This report describes the baseline angiographic findings in the Bypass Angioplasty Revascularization Investigation (BARI) 2 Diabetes (BARI 2D) trial, a randomized study that was initiated after the ...original BARI trial (BARI 1). Unlike BARI 1, which compared coronary artery bypass graft surgery with coronary angioplasty (percutaneous coronary intervention) in patients with and without diabetes, BARI 2D is investigating early versus deferred revascularization as needed in selected patients with type 2 diabetes mellitus and significant stable coronary artery disease (CAD). This analysis included 1,773 patients without previous procedures. The intended mode of revascularization, percutaneous coronary intervention or coronary artery bypass graft surgery, was specified before randomization. Angiographic findings in those randomized to revascularization versus medical treatment were similar. Overall, the mean number of lesions ≥20% diameter stenosis was 4.6 ± 2.3, and the myocardial jeopardy index was 46 ± 24%. Patients selected for the coronary artery bypass graft stratum had a higher mean number of lesions ≥20% diameter stenosis (5.7 vs 4.0, p <0.0001) and a higher myocardial jeopardy index (61% vs 38%, p <0.0001) than those selected for the percutaneous coronary intervention stratum. Female gender, black race, and higher body mass index were associated with less extensive CAD, whereas a history of hypertension, age at entry, low-density lipoprotein cholesterol, and ankle-brachial index ≤0.9 were associated with more extensive CAD. In conclusion, BARI 2D patients, who by design have mild or no symptoms, demonstrate considerable variation in the extent of CAD and amount of jeopardized myocardium. Coronary arteriographic findings are consistent with the intent of the design of BARI 2D. Certain baseline and clinical features were associated with the extent of disease and myocardial jeopardy.
We hypothesized that the time course of left ventricular (LV) outflow tract gradient reduction during septal ethanol ablation for patients with symptomatic hypertrophic obstructive cardiomyopathy is ...related to changes in myocardial mechanics. A total of 21 patients with hypertrophic obstructive cardiomyopathy undergoing septal ethanol ablation were analyzed. LV outflow tract gradient decreased with septal balloon occlusion, further decreased postethanol injection, and partially rebounded at discharge (5-6 days postprocedure). During balloon occlusion longitudinal and circumferential strain significantly decreased in all analyzed segments, significantly improved with alcohol injection only at sites distant to infarction, and normalized at all segments except infarcted ones at discharge. LV twist significantly improved with ethanol injection and remained high at discharge. Myocardial mechanics suggest that the decrease in LV outflow tract gradient during septal ethanol ablation coincides with global LV dysfunction despite only local ischemia during septal balloon occlusion. Global dysfunction is transient and the gradient rebounds when dysfunction is limited to the basal septum.
Objectives The purpose of this study was to investigate whether a relationship exists between an acute reduction in resting left ventricular outflow tract (LVOT) gradient with balloon occlusion and ...the final invasive gradient response following alcohol septal ablation (ASA). Background ASA is an alternative therapy to myectomy surgery to reduce the basal septal thickness and decrease the resting and/or provocable LVOT gradient in patients with hypertrophic cardiomyopathy. Patients have a variable gradient response to occlusion of the septal perforator artery before ethanol infusion for ASA. Methods From November 1998 to November 2008, 120 patients (mean age 60 years range 16 to 87 years, 50% women) with hypertrophic cardiomyopathy underwent ASA at our institution. The resting LVOT gradient (peak systolic left ventricle LV pressure – peak systolic aortic pressure) was measured continuously during the ASA procedure. The time to significant LVOT gradient decrease (defined as >50% decrease from baseline) was recorded following balloon occlusion of the dominant septal perforator coronary artery, which was found to perfuse the basal septum based on contrast echocardiographic studies. Results The mean baseline resting LVOT gradient was 86 ± 43 mm Hg, and it decreased to 17 ± 11 mm Hg following ASA (−80.2%). The mean time to significant gradient reduction was 3.6 ± 2 min (range 25 s to 11 min). The time to significant LVOT gradient reduction strongly correlated with the final magnitude of gradient reduction following ASA (r = –0.81, p < 0.001). Conclusions This study demonstrates a correlation between the time to significant LVOT gradient reduction following septal perforator balloon occlusion and the magnitude of final gradient response after ASA.
Objectives The aim of this study was to compare the survival of patients with hypertrophic cardiomyopathy (HCM) and resting left ventricular outflow tract (LVOT) obstruction managed with an invasive ...versus a conservative strategy. Background In patients with resting obstructive HCM, clinical benefit can be achieved after invasive septal reduction therapy. However, it remains controversial whether invasive treatment improves long-term survival. Methods We studied a consecutive cohort of 649 patients with resting obstructive HCM. Total and HCM-related mortality were compared in 246 patients who were conservatively managed with 403 patients who were invasively managed by surgical myectomy, septal ethanol ablation, or dual-chamber pacing. Results Multivariable analyses (with invasive therapy treated as a time-dependent covariate) showed that an invasive intervention was a significant determinant of overall mortality (hazard ratio: 0.6, 95% confidence interval: 0.4 to 0.97, p = 0.04). Overall survival rates were greater in the invasive (99.2% 1-year, 95.7% 5-year, and 87.8% 10-year survival) than in the conservative (97.3% 1-year, 91.1% 5-year, and 75.8% 10-year survival, p = 0.008) cohort. However, invasive therapy was not found to be a significant independent predictor of HCM-related mortality (hazard ratio: 0.7, 95% confidence interval: 0.4 to 1.3, p = 0.3). The HCM-related survival was 99.5% (1 year), 96.3% (5 years), and 90.2% (10 years) in the invasive cohort, and 97.8% (1 year), 94.6% (5 years), and 86.9% (10 years) in the conservative cohort (p = 0.3). Conclusions Patients treated invasively have an overall survival advantage compared with conservatively treated patients, with the latter group more likely to die from noncardiac causes. The HCM-related mortality is similar, regardless of a conservative versus invasive strategy.
There are three options for the treatment of patients with coronary artery disease: coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI) and optimal medical treatment ...alone. While there has been an active interface between CABG and PCI, medical treatment has not been as vociferously advocated. However, it performs well in randomized trials and is still a treatment arm in studies such as the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. The present review compares these options in acute and chronic coronary syndromes, including the indications for each as summarized by recent American College of Cardiology and American Heart Association guidelines. While the landscape in Canada is changing for CABG and PCI, with an increase in the latter procedure for patients with multivessel disease, optimal medical treatment alone is very effective. There are few subsets, particularly in chronic syndromes, in which revascularization is indicated for prognosis alone
Abstract Study Objective To assess anesthesia-related complications during and following percutaneous nephrolithotomy (PCNL) for staghorn stones. Design Prospective study and a detailed case report. ...Setting Medical center in southern Israel. Patients 20 consecutive patients undergoing PCNL for staghorn stones. Interventions All patients underwent PCNL during general anesthesia. Measurements Duration of surgery, esophageal temperature, hemoglobin (Hb) concentration, and requirements for blood transfusion, mean volume of irrigation fluid, and serum sodium and potassium concentration were recorded. Main Results Mean age was 50.7 ± 14.9 y (range, 26–76 y). Mean duration of the procedure was 120.0 ± 42.5 min (range, 75–240 min). Mean volume of irrigation fluid was 34.1 ± 15.3 L (range, 18–80 L). There was a significant decrease in Hb concentration from 13.7 ± 1.71 to 12.2 ± 1.4 g/dL, but no patient required blood transfusion. There was a statistically significant reduction in esophageal temperature from 36.4°C ± 0.32°C to 35.2°C ± 0.5°C. There were no significant changes in sodium or potassium concentration before or after PCNL. Conclusions Anesthesia during PCNL for staghorn stones is a challenge because of the possibility of fluid absorption, dilutional anemia, hypothermia, or significant blood loss.
Summary Background Little is known about the best antiplatelet treatment immediately after ischaemic stroke or transient ischaemic attack (TIA). The EARLY trial aimed to compare outcome in patients ...given aspirin plus extended-release dipyridamole twice daily either within 24 h of stroke or TIA or after 7 days of aspirin monotherapy. Methods In 46 stroke units in Germany, patients aged 18 years or more who presented with symptoms of an acute ischaemic stroke that caused a measurable neurological deficit (National Institutes of Health stroke scale score ≤20) were randomly assigned to receive 25 mg aspirin plus 200 mg extended-release dipyridamole open-label twice daily or 100 mg aspirin monotherapy open-label once daily for 7 days. Patients were randomised by use of a pseudorandom number generator. All patients were then given open-label aspirin plus extended-release dipyridamole for up to 90 days. The primary endpoint was modified Rankin scale score as recorded by centralised, blinded assessment by telephone (tele-mRS) at 90 days. Vascular adverse events (non-fatal stroke, TIA, non-fatal myocardial infarction, and major bleeding complications) and mortality were assessed in a composite safety and efficacy endpoint. Patients were analysed as treated. This trial is registered, number NCT00562588. Findings Between July, 2007, and February, 2009, 543 patients were treated: 283 received early aspirin plus extended-release dipyridamole and 260 received aspirin plus extended-release dipyridamole after 7 days on aspirin. At day 90, 154 (56%) patients in the aspirin plus early extended-release dipyridamole group and 133 (52%) in the aspirin plus later extended-release dipyridamole group had no or mild disability (tele-mRS 0 or 1; difference 4·1%, 95% CI −4·5 to 12·6, p=0·45). 28 patients in the early initiation group and 38 in the late initiation group reached the composite endpoint (hazard ratio 0·73, 95% CI 0·44–1·19 p=0·20). Interpretation Early initiation of aspirin plus extended-release dipyridamole within 24 h of stroke onset is likely to be as safe and effective in preventing disability as is later initiation after 7 days. Funding Boehringer Ingelheim.
SYNTAX Score and Long-Term Outcomes Ikeno, Fumiaki, MD; Brooks, Maria Mori, PhD; Nakagawa, Kaori, MD ...
Journal of the American College of Cardiology,
2017, Letnik:
69, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Abstract Background The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or ...percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease. Objectives This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Methods Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years. Results A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p < 0.001). Among patients with low SYNTAX scores (≤22), major cardiovascular events did not differ significantly between revascularization and medical therapy, either in the CABG stratum (26.1% vs. 29.9%, p = 0.41) or in the PCI stratum (17.8% vs. 19.2%, p = 0.84). Among patients with mid/high SYNTAX scores, however, major cardiovascular events were lower after revascularization than with medical therapy in the CABG stratum (15.3% vs. 30.3%, p = 0.02), but not in the PCI stratum (35.6% vs. 26.5%, p = 0.12). Conclusions Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305 )
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