-center Patient-centered Outcomes Related to TReatment practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT) study enrolled between June 2011 and September 2015, we classified early revascularization (endovascular or surgical) as procedures being performed within 3 months of presentation. Hierarchical logistic regression was used to identify patient characteristics associated with early revascularization. Variability across sites was estimated using the median odds ratio (OR).

RESULTS

Among 797 participants, early revascularization procedures were performed in 224 (28.1%). Rutherford class 3 (vs Rutherford class 1; OR=1.86, 95% confidence interval [CI] 1.04-3.33) and having lesions in both iliofemoral and below-the-knee arterial segments (vs below the knee only; OR=1.75, 95% CI: 1.15-2.67) were associated with a higher odds of revascularization. Longer PAD duration >12 months (vs 1-6 months; OR=0.50, 95% CI: 0.32-0.77), higher ankle-brachial index scores (per 0.1 unit increase; OR=0.86, 95% CI: 0.78-0.96), and higher Peripheral Artery Questionnaire Summary scores (per 10 unit increase; OR=0.89, 95% CI: 0.80-0.99) were associated with a lower odds of revascularization. The raw rates for revascularization in different sites ranged from 6.25% to 66.28%, and the median OR was 1.88, 95% CI: 1.38-3.57.

CONCLUSIONS

About 1 in 3 patients with symptomatic PAD received early revascularization. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD. There was significant site variability in revascularization patterns, and further studies will better understand the source of this variability and optimal selection criteria for early revascularization.

CLINICAL IMPACT

Real world patterns and predictors of early revascularization in peripheral artery disease are not well understood. In this retrospective analysis of the POTRAIT study, about 1 out of 3 patients with PAD symptoms received early revascularization, with significant site variability. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD.

Clinical Factors Associated with Severity of Colonic Diverticular Bleeding and Impact of Bleeding Site

Factors associated with serious colonic diverticular bleeding (CDB) are unclear, although the incidence of CDB has increased. We carried out this study to clarify factors associated with serious CDB and rebleeding. Subjects included 329 consecutive patients hospitalized for confirmed or suspected CDB between 2004 and 2021. Patients were surveyed regarding backgrounds, treatment, and clinical course. Of 152 with confirmed CDB, 112 showed bleeding from the right colon, and 40 did from the left colon. Patients received red blood cell transfusions in 157 (47.7%), interventional radiology in 13 (4.0%), and surgery in 6 (1.8%) cases. Early rebleeding within one month occurred in 75 (22.8%) patients, and late rebleeding within one year occurred in 62 (18.8%). Factors associated with red blood cell transfusion included confirmed CDB, anticoagulants, and high shock index. The only factor related to interventional radiology or surgery was confirmed CDB, which was also associated with early rebleeding. Late rebleeding was associated with hypertension, chronic kidney disease and past CDB. Right CDB showed higher rates of transfusion and invasive treatment than left CDB. Confirmed CDB had high frequencies of transfusion, invasive treatment, and early rebleeding. Right CDB seemed to be a risk for serious disease. Factors related to late rebleeding were different from those related to early rebleeding of CDB.

Identifying patients with complicated diverticulitis, is it that complicated?

OBJECTIVES

Discriminating simple from complicated diverticulitis solely on clinical bases is challenging. The aim of this study was to identify clinical predictive factor for the need for invasive treatment for patients presenting with acute diverticulitis in the emergency room.

MATERIAL AND METHODS

The records of all patients, who were discharged from a university hospital between January 2010 and March 2018 with "diverticulitis" diagnosis, were reviewed. Data collected included clinical features, whether this was a first or recurrent episode, WBC, and Hinchey score. Patients were divided into conservative and invasive treatment groups. Groups were compared by age, sex, BMI, fever, WBC and CT findings. Hinchey score groups were also compared by age, sex, BMI, fever, WBC.

RESULTS

A total of 809 patients were included. Mean age was 60.6 years, with 10% below 40 years. Most patients were treated conservatively (95.9%) while only 4.1% were treated invasively. WBC at presentation was significantly higher in those who required invasive treatment in comparison with the conservative group (13.72 vs. 11.46K/uL, p= 0.024). A statistically significant higher WBC was found among patients with a higher Hinchey score (13.16 vs 11.69, p <0.005). No difference between the groups was found in terms of age, sex, fever or BMI.

CONCLUSION

This study showed that patients who present with acute diverticulitis and an elevated WBC are prone to a more severe disease and a higher Hinchey score. Prudence should be taken with these patients, and CT scan is warranted as there is a greater chance that invasive treatment will be required.

The Management of Post-appendectomy Abscess in Children; A Historical Cohort Study and Update of the Literature

INTRODUCTION

Recent studies have shown that specific cases of post-appendectomy abscess (PAA) in children could be treated conservatively. However, due to the lack of high-quality evidence, choice of treatment still depends on preferences of the treating surgeon, leading to heterogeneity in clinical practice. Therefore, we aimed to provide an update of recent literature on the management of PAA in children and subsequently evaluate the outcomes of a large multicenter cohort of children treated for PAA.

METHODS

A literature search was performed in Pubmed and Embase, selecting all randomized controlled trials, prospective and retrospective cohort studies, and case series published from 2014 and onward and reporting on children (<18 years) treated for a PAA. Subsequently, a historical cohort study was performed, including all children (<18 years) treated for a radiologically confirmed PAA between 2014 and 2021 in a tertiary referral center and two large peripheral centers. Medical charts were reviewed to compare non-invasive (i.e., antibiotics) and invasive (i.e., drainage procedures) treatment strategies. Primary outcome was the success rate of treatment, defined as no need for further interventions related to PAA or its complications.

RESULTS

The search yielded 1,991 articles, of which three were included. Treatment success ranged between 69-88% and 56-100% for non-invasive and invasive strategies, respectively. Our multicenter cohort study included 70 children with a PAA, of which 29 (41%) were treated non-invasively and 41 (59%) invasively. In the non-invasive group, treatment was effective in 21 patients (72%) compared to 25 patients (61%) in the invasive group. Non-invasive treatment was effective in 100% of unifocal small (<3 cm) and 80% of unifocal medium size PAA (3-6 cm), but not effective for multiple abscesses.

CONCLUSION

Non-invasive treatment of especially unifocal small and medium size (<6 cm) PAA in children seems to be safe and effective. Based on these results, a standardized treatment protocol was developed. Prospective validation of this step-up approach-based treatment protocol is recommended.

Red blood cell distribution width may be a new factor that influence the selection of invasive treatment in patients with renal abscess

BACKGROUND

Red blood cell distribution width (RDW) is associated with the severe morbidity and mortality of some Gram-negative associated chronic diseases. We designed this retrospective study to identify whether RDW can be used as a factor to provide reference for the treatment of renal abscess.

METHODS

All patients with renal abscess in our institution between April 2016 and November 2019 were collected, and 38 cases with the characteristic of initially diagnosis and no prior treatment were enrolled. Conservative treatment group and surgical intervention group were set based on the treatment of patients. Univariate analysis and the regression analysis were adopted to identify the difference between these two groups.

RESULTS

Significant differences were found in Diabetes mellitus, RDW and size of renal abscess in both univariate and multifactor analysis. The median value of RDW in all patients was 13.62%, with 13.15% in conservative treatment group and 14.20% receiving surgical intervention (OR: 9.48, 95% CI: 1.15-78.02). Diabetes was present in 42.11% of patients, with the ratio of 20.0% in conservative treatment group and 66.67% in surgical intervention group (OR: 35.22, 95% CI: 1.55-799.05). The cut-off of RDW and size of renal abscess were 14.07% and 3.9 cm respectively.

CONCLUSIONS

RDW as an independent predictor of mortality in patients with Gram-negative bacteremia showed differences among patients with renal abscess who received different treatments. Since the relationship between RDW and Gram-negative bacteremia related to mortality, higher initial RDW value may represent a higher severity of renal abscess and a greater likelihood of the need of surgical intervention.

Eight-year outcome after invasive treatment of infrainguinal intermittent claudication: A population-based analysis from the Swedish vascular register (Swedvasc)

Objectives:

Invasive treatment of infrainguinal intermittent claudication is controversial, and long-term outcomes are scarce. The study aim was to evaluate 8 years results regarding new vascular interventions on index and contralateral limb, hospitalization, mortality, and amputation in 775 patients revascularized for infrainguinal intermittent claudication in 2009.

Methods:

Data on new vascular interventions retrieved from the Swedish vascular register (Swedvasc) were linked to the Inpatient Register and Cause of Death Register with information on hospitalizations, primary discharge diagnoses according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), deaths, causes of death, and amputations.

Results:

During 8 years of follow-up, 486 new vascular interventions were performed. Patients were admitted for a total of 4662 hospitalizations and spent 25,970 days in hospital. Between 79% and 99% of surviving subjects were hospitalized each year. During follow-up, 311 (40.1%) patients died. The most common causes of hospitalization and death were cerebrovascular disease, ischemic heart disease, or other diseases of the circulatory system, causing 47.5% of hospitalizations and 42.4% of deaths. Seventy-seven major lower limb amputations were performed in 52 patients.

Conclusion:

As patients undergoing invasive treatment of infrainguinal intermittent claudication have high morbidity and mortality, during 8 years of follow-up, the indication for invasive treatment should be carefully weighed against concomitant comorbidities and the timing of this treatment optimized with regard to the patient’s possibilities to enjoy positive treatment effects on quality of life.

The progress in outcomes of the management of patients with non-ST-segment elevation myocardial infarction between 2005 and 2014 in Poland - a propensity score matching analysis from the PL-ACS registry

Introduction

Dynamic changes both in clinical profile and treatment strategy of non ST-segment elevation myocardial infarction (NSTEMI) patients have been observed recently. The exact impact of them on prognosis in a wide national population remains unclear.

Aim

To evaluate the impact of treatment advances between 2005 and 2014 on the outcomes of NSTEMI cases.

Material and methods

NSTEMI patients from the Polish Registry of Acute Coronary Syndromes (PL-ACS) were included to the analysis. The mortality rate in a hospital observation as well as in 12-month follow-up was evaluated.

Results

The frequency of diabetes, hypertension, prior coronary artery interventions (especially percutaneous coronary intervention) raised. A frequency of invasive procedures increased remarkably (coronary angiography from 35.8% to 90.7%; p < 0.05 and percutaneous coronary intervention from 25.7% to 63.6%; p < 0.05). The usage of P2Y12 – inhibitors raised substantially from 56% to 93%; p < 0.05. In-hospital mortality decreased by fifty percent (in women from 6.6% to 3.3%; p < 0.001 and in men from 4.9% to 2.5%; p < 0.001, respectively). Similarly, 12-month mortality decreased up to one third (in women from 21.6% to 15.1%; p < 0.001 and in men from 17.8% to 12.8%; p < 0.001, respectively). Invasive strategy appeared to be the strongest factor decreasing mortality. Into in-hospital observation it reduces triple mortality risk whereas in 12-month follow up twice. Using propensity score matching analysis the impact of the treatment improvements on relative risk reduction was estimated on over 60%.

Conclusions

In last decade the outcomes of NSTEMI in Poland improved substantially. The predominant impact on it had a routine invasive strategy.

Gender-related disparities in the treatment and outcomes in patients with non-ST-segment elevation myocardial infarction: results from the Polish Registry of Acute Coronary Syndromes (PL-ACS) in the years 2012-2014

INTRODUCTION

Gender-related differences in the treatment of patients with non-ST elevation myocardial infarction (NSTEMI) have been reported in many previous studies despite the fact that an equal approach is recommended in all current guidelines. The aim of the study was to investigate whether gender-related discrepancies in the management of NSTEMI patients have changed.

MATERIAL AND METHODS

Between 2012 and 2014 a total of 66,667 patients (38.3% of whom were women) with the final diagnosis of NSTEMI were included into the retrospective analysis of the Polish Registry of Acute Coronary Syndromes (PL-ACS). Differences in clinical profile, treatment, and outcomes were analysed.

RESULTS

Women were older than men and more often had comorbidities. They were less likely to undergo coronary angiography (88.4% vs. 92.1%, p < 0.05) as well as percutaneous coronary intervention (59.6% vs. 71.9%, p < 0.05). In the general population women had also significantly worse in-hospital prognosis as well as in 12-month follow-up. After the age adjustment the outcomes in women were at least as good as in men. In multivariate analysis females had the same risk as men in-hospital RR = 1.02 (95% CI: 0.97-1.08, p = 0.45) and lower in 12-month observation RR = 0.94 (95% CI: 0.92-0.97, p < 0.0001).

CONCLUSIONS

In comparison with previous reports on NSTEMI patients, gender-related disparities in the treatment and outcomes were radically reduced. Unadjusted mortality rates were still higher in women as a consequence of their older age. After the age adjustment, mortality ratios were similar in both genders. The long-term prognosis seems to be even better in women.

Selective transarterial embolization of acute renal hemorrhage: a retrospective study

Introduction: Selective transarterial embolization (STAE) is a minimally invasive treatment method developed as am alternative to surgery for acute renal haemorrhage (ARH). The aim of this study was to evaluate the efficacy and outcome of STAE in ARH patients.Material and methods: The data of patients who underwent STAE with signs of ARH were collected retrospectively. The etiology of renal haemorrhage, localization and type of lesion, embolizing agent used, the amount of contrast material given, duration of fluoroscopy and perioperative and postoperative complications were recorded. Lesions were classified as pseudoaneurysm (PA), arteriovenous fistula (AVF), arterio pelvic fistula (ACF), pathological tumoral vasculature and extravasation.Results: A total of 51 patients were included in the study. The most common symptom was gross hematuria (76.4%) and the most common underlying cause was iatrogenic renal injury (64.7%). Embolizing agents used were n-BCA-iodized oil in 29 patients, coils alone in six patients, coils + n-BCA in four patients, ethanol-iodized oil in three patients, combination of n-BCA-iodized oil and ethanol-iodized oil in two patients, polyvinyl alcohol particles in three patients and covered stent in one patient. Technical success was 100% in all patients and there was no need for reintervention.Conclusions: STAE is a safe, effective and minimally invasive method in emergency treatment of ARH.

Electrical storm - still an extremely poor prognosis. Do these acute states of life-threatening arrhythmias require a multidirectional approach from the start?

Electrical storm (ES) is a state of electrical instability of the heart manifesting as multiple and potentially lethal recurring ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation. This definition is not related to the condition of each patient, who can present from asymptomatic to unconscious and in deep cardiogenic shock. Most patients affected by ES have heart failure (HF) of ischaemic origin. Ischaemia, exacerbation of HF, low ejection fraction, previous ventricular arrhythmias, infection or electrolyte disturbances together with other factors, or a few factors combined, may result in ES. The prognosis of ES survivors is very poor, with 1-year mortality exceeding 40%, which should draw attention to this group of patients as one of extremely high risk. The number of patients with cardioverter-defibrillators is increasing and so is the number of patients suffering from ES. Therefore, each patient should be supported with tailored therapy, and not only restricted to pharmacotherapy or ablation procedures. This paper was written to analyse the most frequent causes of ES and prompt the most appropriate clinical pathways and possibilities, underlining the need for a comprehensive invasive approach to diagnosis, treatment and circulatory stabilization in addition to adequate pharmacotherapy. This approach might help to reduce the mortality rate in this group of patients and improve the prognosis.

Outcomes of in-hospital treatment of cardiac patients who survived cardiac arrest and experienced coronary angiography

Introduction

As coronary artery disease is the most frequent cause of cardiac arrest, early invasive strategies may be beneficial for such patients. This study analyses the impact of in-hospital treatment on short-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors.

Material and methods

Patients admitted to the Cardiac Intensive Care Unit of our hospital within 2-year period were prospectively included in the study.

Results

One hundred thirty-one patients were included in the study, which showed that in-hospital mortality increases uniformly with the severity of the coronary artery lesion (p = 0.044), but an effect of revascularization on number of deaths was not observed (p = 0.64). The presence of coma (p = 0.005) and the combination of male sex and age above 60-year as 2.2-fold (p = 0.048) increasing in-hospital mortality were found. The highest mortality rate occurred during the first 3 days and the death rate of the patients who survived this period is low. We found reduced left ventricular ejection fraction (OR = 6.54; 95% CI: 1.98-21.63; p = 0.002), non-ventricular fibrillation initial rhythm (OR = 2.94; 95% CI: 1.25-6.90; p = 0.014), unconscious at admission (OR = 6.46; 95% CI: 1.96-21.24; p = 0.002) and post-resuscitation coma (OR = 6.00; 95% CI: 2.63-13.66; p < 0.001) or encephalopathy (OR = 2.71; 95% CI: 1.9-6.72; p = 0.031) to be significant prognostic factors for higher in-hospital mortality rate.

Conclusions

We recommend immediate coronary interventions for all survivors of OHCA regardless of their state of consciousness and absence of ischaemic changes on ECG. Early intensive treatment for OHCA patients is indispensable, as the highest mortality rate is within the first 3 days after an event.

Patients With Intermittent Claudication and Chronic Widespread Pain Improves in Health-Related Quality of Life After Invasive but Not After Noninvasive Treatment

Background:

Intermittent claudication (IC) is traditionally managed with risk factor modification, best medical treatment (BMT), and exercise training. Comorbidities such as diabetes and ischemic heart disease affect both results of invasive treatment and health-related quality of life (HRQoL) negatively. It is unknown how chronic widespread pain (CWP) influences the results of invasive treatment. We evaluated the influence of CWP on HRQoL in patients undergoing invasive (open surgery or endovascular treatment) and noninvasive BMT of IC.

Methods:

A total of 242 patients with IC treated with invasive or noninvasive methods responded to the validated HRQoL questionnaires Short Form 36 Health Survey, EuroQoL 5-dimensions, and distribution of pain with the Epipain questionnaire at baseline and after 12 months.

Results:

Invasively treated patients without CWP improved in all primary outcome measures. Patients with CWP reported significant improvements in most of the HRQoL-related outcome measures after invasive treatment, but patients with CWP in the noninvasive treatment group did not improve in any HRQoL-related outcome measure.

Conclusions:

The presence of CWP not should be a cause to withhold invasive treatment in patients with IC.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Early Invasive Versus Selective Strategy for Non-ST-Segment Elevation Acute Coronary Syndrome: The ICTUS Trial

BACKGROUND

The ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years.

OBJECTIVES

The aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T.

METHODS

The ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or spontaneous MI. Additional outcomes included the composite of death or MI, death, MI (spontaneous and procedure-related), and revascularization.

RESULTS

Ten-year death or spontaneous MI was not statistically different between the 2 groups (33.8% vs. 29.0%, hazard ratio [HR]: 1.12; 95% confidence interval [CI]: 0.97 to 1.46; p = 0.11). Revascularization occurred in 82.6% of the early invasive group and 60.5% in the selective invasive group. There were no differences in additional outcomes, except for a higher rate of death or MI in the early invasive group compared with the rates for the selective invasive group (37.6% vs. 30.5%; HR: 1.30; 95% CI: 1.07 to 1.58; p = 0.009), driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs. 2.4%; HR: 2.82; 95% CI: 1.53 to 5.20; p = 0.001).

CONCLUSIONS

In patients with NSTE-ACS and elevated cardiac troponin T levels, an early invasive strategy has no benefit over a selective invasive strategy in reducing the 10-year composite outcome of death or spontaneous MI, and a selective invasive strategy may be a viable option in selected patients.

Clinical Correlates and Prognostic Value of Plasma Galectin-3 Levels in Degenerative Aortic Stenosis: A Single-Center Prospective Study of Patients Referred for Invasive Treatment

Galectin-3 (Gal-3), a β-galactoside-binding lectin, has been implicated in myocardial fibrosis, development of left ventricular (LV) dysfunction and transition from compensated LV hypertrophy to overt heart failure (HF), being a novel prognostic marker in HF. Risk stratification is crucial for the choice of the optimal therapy in degenerative aortic stenosis (AS), affecting elderly subjects with coexistent diseases. Our aim was to assess correlates and prognostic value of circulating Gal-3 in real-world patients with degenerative AS referred for invasive treatment. Gal-3 levels were measured at admission in 80 consecutive patients with symptomatic degenerative AS (mean age: 79 ± 8 years; aortic valve area (AVA) index: 0.4 ± 0.1 cm²/m²). The therapeutic strategy was chosen following a dedicated multidisciplinary team-oriented approach, including surgical valve replacement (n = 11), transcatheter valve implantation (n = 19), balloon aortic valvuloplasty (BAV) (n = 25) and optimal medical therapy (n = 25). Besides routine echocardiographic indices, valvulo-arterial impedance (Zva), an index of global LV afterload, was computed. There were 22 deaths over a median follow-up of 523 days. Baseline Gal-3 correlated negatively with estimated glomerular filtration rate (eGFR) (r = -0.61, p < 0.001) and was unrelated to age, symptomatic status, AVA index, LV ejection fraction, LV mass index or Zva. For the study group as a whole, Gal-3 tended to predict mortality (Gal-3 >17.8 vs. Gal-3 <17.8 ng/mL; hazard ratio (HR): 2.03 (95% confidence interval, 0.88-4.69), p = 0.09), which was abolished upon adjustment for eGFR (HR: 1.70 (0.61-4.73), p = 0.3). However, in post-BAV patients multivariate-adjusted pre-procedural Gal-3 was associated with worse survival (HR: 7.41 (1.52-36.1), p = 0.01) regardless of eGFR. In conclusion, the inverse eGFR-Gal-3 relationship underlies a weak association between Gal-3 and adverse outcome in patients with degenerative AS referred for invasive therapy irrespective of type of treatment employed. In contrast, pre-procedural Gal-3 appears an independent mortality predictor in high-risk AS patients undergoing BAV.

Current and future options for the management of phantom-limb pain

Phantom-limb pain (PLP) belongs among difficult-to-treat chronic pain syndromes. Treatment options for PLP are to a large degree implicated by the level of understanding the mechanisms and nature of PLP. Research and clinical findings acknowledge the neuropathic nature of PLP and also suggest that both peripheral as well as central mechanisms, including neuroplastic changes in central nervous system, can contribute to PLP. Neuroimaging studies in PLP have indicated a relation between PLP and the neuroplastic changes. Further, it has been shown that the pathological neuroplastic changes could be reverted, and there is a parallel between an improvement (reversal) of the neuroplastic changes in PLP and pain relief. These findings facilitated explorations of novel neuromodulatory treatment strategies, adding to the variety of treatment approaches in PLP. Overall, available treatment options in PLP include pharmacological treatment, supportive non-pharmacological non-invasive strategies (eg, neuromodulation using transcranial magnetic stimulation, visual feedback therapy, or motor imagery; peripheral transcutaneous electrical nerve stimulation, physical therapy, reflexology, or various psychotherapeutic approaches), and invasive treatment strategies (eg, surgical destructive procedures, nerve blocks, or invasive neuromodulation using deep brain stimulation, motor cortex stimulation, or spinal cord stimulation). Venues of further development in PLP management include a technological and methodological improvement of existing treatment methods, an implementation of new techniques and products, and a development of new treatment approaches.

Long-Term clinical outcomes according to initial management and thrombolysis in myocardial infarction risk score in patients with acute non-ST-segment elevation myocardial infarction

PURPOSE

There is still debate about the timing of revascularization in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI). We analyzed the long-term clinical outcomes of the timing of revascularization in patients with acute NSTEMI obtained from the Korea Acute Myocardial Infarction Registry (KAMIR).

MATERIALS AND METHODS

2,845 patients with acute NSTEMI (65.6 +/- 12.5 years, 1,836 males) who were enrolled in KAMIR were included in the present study. The therapeutic strategy of NSTEMI was categorized into early invasive (within 48 hours, 65.8 +/- 12.6 years, 856 males) and late invasive treatment (65.3 +/- 12.1 years, 979 males). The initial- and long-term clinical outcomes were compared between two groups according to the level of Thrombolysis In Myocardial Infarction (TIMI) risk score.

RESULTS

There were significant differences in-hospital mortality and the incidence of major adverse cardiac events during one-year clinical follow-up between two groups (2.1% vs. 4.8%, p < 0.001, 10.0% vs. 13.5%, p = 0.004, respectively). According to the TIMI risk score, there was no significant difference of long-term clinical outcomes in patients with low to moderate TIMI risk score, but significant difference in patients with high TIMI risk score (>or= 5 points).

CONCLUSIONS

The old age, high Killip class, low ejection fraction, high TIMI risk score, and late invasive treatment strategy are the independent predictors for the long-term clinical outcomes in patients with NSTEMI.

Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review

Within the framework of evidence-based medicine high-quality randomised trials and systematic reviews are considered a necessary prerequisite for progress in orthopaedics. This paper summarises the currently available evidence on surgical and other invasive procedures for low back pain. Results of systematic reviews conducted within the framework of the Cochrane Back Review Group were used. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated using the evidence summary on surgery and other invasive procedures from the COST B13 European Guidelines for the Management of Acute and Chronic Non-Specific Low Back Pain. Facet joint, epidural, trigger point and sclerosant injections have not clearly been shown to be effective and can consequently not be recommended. There is no scientific evidence on the effectiveness of spinal stenosis surgery. Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc prolapses that fail to resolve with the conservative management. Cognitive intervention Combined with exercises is recommended for chronic low back pain, and fusion surgery may be considered only in carefully selected patients after active rehabilitation programmes during 2 years time have failed. Demanding surgical fusion techniques are not better than the traditional posterolateral fusion without internal fixation.