Abstract Contemporary clinical trials, registries, and meta-analyses, supported by recent results from the EXCEL (Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease) ...and NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trials, have established percutaneous coronary intervention of left main coronary stenosis as a safe alternative to coronary artery bypass grafting in patients with low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) scores. As left main percutaneous coronary intervention gains acceptance, it is imperative to increase awareness for patient selection, risk scoring, intracoronary imaging, vessel preparation, and choice of stenting techniques that will optimize procedural and patient outcomes.
Background Acute pericarditis is common, yet uncertainty persists on its treatment. We thus aimed to conduct a comprehensive systematic review on pharmacologic treatments for acute or recurrent ...pericarditis. Methods Controlled clinical studies were searched in several databases and were included provided they focused on pharmacologic agents for acute pericarditis or its recurrences. Random-effect odds ratios (ORs) were computed for long-term treatment failure, pericarditis recurrence, rehospitalization, and adverse drug effects. Results From 2,078 citations, 7 studies were finally included (451 patients); but only 3 were randomized trials. Treatment comparisons were as follows: colchicine versus standard therapy (3 studies, 265 patients), steroids versus standard therapy (2 studies, 31 patients), low-dose versus high-dose steroids (1 study, 100 patients), and statins versus standard therapy (1 study, 55 patients). Colchicine was associated with a reduced risk of treatment failure (OR = 0.23 0.11-0.49) and recurrent pericarditis (OR = 0.39 0.20-0.77), but with a trend toward more adverse effects (OR = 5.27 0.86-32.16). Overall, steroids were associated with a trend toward increased risk of recurrent pericarditis (OR = 7.50 0.62-90.65). Conversely, low-dose steroids proved superior to high-dose steroids for treatment failure or recurrent pericarditis (OR = 0.29 0.13-0.66), rehospitalizations (OR = 0.19 0.06-0.63), and adverse effects (OR = 0.07 0.01-0.54). Data on statins were inconclusive. Conclusions Clinical evidence informing decision-making for the management of acute pericarditis and its recurrences is still limited to few, small, and/or low-quality clinical studies. Notwithstanding such major caveats, available studies routinely using nonsteroidal anti-inflammatory agents in both experimental and control groups suggest a beneficial risk-benefit profile for colchicine and a detrimental one for steroids, especially when used at high dosages.
Background Drug-eluting stents reduce the risk of restenosis after percutaneous coronary intervention (PCI) but may pose a risk of thrombosis. Cilostazol, an oral antiplatelet agent with pleiotropic ...effects including inhibition of neointimal hyperplasia, could hold the promise of preventing both restenosis and thrombosis. We systematically reviewed randomized clinical trials (RCTs) on the angiographic and clinical impact of cilostazol after PCI. Methods We searched RCT in BioMedCentral, CENTRAL, clinicaltrials.gov, EMBASE, and PubMed (November 2007). Coprimary end points were binary angiographic restenosis and repeat revascularization, abstracted and pooled by means of random-effect relative risks (RRs). Small study/publication bias was appraised with multiple methods. Results A total of 23 RCTs were included (5428 patients), with median follow-up of 6 months. Pooled analysis showed that cilostazol was associated with statistically significant reductions in binary angiographic restenosis (RR = 0.60 0.49-0.73, P < .001) and repeat revascularization (RR = 0.69 0.55-0.86, P = .001). Cilostazol appeared also safe, with no significant increase in the risk of stent thrombosis (RR = 1.35 0.71-2.57, P = .36) or bleeding (RR = 0.71 0.43-1.16, P = .17). However, small study bias was evident for both binary restenosis ( P < .001) and repeat revascularization ( P < .001), suggesting that at least part of the apparent benefits of cilostazol could be due to this type of confounding effect. Conclusions Cilostazol appears effective and safe in reducing the risk of restenosis and repeat revascularization after PCI, but available evidence is limited by small study effects. Awaiting larger RCTs, this inexpensive treatment can be envisaged in selected patients in which drug-eluting stents are contraindicated or when there is a need for neointimal hyperplasia inhibition.
Women who present with coronary artery disease have different characteristics, undergo different treatment, and have a different prognosis than men. The increasing use of coronary stenting has ...improved the outcome of percutaneous coronary intervention (PCI). However, little is known about the outcomes for men versus women after PCI, especially for those presenting with a diagnosis of acute coronary syndrome. Thus, we compared the baseline features, management, and long-term outlook of men versus women undergoing PCI. All consecutive patients who had undergone PCI with stents at our center from July 1, 2002 to June 30, 2004 were identified retrospectively. The primary end point was the long-term rate of major adverse cardiac events (i.e., death, infarction, and repeat revascularization). The secondary end points were the individual components of the major adverse cardiac events and stent thrombosis. A total of 833 patients were included, 210 women (25.2%) and 623 men (75.8%). The women were significantly older (70.9 vs 63 years, p <0.001) and more often had diabetes mellitus (36.2% vs 21.0%, p <0.001) and hypertension (82.3% vs 73.7%, p = 0.006). The number of drug-eluting stents and the length were significantly lower in the female patients. The incidence of major adverse cardiac events after a median follow-up of 60 months was similar for both women and men (38.8% vs 46.4%, p = 0.075), with a trend toward greater mortality rate for women (21.2% vs 15.4%, p = 0.090). All other end points occurred with similar frequencies. Only in the subgroup of ST-segment elevation myocardial infarction were the rates of death significantly greater for the women than for the men (20.0% vs 8.1%; p = 0.029). In conclusion, very long-term follow-up of women undergoing PCI with coronary artery stenting resulted in similar rates of cardiac event compared to those of men, but greater care should be given to women presenting with ST-segment elevation myocardial infarction. Also, despite their greater baseline risk profile, women were significantly less likely to have received effective treatment, the use of including drug-eluting stents.
Volatile Anesthetics Reduce Mortality in Cardiac Surgery Bignami, Elena, MD; Biondi-Zoccai, Giuseppe, MD; Landoni, Giovanni, MD ...
Journal of cardiothoracic and vascular anesthesia,
10/2009, Letnik:
23, Številka:
5
Journal Article
Recenzirano
Objectives A recent meta-analysis suggested that volatile anesthetics reduce postoperative mortality after cardiac surgery. Nonetheless, whether volatile anesthetics improve the outcome of cardiac ...surgical patients is still a matter of debate. The authors investigated whether the use of volatile anesthetics reduces mortality in cardiac surgery. Design, Setting, and Interventions A longitudinal study of 34,310 coronary artery bypass graft interventions performed in Italy estimated the risk-adjusted mortality ratio for each center. A survey was conducted among these centers to investigate whether the use of volatile anesthetics showed a correlation with mortality. Measurements and Main Results All 64 eligible centers provided the required data. The median unadjusted 30-day mortality among participating centers was 2.2% (0.3-8.8), whereas the median risk-adjusted 30-day mortality was 1.8% (0.1-7.2). Risk-adjusted analysis showed that the use of volatile anesthetics was associated with a significantly lower rate of risk-adjusted 30-day mortality (β = −1.172 −2.259, −0.085, R2 = 0.070, p = 0.035). Dichotomization into centers using volatile anesthetics in at least 25% of their cases or in less than 25% yielded even more statistically significant results ( p = 0.003). Furthermore, a longer use of volatile anesthetics was associated with a significantly lower death rate ( p = 0.022); and exploring the impact of the specific volatile anesthetic agent, the use of isoflurane was associated with significant reductions in risk-adjusted mortality rates ( p = 0.039). Conclusions This survey among 64 Italian centers shows that risk-adjusted mortality may be reduced by the use of volatile agents in patients undergoing coronary artery bypass graft surgery.
Objective: Acute renal failure is a common and threatening complication in patients undergoing cardiovascular surgery. To determine the efficacy of fenoldopam in the prevention of acute renal ...failure, the authors performed a systematic review of randomized, controlled trials and propensity-matched studies in patients undergoing cardiovascular surgery. Design: Meta-analysis. Setting: Hospitals. Participants: A total of 1,059 patients from 13 randomized and case-matched studies were included in the analysis. Interventions: None. Measurements and Main Results: Google Scholar, PubMed, and scientific sessions were searched (updated November 2006). Authors and external experts were contacted. Four unblinded reviewers selected controlled trials that used fenoldopam in the prevention or treatment of acute renal failure in cardiovascular surgery. Four reviewers independently abstracted patient data, treatment characteristics, and outcomes. Pooled estimates showed that fenoldopam consistently and significantly reduced the need for renal replacement therapy (odds ratio = 0.37 0.23-0.59, p < 0.001) and in-hospital death (odds ratio = 0.46 0.29-0.75, p = 0.01). These benefits were associated with shorter intensive care unit stay (weighted mean difference WMD = −0.93 days −1.27; −0.58, p = 0.002). Sensitivity analyses, tests for small study bias, and heterogeneity assessment further confirmed the main analysis. Conclusions: This meta-analysis provides evidence that fenoldopam may confer significant benefits in preventing renal replacement therapy and reducing mortality in patients undergoing cardiovascular surgery.
Background Drug-eluting stents (DESs) introduction has somewhat renewed the issues of strategy and stenting technique for treatment of bifurcation lesions. In particular, concerns remain on extensive ...use of DESs, especially in the side branch, and on time of dual antiplatelet therapy (DAT) discontinuation, reflecting lack of pertinent long-term data. This study aimed to evaluate clinical safety and efficacy of different strategies for bifurcations treatment in a large observational real-world registry. Methods A multicenter, retrospective Italian study of consecutive patients undergoing bifurcation percutaneous coronary intervention between January 2002 and December 2006 was performed. The primary end point was the long-term rate of major adverse cardiac events (MACEs). The role of DAT length on outcome was also analyzed. Results A total of 4,314 patients (4,487 lesions) were enrolled at 22 independent centers. In-hospital procedural success rate was 98.7%. After median follow-up of 24 months, MACEs occurred in 17.7%, with cardiac death in 3.4%, myocardial infarction in 4.0%, target lesion revascularization in 13.2%, and stent thrombosis in 2.9%. Extensive multivariable analysis showed that MACEs were independently predicted by age, diabetes, renal failure, systolic dysfunction, multivessel disease, myocardial infarction at admission, restenotic lesion, bare-metal stent implantation, complex stenting strategy, and short duration of DAT. Conclusions This large study based on current clinical practice in an unselected patient population presenting with bifurcation disease and submitted to percutaneous coronary intervention demonstrated favorable long-term clinical results in this challenging patient setting, especially when DESs, simple stenting strategy, and DAT for at least 6 months are used.
Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment ...for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio OR 0.722, 95% confidence interval CI 0.357 to 1.461, p = 0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p = 0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p = 0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p = 0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p = 0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p = 0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p <0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.
Abstract Objectives This study aimed to investigate the cutoff of post–drug-eluting stent (DES) fractional flow reserve (FFR) for prediction of 1- to 3-year target vessel failure (TVF). Background ...FFR immediately after a DES implantation correlates with clinical events. However, the cutoff of post-DES FFR for predicting long-term clinical events remains understudied. Methods Between May 2012 and September 2013, a total of 1,476 patients who had FFR <0.8 at maximal and at baseline underwent DES implantation were prospectively studied in 9 centers. Post-DES FFR was repeat measured. The primary endpoint was the 1-year TVF rate after procedures. Receiver-operating characteristic curves were used to calculate the post-DES FFR value for TVF, then patients were classified on the basis of this value and followed up for 3 years. Results By the end of the first year, 88 (6.0%) TVFs were recorded. A post-DES FFR ≤0.88 strongly correlated with TVF. Disease in the left anterior descending coronary artery (LAD), stent length, and stent diameter were independent factors of impaired post-DES FFR, whereas post-procedure FFR ≤0.88 was the only predictor of TVF, with 40 (4.0%) TVFs in the FFR >0.88 and 48 (8.0%) in the FFR ≤0.88 group (p = 0.001), mainly driven by target vessel revascularization (3.8% vs. 8.8%; p = 0.005) and cardiac death (0.2% vs. 1.3%; p = 0.017). The difference in TVF between 2 groups was maintained through 3-year follow-up (p = 0.002). For patients with LAD lesions, a post-DES FFR ≤0.905 predicted 1-year TVF. Conclusions Post-DES FFR strongly correlated with TVF rate. Mechanisms attributed to and treatments for impaired FFR after stenting should be studied in future studies. (Post-DES FFR Predicts the Clinical Outcomes: DK CRUSH-VII, A Prospective, Multicenter, Registry Study DK CRUSH-VII; ChiCTR-PRCH-12001976 )
Objective The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing ...cardiac surgery under general anesthesia. Design Meta-analysis. Setting Hospitals. Participants A total of 2366 patients from 33 randomized trials. Interventions None. Measurements and Main Results Data sources and study selection: PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 2.7% in the epidural group v 64/1241 5.2% in the control arm, odds ratio OR = 0.61 0.40-0.95, p = 0.03 number needed to treat NNT = 40), the risk of acute renal failure (35/590 5.9% in the epidural group v 54/618 8.7% in the control arm, OR = 0.56 0.34-0.93, p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = −2.48 hours −2.64, −2.32, p < 0.001). Conclusions This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint of mortality and myocardial infarction in patients undergoing cardiac surgery.
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