Objective The aim of our study was to evaluate the long-term outcome of patients exclusively undergoing total arterial revascularization off-pump coronary artery bypass grafting and to compare the ...performance of the radial artery and the right internal thoracic artery as a second conduit. Methods We studied a consecutive series of 1700 patients undergoing off-pump coronary artery bypass grafting, receiving a radial artery or right internal thoracic artery as a second graft for total arterial revascularization, between 2003 and 2010. A total of 1447 patients (85.11%) received bilateral internal thoracic artery grafting, and 253 patients (14.89%) received left internal thoracic artery and radial artery grafting. A propensity score–matched analysis was performed to compare the 2 groups, bilateral internal thoracic artery and left internal thoracic artery and radial artery, relative to overall survival, morbidity, and combined end points event–free survival. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated by Cox regression. Results In the full unmatched patient population, the postoperative survival (HR, 0.59; 95% CI, 0.38-0.92; P = . 021), incidence of reintervention/readmission (HR, 0.42; 95% CI, 0.28-0.61; P < . 001), and combined end points (HR, 0.47; 95% CI, 0.35-0.63; P < . 001) were significantly better in the bilateral internal thoracic artery group. In the propensity score–matched patient population, the incidence of reintervention/readmission (HR, 0.40; 95% CI, 0.18-0.88; P = .02) and combined end points (HR, 0.54; 95% CI, 0.32-0.92; P = .02) were significantly better in the bilateral internal thoracic artery group compared with the left internal thoracic artery–radial artery group. Conclusions The results of our study provide evidence for the superiority of the right internal thoracic artery graft compared with the radial artery as a second conduit in total arterial revascularization off-pump coronary artery bypass grafting.
Purpose: The framing effect refers to a phenomenon wherein, when the same problem is presented using different representations of information, people make significant changes in their decisions. This ...study aimed to explore whether the framing effect could be reduced in medical students and residents by teaching them the statistical concepts of effect size, probability, and sampling for use in the medical decision-making process.Methods: Ninety-five second-year medical students and 100 second-year medical residents of Austral University and Buenos Aires University, Argentina were invited to participate in the study between March and June 2017. A questionnaire was developed to assess the different types of framing effects in medical situations. After an initial administration of the survey, students and residents were taught statistical concepts including effect size, probability, and sampling during 2 individual independent official biostatistics courses. After these interventions, the same questionnaire was randomly administered again, and pre- and post-intervention outcomes were compared among students and residents.Results: Almost every type of framing effect was reproduced either in the students or in the residents. After teaching medical students and residents the analytical process behind statistical concepts, a significant reduction in sample-size, risky-choice, pseudo-certainty, number-size, attribute, goal, and probabilistic formulation framing effects was observed.Conclusion: The decision-making of medical students and residents in simulated medical situations may be affected by different frame descriptions, and these framing effects can be partially reduced by training individuals in probability analysis and statistical sampling methods.
Se define como insuficiencia cardíaca (IC) con fracción de eyección (FE) preservada a aquella que cursa con FE del ventrículo izquierdo ≥50%. Suele agruparse en los estudios aleatorizados a los ...pacientes con FE levemente deteriorada, entre 41 y 49%. A diferencia de la IC con FE deprimida (≤40%), en la cual diferentes intervenciones (antagonistas neurohormonales, terapia eléctrica) demostraron mejorar el pronóstico, hasta hace poco no contábamos con evidencia de estudios aleatorizados en el contexto de la FE >40%. Las guías de práctica recomendaban en general evaluar la etiología, considerar las comorbilidades y controlar las condiciones acompañantes (frecuencia cardíaca, tensión arterial, fibrilación auricular, isquemia). En el subgrupo de los pacientes con FE, entre 41 y 49% había en la guía de IC de la ESC de 2021, una indicación IIb para los antagonistas neurohormonales1.
HF with preserved EF is defined as HF with left ventricular EF ≥ 50%. Patients with slightly impaired EF, between 41 and 49%, are usually considered together with EF ≥ 50% in randomized studies. ...Unlike HF with depressed EF (≤40%) in which different interventions (neurohormonal antagonists, electrical therapy) have been shown to improve prognosis, until recently we did not have evidence from a randomized study in the context of EF >40%. Practice guidelines generally recommended evaluating the etiology, considering comorbidities, and controlling accompanying conditions (heart rate, blood pressure, atrial fibrillation, ischemia). In the subgroup of patients with EF between 41% and 49%, there was a IIb indication for neurohormonal antagonists in the 2021 ESC HF guideline. (1)
Background This was a single-institutional study about total arterial off-pump coronary artery bypass graft surgery (OPCABG) using bilateral internal thoracic arteries in triple-vessel disease. ...Methods We retrospectively reviewed the records of 569 multivessel CABG patients (10% female) who underwent total arterial (bilateral internal thoracic arteries) OPCABG between January 2002 and December 2006. Mean age was 63.9 ± 8.9 years. All patients included underwent OPCABG as an elective procedure. Postoperative angiograms were evaluated during a postoperative follow-up period. Early and midterm outcomes, including overall patient survival, freedom from readmission and reintervention, freedom from the combined endpoint of cardiac events and quality of life, were evaluated. Multivariate analysis was used to find determinants of late death. Overall survival and freedom from combined endpoints were determined by the Kaplan-Meier method. Results The average number of distal anastomoses per patient was 3.18 ± 0.4. The average operation time was 209.7 ± 41.7 minutes. Thirty-day mortality was 0.88% (5 of 569). Overall patency rate for all grafts studies was 94.3% (632 of 670). Mean follow-up time was 810 days (range, 8 days to 61 months). Cumulative patient survival at 4 years was 93.3% ± 1.9%. Significant predictors of late mortality were age (hazard ratio, 1.06; 95% confidence interval: 1.01 to 1.12), previous stroke (hazard ratio, 6.5; 95% confidence interval: 1.8 to 23.5), and moderate to severe left ventricle ejection fraction (hazard ratio, 3.3; 95% confidence interval: 1.2 to 8.8). Freedom from hospital readmission and reintervention at 4 years was 91.7% ± 3.5%. Freedom from combined endpoint (death, hospital readmission, and reintervention) at 4 years was 86.9% ± 3.6%. There was a marked improvement in patients' quality of life at follow-up (Duke Activity Status Index score > 45 in more than 70% patients). Conclusions Total arterial (bilateral internal thoracic arteries) OPCABG is feasible with a safe outcome in terms of hospital mortality. At follow-up the incidence of death, hospital readmission and reintervention and patients' quality of life are acceptable with favorable graft patency rates.
ObjectivesThe aim of this study was to develop consensus among Argentine cardiologists on a care bundle to reduce readmissions of patients with heart failure (HF).SettingHospitals and cardiology ...clinics in Argentina that provide in-hospital care for patients with HF.ParticipantsTwenty-four cardiology experts participated in the two online rounds and 18 (75%) of them participated in the third-round meeting.MethodsThis study used a mixed-method design; it was conducted between August 2019 and January 2020. The development of a care bundle (a set of evidence-based interventions applied to improve clinical outcomes) involved three phases: (1) a literature review to define the list of interventions to be evaluated; (2) a modified Delphi panel to select interventions for the bundle and (3) definition of the HF care bundle. Also, the process included three rounds of scoring.ResultsTwenty-six interventions were evaluated. The interventions in the final bundle covered four categories: medication, continuum of care, lifestyle habits, predischarge tests. These were: medication: beta-blockers, angiotensin receptor neprilysin inhibitors or ACE-inhibitors, furosemide and antimineralocorticoids; continuum of care: follow-up appointment, daily weight monitoring; lifestyle habits: smoking cessation counselling and low-sodium diet; predischarge tests: renal function, ionogram, blood pressure control, echocardiogram and determination of decompensating cause.ConclusionFollowing a systematic mixed-method approach, we have developed a care bundle of interventions that could decrease readmission of patients with HF. The application of this bundle could contribute to scale evidence-based interventions.
Objective The aim of our study was to evaluate the impact of recent clopidrogel use before off-pump coronary artery bypass grafting on the postoperative risk of bleeding. Methods During the period ...January 2003 to December 2006, 1104 consecutive patients underwent off-pump coronary artery bypass grafting. Patients were divided into two groups according to the recent use of clopidrogel (within 7 days). We performed a propensity score to further adjust for differences between the patients with and without recent use of clopidrogel. Results Mean age was 64 ± 14 years and 87% were male. The clopidrogel group had a greater incidence of patients in unstable condition, requiring emergency coronary bypass grafting, and with a high EuroSCORE. Propensity score analysis selected 88 patients with and 176 without recent use of clopidrogel. By propensity score, the clopidrogel group had higher requirements for fresh frozen plasma units (18.1% vs 8.5%; P = .02), reoperation owing to bleeding (5.6% vs 0.5%; P = .009), and higher need for postoperative mechanical ventilation (4% vs 10%; P = .04), whereas mortality and length of stay were similar between groups. Conclusion Recent use of clopidogrel before off-pump coronary artery bypass grafting is associated with greater risk for bleeding with similar mortality rate.
In a trial involving patients with heart failure and a mildly reduced or preserved ejection fraction, dapagliflozin reduced the risk of worsening heart failure or cardiovascular death.
Distal embolization may decrease myocardial reperfusion after primary percutaneous coronary intervention (PCI). Nonetheless, results of previous trials assessing the role of distal protection during ...primary PCI have been controversial. The Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial (PREMIAR) was a prospective, randomized, controlled study designed to evaluate the role of filter-based distal protection during PCI in patients with acute ST-segment elevation myocardial infarction at high risk of embolic events (including only baseline Thrombolysis In Myocardial Infarction grade 0 to 2 flow). The primary end point was continuous monitoring of ST-segment resolution. Secondary end points included core laboratory analysis of angiographic myocardial blush, ejection fraction measured by cardiac ultrasound, and adverse cardiac events at 6 months. From a total of 194 enrolled patients, 140 subjects were randomized to PCI with or without embolic protection, and 54 were included in a registry arm due to the presence of angiographic exclusion criteria. Baseline characteristics were comparable between arms. The rate of complete ST-segment resolution (≥70%) at 60 minutes was similar in patients treated with or without distal protection (61.2% vs 60.3%, respectively, p = 0.85). Angiographic myocardial blush (67% vs 70.7%, p = 0.73), in-hospital ejection fraction (47.4 ± 9.9% vs 45.3 ± 7.3%, p = 0.29), and combined end point of death, heart failure, or reinfarction at 6 months (14.3% vs 15.7%, p = 0.81) were consistently achieved in a similar proportion in the 2 groups. In conclusion, the use of filter-based distal protection is safe and effectively retrieves debris; however, such use does not translate into an improvement of myocardial reperfusion, left ventricular performance, or clinical outcomes.
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