Objectives This study was designed to better understand the functional correlates and the prognostic relevance of exercise-induced painless ischemia relative to painful ischemia in patients with ...stable coronary artery disease and previous myocardial infarction (MI).
Background The usefulness of exercise testing (ET) for predicting cardiac events, years after MI, although suggested and widely applied, is questionable. In particular, previous studies have reached conflicting conclusions as to whether exercise-induced painless ischemia is related to a less severe myocardial ischemia or to a different prognosis than painful ischemia.
Methods and Results Seven hundred sixty-six consecutive stable patients (mean age 57 ± 8.6 years, 89% men) with previous MI (mean time from MI 2.8 ± 0.75 years) who underwent a Bruce treadmill test and whose data were prospectively entered into our institutional database were enrolled. Patients were followed up for an average of 7 ± 0.6 years. End points were (1) cardiac death, (2) cardiac death or nonfatal reinfarction (primary), (3) cardiac death, nonfatal reinfarction, or unstable angina (secondary), and (4) cardiac death, nonfatal reinfarction, unstable angina, or revascularization procedures (secondary, restricted). These patients were retrospectively classified into 4 groups according to exercise test results: (1) painless ischemia, 156 patients; (2) painful ischemia, 75 patients; (3) negative ET, 99 patients; and (4) nondiagnostic ET, the remaining 436 patients. Patients with painless ischemia had less functional impairment and less exercise ischemia than the symptomatic patients (longer exercise duration
P < .001, higher double product
P < .001, higher ischemic threshold
P < .001, and shorter time to ST normalization
P < .001). Patients with painful ischemia had significantly (
P < .0005) increased 6-year risk rates of secondary and restricted end points (49% and 64%, respectively) versus those with painless ischemia (28% and 35%), no inducible ischemia (25% and 27%), or nondiagnostic ET (32% and 37%). Adverse outcomes were mainly the result of higher incidence of unstable angina or revascularization procedures. At multivariate analysis, neither painless nor painful exercise-induced ischemia were independent predictors of end points.
Conclusions Stable patients with previous MI represent a very low-risk population. In this subset, painless exercise-induced ischemia signifies less severe ischemia than the symptomatic one and has a limited prognostic power. Thus painless exercise-induced ischemia in stable patients with previous MI does not identify patients at increased risk. (Am Heart J 1998;136:894-904.)
To evaluate the possibility to perform both percutaneous coronary interventions (PCI) and atrial septal defect (ASD) transcatheter treatment during the same session. Transcatheter ASD closure is a ...well-established alternative to surgery and the treatment of choice for single vessel coronary artery disease (CAD) is accepted to be PCI.
From January 2000 to December 2005, 985 patients were referred to our center for ASD closure. One hundred thirty four patients (59 males, mean age 58 +/- 4 years, range 45-72 years) were included in a prospective protocol of ASD transcatheter closure and coronary angiography.
In 7 patients we found a coronary artery disease. A combined single setting definitive percutaneous approach (ASD closure and PCI) was performed in 6 patients. The patient number 4 was judged unsuitable for PCI and then was referred for surgery. There was no acute intra-procedural complication in all patients; renal functions pre and post procedure showed no change despite the increase in the amount of contrast used.
Our report showed the feasibility of both PCI and ASD transcatheter treatment during the same session.
Antegrade femoral artery access is often used for diagnostic and interventional purposes in patients with critical limb ischemia, given its potential advantages in terms of visualization and back-up. ...However, it may be associated with an increased risk of local vascular complications, especially in the presence of common femoral artery atherosclerosis. We hereby report a case of antegrade femoral access in a previously stented common artery, which enabled successful recanalization of a totally occluded superficial femoral artery. Despite the procedural success, retroperitoneal bleeding occurred after sheath removal, which was nonetheless effectively managed with prolonged balloon inflations by means of contralateral femoral artery access. This clinical vignette, the first to date to report on antegrade access in a stented femoral artery, supports its feasibility despite the presence of a real bleeding risk.
To provide further information on the clinical and pathological prognostic factors in triple-negative breast cancer (TNBC), for which limited and inconsistent data are available.
Pathological ...characteristics and clinical records of 841 TNBCs diagnosed between 1994 and 2015 in four major oncologic centers from Sardinia, Italy, were reviewed. Multivariate hazard ratios (HRs) for mortality and recurrence according to various clinicopathological factors were estimated using Cox proportional hazards models.
After a mean follow-up of 4.3 years, 275 (33.3%) TNBC patients had a progression of the disease and 170 (20.2%) died. After allowance for study center, age at diagnosis, and various clinicopathological factors, all components of the TNM staging system were identified as significant independent prognostic factors for TNBC mortality. The HRs were 3.13, 9.65, and 29.0, for stage II, III and IV, respectively, vs stage I. Necrosis and Ki-67 > 16% were also associated with increased mortality (HR: 1.61 and 1.99, respectively). Patients with tumor histotypes other than ductal invasive/lobular carcinomas had a more favorable prognosis (HR: 0.40 vs ductal invasive carcinoma). No significant associations with mortality were found for histologic grade, tumor infiltrating lymphocytes, and lymphovascular invasion. Among lymph node positive TNBCs, lymph node ratio appeared to be a stronger predictor of mortality than pathological lymph nodes stage (HR: 0.80 for pN3 vs pN1, and 3.05 for >0.65 vs <0.21 lymph node ratio), respectively. Consistent results were observed for cancer recurrence, except for Ki-67 and necrosis that were not found to be significant predictors for recurrence.
This uniquely large study of TNBC patients provides further evidence that, besides tumor stage at diagnosis, lymph node ratio among lymph node positive tumors is an additional relevant predictor of survival and tumor recurrence, while Ki-67 seems to be predictive of mortality, but not of recurrence.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Triple Negative breast cancer (TNBC) includes a heterogeneous group of tumors with different clinico-pathological features, molecular alterations and treatment responsivity. Our aim was to evaluate ...the clinico-pathological heterogeneity and prognostic significance of TNBC histologic variants, comparing "special types" to high-grade invasive breast carcinomas of no special type (IBC-NST).
This study was performed on data obtained from TNBC Database, including pathological features and clinical records of 1009 TNBCs patients diagnosed between 1994 and 2015 in the four most important Oncology Units located in different hospitals in Sardinia, Italy. Kaplan-Meier analysis, log-rank test and multivariate Cox proportional-hazards regression were applied for overall survival (OS) and disease free survival (DFS) according to TNBC histologic types.
TNBC "special types" showed significant differences for several clinico-pathological features when compared to IBC-NST. We observed that in apocrine carcinomas as tumor size increased, the number of metastatic lymph nodes manifestly increased. Adenoid cystic carcinoma showed the smallest tumor size relative to IBC-NST. At five-year follow-up, OS was 92.1, 100.0, and 94.5% for patients with apocrine, adenoid cystic and medullary carcinoma, respectively; patients with lobular and metaplastic carcinoma showed the worst OS, with 79.7 and 84.3%, respectively. At ten-years, patients with adenoid cystic (100.0%) and medullary (94.5%) carcinoma showed a favourable prognosis, whereas patients with lobular carcinoma showed the worst prognosis (73.8%). TNBC medullary type was an independent prognostic factor for DFS compared to IBC-NST.
Our study confirms that an accurate and reliable histopathologic definition of TNBC subtypes has a significant clinical utility and is effective in the therapeutic decision-making process, with the aim to develop innovative and personalized treatments.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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