Minority of CHD patients do recommended exercise
29 February 2008
Study findings reveal that patients with coronary heart disease often do not comply with physical activity recommendations, and are less likely to do so than individuals without CHD.
Information, reassurance, and support aid post-CABG recovery
29 February 2008
The results of a small, qualitative UK survey show that patients undergoing coronary bypass grafting surgery who may feel anxious or depressed about their recovery can be helped if they remain optimistic and are given information, reassurance, and support from the healthcare team and their social network.
Persistent hyperglycemia in AMI predicts in-hospital mortality
29 February 2008
Persistent hyperglycemia determined by multiple glucose assessments during hospitalization for acute myocardial infarction better predicts mortality than hyperglycemia on admission, research shows.
Showing posts with label CABG. Show all posts
Showing posts with label CABG. Show all posts
Saturday, March 1, 2008
Thursday, January 24, 2008
Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
New England Journal of Medicine, January 24, 2008.
Edward L. Hannan, Ph.D., Chuntao Wu, M.D., Ph.D., Gary Walford, M.D., Alfred T. Culliford, M.D., Jeffrey P. Gold, M.D., Craig R. Smith, M.D., Robert S.D. Higgins, M.D., Russell E. Carlson, M.D., and Robert H. Jones, M.D.
ABSTRACT
Background Numerous studies have compared the outcomes of two competing interventions for multivessel coronary artery disease: coronary-artery bypass grafting (CABG) and coronary stenting. However, little information has become available since the introduction of drug-eluting stents.
Methods We identified patients with multivessel disease who received drug-eluting stents or underwent CABG in New York State between October 1, 2003, and December 31, 2004, and we compared adverse outcomes (death, death or myocardial infarction, or repeat revascularization) through December 31, 2005, after adjustment for differences in baseline risk factors among the patients.
Results In comparison with treatment with a drug-eluting stent, CABG was associated with lower 18-month rates of death and of death or myocardial infarction both for patients with three-vessel disease and for patients with two-vessel disease. Among patients with three-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.80 (95% confidence interval [CI], 0.65 to 0.97) and the adjusted survival rate was 94.0% versus 92.7% (P=0.03); the adjusted hazard ratio for death or myocardial infarction was 0.75 (95% CI, 0.63 to 0.89) and the adjusted rate of survival free from myocardial infarction was 92.1% versus 89.7% (P<0.001). Among patients with two-vessel disease who underwent CABG, as compared with those who received a stent, the adjusted hazard ratio for death was 0.71 (95% CI, 0.57 to 0.89) and the adjusted survival rate was 96.0% versus 94.6% (P=0.003); the adjusted hazard ratio for death or myocardial infarction was 0.71 (95% CI, 0.59 to 0.87) and the adjusted rate of survival free from myocardial infarction was 94.5% versus 92.5% (P<0.001). Patients undergoing CABG also had lower rates of repeat revascularization.
Conclusions For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization.
Tuesday, December 11, 2007
Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?
Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?
Raymond J. Gibbons, MD; George D. Lundberg, MD
Medscape General Medicine. 2007;9(4):49. ©2007 Medscape
Posted 12/05/2007
Dr. Lundberg: It was a forerunner of a lot of good things. Let's talk about cardiology, and let's talk about angina pectoris: stable, unstable. Stable is more common?
Dr. Gibbons: Stable is much more common, and I think it's of more current interest. Our management of stable angina has obviously consisted of medications. But we knew from randomized trials in bypass surgery conducted 20 years ago that certain patients with very severe problems, particularly left main disease and 3-vessel disease with prior abnormal ventricular function, benefited from surgery from the standpoint of survival. As percutaneous coronary intervention [PCI] came along, we thought that patients who had less severe coronary artery disease probably would benefit, from the standpoint of survival and myocardial infarction, from PCI.
Dr. Lundberg: That's sensible.
Dr. Gibbons: And that was incorporated into national guidelines. This year, however, there have been 2 studies that have been published, OAT and COURAGE, that have both challenged that assumption. I think the study that is most pertinent to chronic stable angina is COURAGE. In a large trial conducted in the VA [Veterans Administration], certain other academic medical centers in the United States, including my own, and Canada, the investigators showed that with optimal medical therapy.
Dr. Lundberg: Okay. What do you call that? What is optimal medical therapy?
Dr. Gibbons: Well, previous trials had focused on just relieving angina. That trial had a different comprehensive approach: risk factor reduction. They just didn't treat angina, they also treated the risk factors very aggressively, and did very well even after 5 years at meeting targets for LDL [low density lipoprotein], for blood pressure, getting patients to stop smoking, getting them to exercise. And compared to optimal therapy, optimal therapy plus PCI did not convey an advantage with respect to heart attack or death. That was news, challenging the assumption that we had all along. It has led to a decrease, already, in the use of stents in the country. And I think it poses a challenge for practicing physicians to do as well with medical therapy in treating risk factors and symptoms, as occurred in the trial.
Dr. Lundberg: And of course, one of the things they have to do is handle patient compliance in terms of long-term use of whatever they're supposed to do.
Dr. Gibbons: I think they need to be very clear on educating the patient about the importance of, not just treatment for their chest pain, but treatment for the plaque and underlying coronary artery disease to prevent events. The patients have to understand the importance of taking aspirin, the importance of lowering their cholesterol to appropriate targets -- ideally an LDL of less than 100 -- and also not to smoke.
Dr. Lundberg: Of course, we live in a society with a medical-industrial complex with huge amounts of money that flow through the system into lots of people's pockets. If you're going to do surgery, or if you're going to do percutaneous stent implants, etc, it probably accrues a lot more money to people who are doing it, and it costs the insurance companies and the government a lot more to do that. So, there must be a tension developing there.
Dr. Gibbons: There's a clear tension, and I think there is an undercurrent of concern raised about the trial. For example, there's a tendency to point out there was a modest difference in pain relief, but it was modest. It was less than 10% of the patients had more complete pain relief by PCI at a year, and that [number] diminished over subsequent management of the patients. And a very comprehensive quality-of-life cost-effectiveness analysis presented here at the American Heart Association meeting this year by Dr. Weintraub, an expert in cost-effectiveness, showed that no matter what assumption you made, the effect on quality of life was minimal and very cost-ineffective.
Dr. Lundberg: So, for a stable angina at this time, optimal medical therapy is the best way to go?
Dr. Gibbons: It's clearly the best way to go. The challenge for all of us in the healthcare system is to do the best job we can of getting patients to comply with guideline-indicated medications.
Dr. Lundberg: There you are. Thank you all for being with us today. We've been talking with Dr. Raymond Gibbons, professor of medicine at the Mayo Clinic College of Medicine and a former president of the American Heart Association. Thank you for being with us. And thank you for being with us.
Reader Comments on: Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?See reader comments on this article and provide your own.
Readers are encouraged to respond to the author at gibbons.raymond@mayo.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu
Raymond J. Gibbons, MD, Arthur M. and Gladys D. Gray Professor of Medicine, Mayo Clinic, Rochester, MinnesotaGeorge D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine; Adjunct Professor of Health Policy, Harvard School of Public Health, Boston, Massachusetts; Consulting Professor, Stanford University School of Medicine, Stanford, CaliforniaAuthor's email: gibbons.raymond@mayo.edu
Raymond J. Gibbons, MD; George D. Lundberg, MD
Medscape General Medicine. 2007;9(4):49. ©2007 Medscape
Posted 12/05/2007
Dr. Lundberg: It was a forerunner of a lot of good things. Let's talk about cardiology, and let's talk about angina pectoris: stable, unstable. Stable is more common?
Dr. Gibbons: Stable is much more common, and I think it's of more current interest. Our management of stable angina has obviously consisted of medications. But we knew from randomized trials in bypass surgery conducted 20 years ago that certain patients with very severe problems, particularly left main disease and 3-vessel disease with prior abnormal ventricular function, benefited from surgery from the standpoint of survival. As percutaneous coronary intervention [PCI] came along, we thought that patients who had less severe coronary artery disease probably would benefit, from the standpoint of survival and myocardial infarction, from PCI.
Dr. Lundberg: That's sensible.
Dr. Gibbons: And that was incorporated into national guidelines. This year, however, there have been 2 studies that have been published, OAT and COURAGE, that have both challenged that assumption. I think the study that is most pertinent to chronic stable angina is COURAGE. In a large trial conducted in the VA [Veterans Administration], certain other academic medical centers in the United States, including my own, and Canada, the investigators showed that with optimal medical therapy.
Dr. Lundberg: Okay. What do you call that? What is optimal medical therapy?
Dr. Gibbons: Well, previous trials had focused on just relieving angina. That trial had a different comprehensive approach: risk factor reduction. They just didn't treat angina, they also treated the risk factors very aggressively, and did very well even after 5 years at meeting targets for LDL [low density lipoprotein], for blood pressure, getting patients to stop smoking, getting them to exercise. And compared to optimal therapy, optimal therapy plus PCI did not convey an advantage with respect to heart attack or death. That was news, challenging the assumption that we had all along. It has led to a decrease, already, in the use of stents in the country. And I think it poses a challenge for practicing physicians to do as well with medical therapy in treating risk factors and symptoms, as occurred in the trial.
Dr. Lundberg: And of course, one of the things they have to do is handle patient compliance in terms of long-term use of whatever they're supposed to do.
Dr. Gibbons: I think they need to be very clear on educating the patient about the importance of, not just treatment for their chest pain, but treatment for the plaque and underlying coronary artery disease to prevent events. The patients have to understand the importance of taking aspirin, the importance of lowering their cholesterol to appropriate targets -- ideally an LDL of less than 100 -- and also not to smoke.
Dr. Lundberg: Of course, we live in a society with a medical-industrial complex with huge amounts of money that flow through the system into lots of people's pockets. If you're going to do surgery, or if you're going to do percutaneous stent implants, etc, it probably accrues a lot more money to people who are doing it, and it costs the insurance companies and the government a lot more to do that. So, there must be a tension developing there.
Dr. Gibbons: There's a clear tension, and I think there is an undercurrent of concern raised about the trial. For example, there's a tendency to point out there was a modest difference in pain relief, but it was modest. It was less than 10% of the patients had more complete pain relief by PCI at a year, and that [number] diminished over subsequent management of the patients. And a very comprehensive quality-of-life cost-effectiveness analysis presented here at the American Heart Association meeting this year by Dr. Weintraub, an expert in cost-effectiveness, showed that no matter what assumption you made, the effect on quality of life was minimal and very cost-ineffective.
Dr. Lundberg: So, for a stable angina at this time, optimal medical therapy is the best way to go?
Dr. Gibbons: It's clearly the best way to go. The challenge for all of us in the healthcare system is to do the best job we can of getting patients to comply with guideline-indicated medications.
Dr. Lundberg: There you are. Thank you all for being with us today. We've been talking with Dr. Raymond Gibbons, professor of medicine at the Mayo Clinic College of Medicine and a former president of the American Heart Association. Thank you for being with us. And thank you for being with us.
Reader Comments on: Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?See reader comments on this article and provide your own.
Readers are encouraged to respond to the author at gibbons.raymond@mayo.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu
Raymond J. Gibbons, MD, Arthur M. and Gladys D. Gray Professor of Medicine, Mayo Clinic, Rochester, MinnesotaGeorge D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine; Adjunct Professor of Health Policy, Harvard School of Public Health, Boston, Massachusetts; Consulting Professor, Stanford University School of Medicine, Stanford, CaliforniaAuthor's email: gibbons.raymond@mayo.edu
Friday, December 7, 2007
Comparison of bypass surgery with drug‐eluting stents for diabetic patients with multivessel disease
Comparison of bypass surgery with drug‐eluting stents for diabetic patients with multivessel disease
International Journal of Cardiology
Volume 123, Issue 1, Pages 34-42 (15 December 2007)
Michael S. Leea, Faizi Jamalb, Gautam Kediab, Gilbert Changb, Nikhil Kapoorb, James Forresterb, Lawrence Czerb, Raymond Zimmera, Michele DeRobertisb, Alfredo Trentob, Raj R. Makkarb
Abstract
Background
This retrospective study of prospectively collected data compared coronary artery bypass graft (CABG) surgery to drug‐eluting stenting (DES) in diabetic patients with multivessel coronary artery disease (CAD). Prior randomized trials and clinical studies have suggested that CABG may be the preferred revascularization strategy in diabetic patients with multivessel CAD. Data are limited regarding the impact of DES vs. CABG on clinical outcomes.
Methods
We included 205 consecutive diabetic patients who underwent either CABG (n=103) or DES (n=102). The primary clinical end points were freedom from major adverse cardiac events (MACE) at 30 days and 1 year.
Results
Baseline characteristics were similar between both groups. At 1 year, the mortality rate was similar in the CABG and DES group (8% vs. 10%, p=0.6) but the MACE rate was lower in the CABG group (12% vs. 27%, p=0.006) due to less repeat revascularization with CABG (3% vs. 20%, p<0.001). Stroke occurred only in the CABG group (4% vs. 0%, p=0.04). Angiographically‐documented stent thrombosis after DES occurred in 3%. Presentation with acute myocardial infarction (hazard ratio [HR], 2.26, 95% CI, 1.13 to 4.55) and DES (HR, 2.4, 95% CI, 1.23 to 4.77) were positive independent predictors, whereas therapy with a statin was a negative independent predictor of MACE (HR, 0.40, 95% CI, 0.21 to 0.76).
Conclusions
Bypass surgery was associated with less MACE primarily due to the higher repeat revascularization rate with DES and is therefore superior to DES despite more extensive CAD in CABG patients.
International Journal of Cardiology
Volume 123, Issue 1, Pages 34-42 (15 December 2007)
Michael S. Leea, Faizi Jamalb, Gautam Kediab, Gilbert Changb, Nikhil Kapoorb, James Forresterb, Lawrence Czerb, Raymond Zimmera, Michele DeRobertisb, Alfredo Trentob, Raj R. Makkarb
Abstract
Background
This retrospective study of prospectively collected data compared coronary artery bypass graft (CABG) surgery to drug‐eluting stenting (DES) in diabetic patients with multivessel coronary artery disease (CAD). Prior randomized trials and clinical studies have suggested that CABG may be the preferred revascularization strategy in diabetic patients with multivessel CAD. Data are limited regarding the impact of DES vs. CABG on clinical outcomes.
Methods
We included 205 consecutive diabetic patients who underwent either CABG (n=103) or DES (n=102). The primary clinical end points were freedom from major adverse cardiac events (MACE) at 30 days and 1 year.
Results
Baseline characteristics were similar between both groups. At 1 year, the mortality rate was similar in the CABG and DES group (8% vs. 10%, p=0.6) but the MACE rate was lower in the CABG group (12% vs. 27%, p=0.006) due to less repeat revascularization with CABG (3% vs. 20%, p<0.001). Stroke occurred only in the CABG group (4% vs. 0%, p=0.04). Angiographically‐documented stent thrombosis after DES occurred in 3%. Presentation with acute myocardial infarction (hazard ratio [HR], 2.26, 95% CI, 1.13 to 4.55) and DES (HR, 2.4, 95% CI, 1.23 to 4.77) were positive independent predictors, whereas therapy with a statin was a negative independent predictor of MACE (HR, 0.40, 95% CI, 0.21 to 0.76).
Conclusions
Bypass surgery was associated with less MACE primarily due to the higher repeat revascularization rate with DES and is therefore superior to DES despite more extensive CAD in CABG patients.
Friday, November 16, 2007
Angioplasty vs. Bypass Surgery
Surgery for Heart Disease: Angioplasty vs. Bypass Surgery
Johns Hopkins Health Alerts: Heart Health
Johns Hopkins experts discuss these two life-saving procedures and reviews the advantages and risks of each.
The pain of angina, usually experienced in the chest, is caused by a shortage of blood and oxygen to the heart muscle due to partial blockage of a coronary artery. The two goals in treating angina symptoms are to decrease the heart’s demand for oxygen and to increase its blood supply.
Several types of drugs can often help control angina pain. But when medication is not successful, revascularization—bypass surgery or angioplasty—may be necessary.
Since neither bypass surgery or angioplasty is a cure for atherosclerosis, it is essential to continue dietary and other preventive lifestyle measures and, in many cases, to take lipid-lowering drugs, blood pressure-lowering drugs, and aspirin after undergoing one of these procedures.
Angioplasty and Bypass Surgery -- Two Techniques to Improve Blood FlowEach year more than 300,000 people in the United States undergo coronary artery bypass graft surgery (often called CABG or, simply, bypass surgery). During bypass surgery, a blood vessel from elsewhere in the body is used to reroute blood around a segment of a coronary artery narrowed by atherosclerosis. When needed, five or more bypass grafts can be performed during a single bypass surgery.
About 90%of people who undergo bypass surgery experience relief of angina symptoms after the procedure. Bypass surgery is extremely successful, even for people with extensive heart disease or who are elderly. But bypass surgery is arduous for patients, requiring general anesthesia and four to six days of hospitalization. And bypass surgery is usually performed with the help of a heart-lung machine that maintains blood circulation while the heart is stopped.
About 640,000 Americans a year undergo percutaneous transluminal coronary angioplasty (often called PTCA or, simply, angioplasty). Angioplasty involves inserting a balloon-tipped catheter into an artery; the balloon is guided to the diseased section of the coronary artery and inflated to break up and compress artery-clogging plaque.
Conventional angioplasty does not remove atherosclerotic plaque from the coronary arteries but instead widens the channel (lumen) through which blood flows by squeezing the plaque against the artery wall, cracking the hard part of the plaque, and/or stretching the artery.
About 90% of people notice an immediate improvement in symptoms when the artery lumen is at least 50% open after angioplasty. In about 85% of cases, a small, scaffold-like device called a stent is permanently placed in the artery during angioplasty to help keep the artery open. This helps reduce the rate of restenosis (further narrowing of the artery) to 10% to 20% (compared to 20% to 40% without a stent).
Angioplasty is performed in a cardiac catheterization laboratory and generally takes about one to two hours. Angioplasty does not require general anesthesia and usually involves no more than a night’s stay in the hospital. The risks associated with angioplasty are low.
Factors To Weigh in Choosing Angioplasty or Bypass SurgeryAngioplasty has several advantages over bypass surgery. Angioplasty is a relatively simple procedure, there is no need for general anesthesia, and the rigors of open heart surgery are avoided.
A major disadvantage of angioplasty is restenosis in the first six months after the procedure. People who undergo angioplasty must accept the risk that a repeat angioplasty or, ultimately, bypass surgery may become necessary.
Recurring angina is another consideration. These risks are considerably decreased with the implantation of a stent. Another disadvantage to angioplasty is that many people with coronary heart disease are not suitable candidates for angioplasty.
Bypass surgery may keep arteries open longer and improve blood flow through the coronary arteries more than angioplasty. Bypass surgery generally provides good relief of angina for at least five years.
In addition, bypass surgery is generally favored over angioplasty in people with one or more of the following:
· Disease in the left main coronary artery. This vessel is the main artery supplying blood to the heart, and even a brief period of blockage could damage heart muscle or be fatal.
· Diffuse coronary heart disease. Angioplasty is not effective for the treatment of multiple blockages in several vessels.
· Blockages at an arterial branch. If the blockage is at a point where one artery meets another, angioplasty may move the plaque into the adjacent artery, causing a new blockage.
· Diabetes. In the Bypass Angioplasty Revascularization Investigation (BARI) study, seven-year survival for people with diabetes was significantly better in those who underwent bypass surgery (76%) than angioplasty (56%). However, this study was conducted before traditional and drug-coated stents were available, and if the study were repeated today the results may be different.
Other factors. Other factors that make bypass surgery a better choice than angioplasty include severe disease of the three major coronary arteries (especially in people with reduced left ventricular function) and a history of heart failure.
Two drawbacks to bypass surgery are longer hospital stays and rehabilitation time than with angioplasty. In addition, a recent study of 261 bypass surgery patients found that about 40% of them had a decline in cognitive function that persisted five years after surgery. It is possible, however, that this decline was caused by underlying vascular disease in these patients and not the bypass surgery itself.
Johns Hopkins Health Alerts: Heart Health
Johns Hopkins experts discuss these two life-saving procedures and reviews the advantages and risks of each.
The pain of angina, usually experienced in the chest, is caused by a shortage of blood and oxygen to the heart muscle due to partial blockage of a coronary artery. The two goals in treating angina symptoms are to decrease the heart’s demand for oxygen and to increase its blood supply.
Several types of drugs can often help control angina pain. But when medication is not successful, revascularization—bypass surgery or angioplasty—may be necessary.
Since neither bypass surgery or angioplasty is a cure for atherosclerosis, it is essential to continue dietary and other preventive lifestyle measures and, in many cases, to take lipid-lowering drugs, blood pressure-lowering drugs, and aspirin after undergoing one of these procedures.
Angioplasty and Bypass Surgery -- Two Techniques to Improve Blood FlowEach year more than 300,000 people in the United States undergo coronary artery bypass graft surgery (often called CABG or, simply, bypass surgery). During bypass surgery, a blood vessel from elsewhere in the body is used to reroute blood around a segment of a coronary artery narrowed by atherosclerosis. When needed, five or more bypass grafts can be performed during a single bypass surgery.
About 90%of people who undergo bypass surgery experience relief of angina symptoms after the procedure. Bypass surgery is extremely successful, even for people with extensive heart disease or who are elderly. But bypass surgery is arduous for patients, requiring general anesthesia and four to six days of hospitalization. And bypass surgery is usually performed with the help of a heart-lung machine that maintains blood circulation while the heart is stopped.
About 640,000 Americans a year undergo percutaneous transluminal coronary angioplasty (often called PTCA or, simply, angioplasty). Angioplasty involves inserting a balloon-tipped catheter into an artery; the balloon is guided to the diseased section of the coronary artery and inflated to break up and compress artery-clogging plaque.
Conventional angioplasty does not remove atherosclerotic plaque from the coronary arteries but instead widens the channel (lumen) through which blood flows by squeezing the plaque against the artery wall, cracking the hard part of the plaque, and/or stretching the artery.
About 90% of people notice an immediate improvement in symptoms when the artery lumen is at least 50% open after angioplasty. In about 85% of cases, a small, scaffold-like device called a stent is permanently placed in the artery during angioplasty to help keep the artery open. This helps reduce the rate of restenosis (further narrowing of the artery) to 10% to 20% (compared to 20% to 40% without a stent).
Angioplasty is performed in a cardiac catheterization laboratory and generally takes about one to two hours. Angioplasty does not require general anesthesia and usually involves no more than a night’s stay in the hospital. The risks associated with angioplasty are low.
Factors To Weigh in Choosing Angioplasty or Bypass SurgeryAngioplasty has several advantages over bypass surgery. Angioplasty is a relatively simple procedure, there is no need for general anesthesia, and the rigors of open heart surgery are avoided.
A major disadvantage of angioplasty is restenosis in the first six months after the procedure. People who undergo angioplasty must accept the risk that a repeat angioplasty or, ultimately, bypass surgery may become necessary.
Recurring angina is another consideration. These risks are considerably decreased with the implantation of a stent. Another disadvantage to angioplasty is that many people with coronary heart disease are not suitable candidates for angioplasty.
Bypass surgery may keep arteries open longer and improve blood flow through the coronary arteries more than angioplasty. Bypass surgery generally provides good relief of angina for at least five years.
In addition, bypass surgery is generally favored over angioplasty in people with one or more of the following:
· Disease in the left main coronary artery. This vessel is the main artery supplying blood to the heart, and even a brief period of blockage could damage heart muscle or be fatal.
· Diffuse coronary heart disease. Angioplasty is not effective for the treatment of multiple blockages in several vessels.
· Blockages at an arterial branch. If the blockage is at a point where one artery meets another, angioplasty may move the plaque into the adjacent artery, causing a new blockage.
· Diabetes. In the Bypass Angioplasty Revascularization Investigation (BARI) study, seven-year survival for people with diabetes was significantly better in those who underwent bypass surgery (76%) than angioplasty (56%). However, this study was conducted before traditional and drug-coated stents were available, and if the study were repeated today the results may be different.
Other factors. Other factors that make bypass surgery a better choice than angioplasty include severe disease of the three major coronary arteries (especially in people with reduced left ventricular function) and a history of heart failure.
Two drawbacks to bypass surgery are longer hospital stays and rehabilitation time than with angioplasty. In addition, a recent study of 261 bypass surgery patients found that about 40% of them had a decline in cognitive function that persisted five years after surgery. It is possible, however, that this decline was caused by underlying vascular disease in these patients and not the bypass surgery itself.
Wednesday, November 7, 2007
Efficacy of CABG vs. Percutaneous Coronary Intervention
Efficacy of CABG vs. Percutaneous Coronary Intervention
CABG increases rates of relief of angina (NNT 12 at 1 year, NNT 20 at 5 years) and decreases rates of repeat revascularization (NNT 5 at 1 year, NNT 3 at 5 years) compared to percutaneous coronary intervention (PCI), but no difference in overall survival (level 1 [likely reliable] evidence), based on a systematic review of 23 randomized trials in 9,963 patients. CABG increased 30-day risk of stroke (NNH 167). PCI included balloon angioplasty or stents in most trials; only 1 small trial used drug-eluting stents
(Ann Intern Med 2007 Nov 20;147(10):early online full-text, AHRQ Comparative Effectiveness Review 2007 Oct:9 PDF).
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV, Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA.
the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
20 November 2007 Volume 147 Issue 10
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
Editors' Notes
Context
The relative benefits and harms of coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI) are sometimes unclear.
Contribution
This systematic review of 23 randomized trials found that survival at 10 years was similar for CABG and PCI, even among diabetic patients. Procedural strokes and angina relief were more common after CABG (risk difference, 0.6% and about 5% to 8%, respectively), whereas repeated revascularization procedures were more common after PCI (risk difference, 24% at 1 year).
Caution
Only 1 small trial used drug-eluting stents, and Few patients with extensive coronary disease or poor ventricular function were enrolled.
CABG increases rates of relief of angina (NNT 12 at 1 year, NNT 20 at 5 years) and decreases rates of repeat revascularization (NNT 5 at 1 year, NNT 3 at 5 years) compared to percutaneous coronary intervention (PCI), but no difference in overall survival (level 1 [likely reliable] evidence), based on a systematic review of 23 randomized trials in 9,963 patients. CABG increased 30-day risk of stroke (NNH 167). PCI included balloon angioplasty or stents in most trials; only 1 small trial used drug-eluting stents
(Ann Intern Med 2007 Nov 20;147(10):early online full-text, AHRQ Comparative Effectiveness Review 2007 Oct:9 PDF).
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV, Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA.
the Center for Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
20 November 2007 Volume 147 Issue 10
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
Editors' Notes
Context
The relative benefits and harms of coronary artery bypass surgery (CABG) versus percutaneous coronary intervention (PCI) are sometimes unclear.
Contribution
This systematic review of 23 randomized trials found that survival at 10 years was similar for CABG and PCI, even among diabetic patients. Procedural strokes and angina relief were more common after CABG (risk difference, 0.6% and about 5% to 8%, respectively), whereas repeated revascularization procedures were more common after PCI (risk difference, 24% at 1 year).
Caution
Only 1 small trial used drug-eluting stents, and Few patients with extensive coronary disease or poor ventricular function were enrolled.
Monday, October 15, 2007
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery
Annals of Internal Medicine
20 November 2007 Volume 147 Issue 10
Dena M. Bravata, MD, MS; Allison L. Gienger, BA; Kathryn M. McDonald, MM; Vandana Sundaram, MPH; Marco V. Perez, MD; Robin Varghese, MD, MS; John R. Kapoor, MD, PhD; Reza Ardehali, MD, PhD; Douglas K. Owens, MD, MS; and Mark A. Hlatky, MD
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures
Annals of Internal Medicine
20 November 2007 Volume 147 Issue 10
Dena M. Bravata, MD, MS; Allison L. Gienger, BA; Kathryn M. McDonald, MM; Vandana Sundaram, MPH; Marco V. Perez, MD; Robin Varghese, MD, MS; John R. Kapoor, MD, PhD; Reza Ardehali, MD, PhD; Douglas K. Owens, MD, MS; and Mark A. Hlatky, MD
Background: The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood.
Purpose: To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated.
Data Sources: MEDLINE, EMBASE, and Cochrane databases (1966–2006); conference proceedings; and bibliographies of retrieved articles.
Study Selection: Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
Data Extraction: Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
Data Synthesis: We identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedural strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG–PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
Limitations: The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
Conclusion: Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures
Sunday, October 7, 2007
Coronary artery bypass graft vs. percutaneous coronary angioplasty: CABG on the rebound?.
Coronary artery bypass graft vs. percutaneous coronary angioplasty: CABG on the rebound?.
Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, UK
Current Opinion in Cardiology. 22(6):517-523, November 2007.
Taggart, David P
Purpose of review: To examine the benefits of coronary artery bypass grafting (CABG) against percutaneous coronary intervention (PCI) and particularly the use of drug-eluting stents (DES) in situations where CABG has traditionally been considered the most effective therapy on clinical and economic grounds.
Recent findings: Current studies reconfirm that CABG is still the best therapy in terms of improved survival and freedom from reintervention for most patients with proximal left anterior descending, multivessel and left main-stem coronary artery disease (CAD) and that these benefits are even greater in diabetic patients. Health economic analyses also confirm the cost-effectiveness of medical therapy and CABG but not PCI. Furthermore, several meta-analyses have shown that DES do not improve survival or freedom from myocardial infarction compared with bare metal stents, but increase the risk of stent thrombosis, with associated medical and financial implications for prolonged dual antiplatelet medication.
Summary: In view of the evidence in favour of CABG, this article questions the justifiability of some trials of PCI vs. CABG, especially in diabetic patients and those with left main-stem CAD, and exhorts the need for a multidisciplinary team approach to the management of CAD as a minimum standard of care.
Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, UK
Current Opinion in Cardiology. 22(6):517-523, November 2007.
Taggart, David P
Purpose of review: To examine the benefits of coronary artery bypass grafting (CABG) against percutaneous coronary intervention (PCI) and particularly the use of drug-eluting stents (DES) in situations where CABG has traditionally been considered the most effective therapy on clinical and economic grounds.
Recent findings: Current studies reconfirm that CABG is still the best therapy in terms of improved survival and freedom from reintervention for most patients with proximal left anterior descending, multivessel and left main-stem coronary artery disease (CAD) and that these benefits are even greater in diabetic patients. Health economic analyses also confirm the cost-effectiveness of medical therapy and CABG but not PCI. Furthermore, several meta-analyses have shown that DES do not improve survival or freedom from myocardial infarction compared with bare metal stents, but increase the risk of stent thrombosis, with associated medical and financial implications for prolonged dual antiplatelet medication.
Summary: In view of the evidence in favour of CABG, this article questions the justifiability of some trials of PCI vs. CABG, especially in diabetic patients and those with left main-stem CAD, and exhorts the need for a multidisciplinary team approach to the management of CAD as a minimum standard of care.
Monday, October 1, 2007
Dyssynchrony predicts poor prognosis after CABG
Severe Left Ventricular Dyssynchrony Is Associated With Poor Prognosis in Patients With Moderate Systolic Heart Failure Undergoing Coronary Artery Bypass Grafting
J Am Coll Cardiol, 2007; 50:1315-1323, doi:10.1016/j.jacc.2007.03.070 (Published online 14 September 2007
Reprint requests and correspondence: Dr. Martin Penicka, Cardiocenter, Department of Cardiology, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady in Prague, Srobarova 50, 10034 Prague, Czech Republic. (Email: penicka@fnkv.cz
Objectives: The objective of the present study was to assess the relationship between the presence of left ventricular (LV) dyssynchrony and clinical outcome in patients with moderate systolic heart failure undergoing coronary artery bypass graft (CABG) surgery.
Background: The presence of LV dyssynchrony is associated with poor prognosis in patients with LV dysfunction.
Methods: The study consisted of 215 consecutive patients with ischemic cardiomyopathy and dyspnea (age 65 ± 9 years, 81% male) undergoing CABG. Dyssynchrony was calculated by tissue Doppler imaging from regional time intervals in basal LV segments before and 1 month after CABG. Myocardial viability was assessed using single-photon emission computed tomography (SPECT) before CABG.
Results: Twenty-five patients (11.6%) died within 30 days (in-hospital mortality) of CABG. The presence of pre-CABG dyssynchrony 119 ms had the highest predictive accuracy for in-hospital mortality, with a sensitivity of 84% and a specificity of 71%. During the median follow-up period of 359 days (interquartile range 219 to 561), an additional 19 patients (10.3%) died and 34 patients (18.5%) were hospitalized for worsening heart failure. At Cox regression analysis, post-CABG dyssynchrony 72 ms and 5 viable segments were identified as independent predictors of clinical events, with a hazard ratio (HR) of 5.02, 95% confidence interval (CI) 2.57 to 10.02 (p < 0.001), and an HR of 0.63, 95% CI 0.55 to 0.75 (p < 0.001), respectively. Patients without post-CABG dyssynchrony and with viable myocardium had excellent prognosis compared with patients with severe post-CABG dyssynchrony and nonviable myocardium (event rate 3% vs. 64%; p < 0.001).
Conclusions: The presence of severe LV dyssynchrony is associated with poor clinical outcomes despite revascularization. These results advocate a routine assessment of both LV dyssynchrony and viability to predict outcome in systolic heart failure patients undergoing CABG surgery.
J Am Coll Cardiol, 2007; 50:1315-1323, doi:10.1016/j.jacc.2007.03.070 (Published online 14 September 2007
Reprint requests and correspondence: Dr. Martin Penicka, Cardiocenter, Department of Cardiology, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady in Prague, Srobarova 50, 10034 Prague, Czech Republic. (Email: penicka@fnkv.cz
Objectives: The objective of the present study was to assess the relationship between the presence of left ventricular (LV) dyssynchrony and clinical outcome in patients with moderate systolic heart failure undergoing coronary artery bypass graft (CABG) surgery.
Background: The presence of LV dyssynchrony is associated with poor prognosis in patients with LV dysfunction.
Methods: The study consisted of 215 consecutive patients with ischemic cardiomyopathy and dyspnea (age 65 ± 9 years, 81% male) undergoing CABG. Dyssynchrony was calculated by tissue Doppler imaging from regional time intervals in basal LV segments before and 1 month after CABG. Myocardial viability was assessed using single-photon emission computed tomography (SPECT) before CABG.
Results: Twenty-five patients (11.6%) died within 30 days (in-hospital mortality) of CABG. The presence of pre-CABG dyssynchrony 119 ms had the highest predictive accuracy for in-hospital mortality, with a sensitivity of 84% and a specificity of 71%. During the median follow-up period of 359 days (interquartile range 219 to 561), an additional 19 patients (10.3%) died and 34 patients (18.5%) were hospitalized for worsening heart failure. At Cox regression analysis, post-CABG dyssynchrony 72 ms and 5 viable segments were identified as independent predictors of clinical events, with a hazard ratio (HR) of 5.02, 95% confidence interval (CI) 2.57 to 10.02 (p < 0.001), and an HR of 0.63, 95% CI 0.55 to 0.75 (p < 0.001), respectively. Patients without post-CABG dyssynchrony and with viable myocardium had excellent prognosis compared with patients with severe post-CABG dyssynchrony and nonviable myocardium (event rate 3% vs. 64%; p < 0.001).
Conclusions: The presence of severe LV dyssynchrony is associated with poor clinical outcomes despite revascularization. These results advocate a routine assessment of both LV dyssynchrony and viability to predict outcome in systolic heart failure patients undergoing CABG surgery.
Wednesday, September 19, 2007
ESC Congress - News - 2007 - CORONARY REVASCULARIZATION
Burning questions in coronary revascularisation Symposium
In this interesting session the role of surgical revascularisation was discussed. The number of CABG procedures has considerably decreased in the last ten years, with a concomitant increase in PCI procedures.
Despite this trend, surgical revascularisation still plays an important role. Looking accurately in the results reported by the randomised trials comparing CABG versus PCI in multivessel disease, most of the enrolled patients have two vessel disease and normal ejection fraction. This selection bias eliminates or reduces the group of patients with triple vessel disease, left main stenosis or low ejection fraction, who benefit most from CABG.
On the basis of the data from the literature, surgical revascularisation still remains the treatment of choice for patients with triple vessel disease, left main stenosis and low ejection fraction.
The advantage of surgical revascularisation is more pronounced in patients treated by complete arterial revascularisation. The results reported in the literature for different type of grafts show that the use of bilateral internal mammary artery have an important impact on long term survival and freedom from reoperation.
The use of technical solutions like the Y graft offer the possibility to revascularise all the coronaries with the use of two mammary grafts, giving patients the best option for a durable operation. The role of complete versus incomplete myocardial revascularisation has been analysed, and data currently available are inconclusive on this topic. New data are necessary to answer to this question.
Finally an accurate analysis was done about the role of previous PCI on the results of patients treated by CABG. This revision of the literature clearly shows that patients previously treated by PCI have higher mortality and worse long term results after CABG. The reason of this finding is not clear but is probably related to the activation of an inflammatory process by the PCI procedure.
Friday, August 31, 2007
Angioplasties Increasing, Bypass Surgeries Decreasing
Angioplasties Increasing, Bypass Surgeries Decreasing
31 Aug 2007
Use of transluminal coronary angioplasty, or PTCA, a procedure for opening blocked arteries in patients with coronary artery disease, is now used nearly three times more often than the older and more invasive coronary artery bypass graft surgery (CABG), according to the latest News and Numbers from the Agency for Healthcare Research and Quality.
AHRQ found that:
The number of angioplasties nearly doubled from 1993 to 2005, rising steadily from 418,000 to 800,000 a year.
In contrast, heart bypass surgeries rose slowly from 344,000 to 426,000 a year between 1993 and 1997, and then declined steadily to 278,000 a year by 2005.
Although hospital stays in 2005 for angioplasty are much shorter than they were in 1993 (on average 2.7 days instead of 4.6 days), hospital charges have increased by more than 50 percent during the period, rising from $31,300 to $48,000 (adjusted for inflation).
With 1.1 million hospital stays in 2005, coronary artery disease was the third most common reason for hospitalization after childbirth and pneumonia.
It was the second leading reason for men, and the seventh for women.
http://www.ahrq,gov
31 Aug 2007
Use of transluminal coronary angioplasty, or PTCA, a procedure for opening blocked arteries in patients with coronary artery disease, is now used nearly three times more often than the older and more invasive coronary artery bypass graft surgery (CABG), according to the latest News and Numbers from the Agency for Healthcare Research and Quality.
AHRQ found that:
The number of angioplasties nearly doubled from 1993 to 2005, rising steadily from 418,000 to 800,000 a year.
In contrast, heart bypass surgeries rose slowly from 344,000 to 426,000 a year between 1993 and 1997, and then declined steadily to 278,000 a year by 2005.
Although hospital stays in 2005 for angioplasty are much shorter than they were in 1993 (on average 2.7 days instead of 4.6 days), hospital charges have increased by more than 50 percent during the period, rising from $31,300 to $48,000 (adjusted for inflation).
With 1.1 million hospital stays in 2005, coronary artery disease was the third most common reason for hospitalization after childbirth and pneumonia.
It was the second leading reason for men, and the seventh for women.
http://www.ahrq,gov
Tuesday, August 21, 2007
ECG parameters predict prognosis in CABG patients
Quantitative Measures of Electrocardiographic Left Ventricular Mass, Conduction, and Repolarization, and Long-Term Survival After Coronary Artery Bypass Grafting
Michael S. Lauer, MD; Derlis Martino, MD; Hemant Ishwaran, PhD; Eugene H. Blackstone, MD
From the Department of Cardiovascular Medicine (M.S.L.), the Department of Thoracic and Cardiovascular Surgery (D.M., H.I., E.H.B.), and the Department of Quantitative Health Sciences (H.I., E.H.B.), The Cleveland Clinic Foundation, and the Department of Epidemiology and Biostatistics (M.S.L.), Case Western Reserve University School of Medicine, Cleveland, Ohio.
Correspondence to Dr Michael S. Lauer, Division of Prevention and Population Science, National Heart, Lung, and Blood Institute, 6701 Rockledge Dr, Room 10122, Bethesda, Md 20892. E-mail lauer@nhlbi.nih.gov
Received April 12, 2006; accepted June 8, 2007.
Background— Quantitative ECG measures of left ventricular mass and repolarization predict outcome in population-based cohorts and patients with hypertension. We assessed the prognostic value of preoperative quantitative electrocardiography in patients who underwent isolated coronary artery bypass grafting.
Methods and Results— For 6 years we followed 8166 patients who underwent primary isolated coronary artery bypass grafting between 1990 and 2003, all of whom had routine preoperative ECGs. With use of specialized digital software, quantitative measures were recorded on ventricular rate, P duration, PR interval, QRS duration, QT interval, QRS axis, Sokolow-Lyon and Cornell voltages, and ST-segment depression and slope. There were 1516 deaths. After adjustment for age, gender, clinical characteristics, left ventricular ejection fraction, and other confounders, death was independently predicted by ventricular rate (adjusted hazard ratio [AHR] for 90 versus 60 beats per minute, 1.34; 95% confidence interval [CI], 1.21 to 1.50; P<.0001), PR interval (AHR for 200 versus 150 ms, 1.05; 95% CI, 1.00 to 1.10; P<.0001), QRS duration (AHR for 120 versus 80 ms, 1.24; 95% CI, 1.07 to 1.44; P<.0001), Sokolow-Lyon voltage (AHR for 3.5 versus 1.5 mV, 1.18; 95% CI, 1.05 to 1.31; P<.0001), and ST-segment slope (AHR for –0.1 versus 0 mV, 1.16; 95% CI, 1.02 to 1.31; P<.0001). We derived a quantitative ECG score and demonstrated that, with the exception of age, it was the most powerful predictor of long-term death.
Conclusions— Quantitative ECG measures of left ventricular rate, mass, and repolarization are predictive of mortality among patients who underwent isolated coronary artery bypass grafting. These findings suggest that quantitative electrocardiography may be valuable for risk stratification in patients with severe coronary artery disease.
Circulation 2007; 116: 888-893
Michael S. Lauer, MD; Derlis Martino, MD; Hemant Ishwaran, PhD; Eugene H. Blackstone, MD
From the Department of Cardiovascular Medicine (M.S.L.), the Department of Thoracic and Cardiovascular Surgery (D.M., H.I., E.H.B.), and the Department of Quantitative Health Sciences (H.I., E.H.B.), The Cleveland Clinic Foundation, and the Department of Epidemiology and Biostatistics (M.S.L.), Case Western Reserve University School of Medicine, Cleveland, Ohio.
Correspondence to Dr Michael S. Lauer, Division of Prevention and Population Science, National Heart, Lung, and Blood Institute, 6701 Rockledge Dr, Room 10122, Bethesda, Md 20892. E-mail lauer@nhlbi.nih.gov
Received April 12, 2006; accepted June 8, 2007.
Background— Quantitative ECG measures of left ventricular mass and repolarization predict outcome in population-based cohorts and patients with hypertension. We assessed the prognostic value of preoperative quantitative electrocardiography in patients who underwent isolated coronary artery bypass grafting.
Methods and Results— For 6 years we followed 8166 patients who underwent primary isolated coronary artery bypass grafting between 1990 and 2003, all of whom had routine preoperative ECGs. With use of specialized digital software, quantitative measures were recorded on ventricular rate, P duration, PR interval, QRS duration, QT interval, QRS axis, Sokolow-Lyon and Cornell voltages, and ST-segment depression and slope. There were 1516 deaths. After adjustment for age, gender, clinical characteristics, left ventricular ejection fraction, and other confounders, death was independently predicted by ventricular rate (adjusted hazard ratio [AHR] for 90 versus 60 beats per minute, 1.34; 95% confidence interval [CI], 1.21 to 1.50; P<.0001), PR interval (AHR for 200 versus 150 ms, 1.05; 95% CI, 1.00 to 1.10; P<.0001), QRS duration (AHR for 120 versus 80 ms, 1.24; 95% CI, 1.07 to 1.44; P<.0001), Sokolow-Lyon voltage (AHR for 3.5 versus 1.5 mV, 1.18; 95% CI, 1.05 to 1.31; P<.0001), and ST-segment slope (AHR for –0.1 versus 0 mV, 1.16; 95% CI, 1.02 to 1.31; P<.0001). We derived a quantitative ECG score and demonstrated that, with the exception of age, it was the most powerful predictor of long-term death.
Conclusions— Quantitative ECG measures of left ventricular rate, mass, and repolarization are predictive of mortality among patients who underwent isolated coronary artery bypass grafting. These findings suggest that quantitative electrocardiography may be valuable for risk stratification in patients with severe coronary artery disease.
Circulation 2007; 116: 888-893
Tuesday, June 5, 2007
Specialist care cuts heart deaths
Specialist care cuts heart deaths
Swift treatment to re-open the arteries at a specialist centre significantly increases the chances of surviving a heart attack, a study has found.
Doctors at Harefield Hospital found under 3% of patients treated with angioplasty at the specialist heart centre had died after 30 days.
But of those patients taken first to a general hospital before referral to the centre, more than 10% died.
The study was presented at a British Cardiovascular Society Conference.
This gives better long-term results - time is muscle Dr Miles Dalby
The British Heart Foundation estimates that 230,000 people in the UK have a heart attack each year, and that about 30% of these are fatal.
Dr Miles Dalby, a consultant cardiologist at Harefield Hospital, and colleagues looked at 180 patients who received direct primary angioplasty at their hospital.
Fast treatment
The patients were taken there directly by ambulance staff trained to identify patients who would benefit from the treatment.
Dr Dalby says patients at the hospital's heart attack centre receive treatment and have their blood flow restored within an average of 24 minutes after arrival.
They compared these with 181 patients who had received the treatment after being referred to the centre from a general hospital.
Cardiologists perform primary angioplasty to clear blockages in the heart's arteries - the artery is unblocked using a thin tube, then opened by inflating a small balloon, and held open with a metal tube, or stent.
In non-specialist centres treatment is often by thrombolysis drugs which dissolve the blood clots, but the study found in patients treated with thrombolysis in the preceding two years, around 9% died.
Dr Dalby said prompt treatment is vital for effective primary angioplasty, and that taking patients directly to heart attacks centres could reduce the number of deaths "significantly."
He said: "During a heart attack, blood flow to the heart muscle is blocked which damages it.
"The sooner the patient receives treatment enabling the blood flow to return to the coronary arteries, the less damage occurs.
"This gives better long-term results - time is muscle."
More detail needed
Dr Clive Weston, associate director of Royal College of Physician's Myocardial Infarction National Audit Project, which collects data on heart attack patients, said the results were "quite remarkable".
However he warned that in rural areas, where it make take some time to travel to a specialist centre, methods such as delivering thrombolytic treatments in ambulances could be more effective.
And he said the data needed to be explored in more detail to check there were no biases.
Thrombolysis is very effective if delivered soon after heart attack symptoms develop.
However, as time passes, angioplasty becomes the more effective treatment.
And Dr Weston said another benefit of primary angioplasty was that it allowed to doctors to see more of the coronary anatomy so they could see what had caused the heart attack and help prevent future attacks.
Judy O'Sullivan, cardiac nurse at the British Heart Foundation, said: "The study published by the Harefield team shows promising results for recent advances in the treatment of heart attacks at such specialist centres."
She said in the future angioplasty was likely to supercede thrombolysis as the treatment of choice for heart attacks,and added that patients' speed of response in dialling 999 could also affect their survival chances.
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/6719075.stm
Published: 2007/06/05 07:31:17 GMT
Swift treatment to re-open the arteries at a specialist centre significantly increases the chances of surviving a heart attack, a study has found.
Doctors at Harefield Hospital found under 3% of patients treated with angioplasty at the specialist heart centre had died after 30 days.
But of those patients taken first to a general hospital before referral to the centre, more than 10% died.
The study was presented at a British Cardiovascular Society Conference.
This gives better long-term results - time is muscle Dr Miles Dalby
The British Heart Foundation estimates that 230,000 people in the UK have a heart attack each year, and that about 30% of these are fatal.
Dr Miles Dalby, a consultant cardiologist at Harefield Hospital, and colleagues looked at 180 patients who received direct primary angioplasty at their hospital.
Fast treatment
The patients were taken there directly by ambulance staff trained to identify patients who would benefit from the treatment.
Dr Dalby says patients at the hospital's heart attack centre receive treatment and have their blood flow restored within an average of 24 minutes after arrival.
They compared these with 181 patients who had received the treatment after being referred to the centre from a general hospital.
Cardiologists perform primary angioplasty to clear blockages in the heart's arteries - the artery is unblocked using a thin tube, then opened by inflating a small balloon, and held open with a metal tube, or stent.
In non-specialist centres treatment is often by thrombolysis drugs which dissolve the blood clots, but the study found in patients treated with thrombolysis in the preceding two years, around 9% died.
Dr Dalby said prompt treatment is vital for effective primary angioplasty, and that taking patients directly to heart attacks centres could reduce the number of deaths "significantly."
He said: "During a heart attack, blood flow to the heart muscle is blocked which damages it.
"The sooner the patient receives treatment enabling the blood flow to return to the coronary arteries, the less damage occurs.
"This gives better long-term results - time is muscle."
More detail needed
Dr Clive Weston, associate director of Royal College of Physician's Myocardial Infarction National Audit Project, which collects data on heart attack patients, said the results were "quite remarkable".
However he warned that in rural areas, where it make take some time to travel to a specialist centre, methods such as delivering thrombolytic treatments in ambulances could be more effective.
And he said the data needed to be explored in more detail to check there were no biases.
Thrombolysis is very effective if delivered soon after heart attack symptoms develop.
However, as time passes, angioplasty becomes the more effective treatment.
And Dr Weston said another benefit of primary angioplasty was that it allowed to doctors to see more of the coronary anatomy so they could see what had caused the heart attack and help prevent future attacks.
Judy O'Sullivan, cardiac nurse at the British Heart Foundation, said: "The study published by the Harefield team shows promising results for recent advances in the treatment of heart attacks at such specialist centres."
She said in the future angioplasty was likely to supercede thrombolysis as the treatment of choice for heart attacks,and added that patients' speed of response in dialling 999 could also affect their survival chances.
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/6719075.stm
Published: 2007/06/05 07:31:17 GMT
Tuesday, April 24, 2007
Noncoronary vascular surgery in high-CV-risk patients: Add PCI or CABG?
Noncoronary vascular surgery in high-CV-risk patients: Add PCI or CABG?
April 20, 2007
Washington, DC - Perioperative PCI or CABG makes little clinical impact in high-cardiovascular-risk patients with ischemic heart disease who undergo major noncoronary vascular surgery, suggests a randomized but inconclusive study [1].
Designed to clarify feasibility and safety considerations for any future larger, definitive exploration of the strategy, the study wasn't statistically strong enough to show whether adding perioperative coronary revascularization makes a clinical difference, caution the authors, led by Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands).
But having set the stage for a larger trial, according to the group as well as an accompanying editorial [2], the pilot study raises questions about CV screening before noncardiac surgery and the clinical importance of any discovered coronary stenoses that would be targeted by perioperative revascularization as compared with, for example, vulnerable plaques that are angiographically invisible.
The trial's neutral findings may relate to histopathologic evidence "that the pathophysiology surrounding fatal MI in the perioperative period after noncardiac surgery often includes unstable plaque and plaque disruption," write the editorialists, Drs Mauro Moscucci and Noah Jones (University of Michigan, Ann Arbor). "Thus, it is possible that revascularization of stable coronary artery stenosis might not add significantly to the effect of optimal medical therapy, similar to what has been shown for other low-risk patients with stable coronary artery disease."
The findings from the fifth Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-5) pilot study and its accompanying editorial are published online April 13, 2007 by the Journal of the American College of Cardiology. They follow similar results from the Coronary Artery Revascularization Prophylaxis (CARP) trial, published in 2004 and reported by heartwire at the time, that compared the invasive and conservative perioperative strategies in a lower-risk CAD population [3].
Conducted in four European countries and Brazil over five years ending in 2005, DECREASE-5 randomized 101 patients with CAD who were scheduled for open abdominal aortic or infrainguinal arterial surgeries to receive either perioperative PCI or CABG (32 and 17 patients, respectively) or medical therapy (52 patients). Patients had been required to have at least three major cardiac risk factors (eg, angina, evidence of prior MI or neurologic events, heart failure, diabetes, or renal dysfunction) as well as stress-test-documented myocardial ischemia. Beta blockers were initiated for any patient not already on them.
In the PCI/CABG group, two patients died from ruptured aortic aneurysms prior to their noncoronary surgical procedures, "consistent with the fact that urgent or emergency vascular surgery in unstable patients should not be delayed by revascularization," Moscucci and Jones caution.
Rates of the primary end point, a 30-day composite of all-cause mortality and nonfatal MI, were 43% and 33%, respectively (p=0.30). Even out to one year, the rates were similar, at 49% and 44%, respectively (p=0.48). Incidences of the primary-end-point components did not differ between the groups. None in the medical-management group required coronary revascularization within a year of the noncoronary vascular surgery.
As none of the conservatively managed patients underwent diagnostic catheterization, yet their outcomes were similar to those managed with PCI or CABG, write the editorialists, "effective beta blockade and medical therapy might be sufficient, raising the question of whether stable patients scheduled for major vascular surgery should even be screened with stress testing."
However, they conclude, "the debate on screening and revascularization for patients with peripheral arterial disease and scheduled for major vascular surgery continues to be far from settled." DECREASE-5 provided safety and sample-size information needed for a larger exploration of the issue, they write. "It is now time to move forward with such a trial."
Moscucci reports receiving consulting fees from Pfizer and Boston Scientific, lecture fees from Pfizer, and grant support from Cordis
Sources
1. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V pilot study. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2006.11.052. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
2. Moscucci M, Jones N. Coronary revascularization before noncardiac vascular surgery: One more step forward in understanding its role. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2007.01.068 . Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
3. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Eng J Med 2004; 351:2795-2804.
Related links
Risk for death, stroke increased with combined CABG and CEA [Other News > Medscape Medical News; Jan 16, 2007]
Higher risk of stroke and death in patients undergoing combined CEA-CABG surgery vs CABG alone [HeartWire > Other News; Apr 25, 2005]
No benefit from revascularization before vascular surgery: CARP published [HeartWire > Other News; Dec 29, 2004]
April 20, 2007
Washington, DC - Perioperative PCI or CABG makes little clinical impact in high-cardiovascular-risk patients with ischemic heart disease who undergo major noncoronary vascular surgery, suggests a randomized but inconclusive study [1].
Designed to clarify feasibility and safety considerations for any future larger, definitive exploration of the strategy, the study wasn't statistically strong enough to show whether adding perioperative coronary revascularization makes a clinical difference, caution the authors, led by Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands).
But having set the stage for a larger trial, according to the group as well as an accompanying editorial [2], the pilot study raises questions about CV screening before noncardiac surgery and the clinical importance of any discovered coronary stenoses that would be targeted by perioperative revascularization as compared with, for example, vulnerable plaques that are angiographically invisible.
The trial's neutral findings may relate to histopathologic evidence "that the pathophysiology surrounding fatal MI in the perioperative period after noncardiac surgery often includes unstable plaque and plaque disruption," write the editorialists, Drs Mauro Moscucci and Noah Jones (University of Michigan, Ann Arbor). "Thus, it is possible that revascularization of stable coronary artery stenosis might not add significantly to the effect of optimal medical therapy, similar to what has been shown for other low-risk patients with stable coronary artery disease."
The findings from the fifth Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-5) pilot study and its accompanying editorial are published online April 13, 2007 by the Journal of the American College of Cardiology. They follow similar results from the Coronary Artery Revascularization Prophylaxis (CARP) trial, published in 2004 and reported by heartwire at the time, that compared the invasive and conservative perioperative strategies in a lower-risk CAD population [3].
Conducted in four European countries and Brazil over five years ending in 2005, DECREASE-5 randomized 101 patients with CAD who were scheduled for open abdominal aortic or infrainguinal arterial surgeries to receive either perioperative PCI or CABG (32 and 17 patients, respectively) or medical therapy (52 patients). Patients had been required to have at least three major cardiac risk factors (eg, angina, evidence of prior MI or neurologic events, heart failure, diabetes, or renal dysfunction) as well as stress-test-documented myocardial ischemia. Beta blockers were initiated for any patient not already on them.
In the PCI/CABG group, two patients died from ruptured aortic aneurysms prior to their noncoronary surgical procedures, "consistent with the fact that urgent or emergency vascular surgery in unstable patients should not be delayed by revascularization," Moscucci and Jones caution.
Rates of the primary end point, a 30-day composite of all-cause mortality and nonfatal MI, were 43% and 33%, respectively (p=0.30). Even out to one year, the rates were similar, at 49% and 44%, respectively (p=0.48). Incidences of the primary-end-point components did not differ between the groups. None in the medical-management group required coronary revascularization within a year of the noncoronary vascular surgery.
As none of the conservatively managed patients underwent diagnostic catheterization, yet their outcomes were similar to those managed with PCI or CABG, write the editorialists, "effective beta blockade and medical therapy might be sufficient, raising the question of whether stable patients scheduled for major vascular surgery should even be screened with stress testing."
However, they conclude, "the debate on screening and revascularization for patients with peripheral arterial disease and scheduled for major vascular surgery continues to be far from settled." DECREASE-5 provided safety and sample-size information needed for a larger exploration of the issue, they write. "It is now time to move forward with such a trial."
Moscucci reports receiving consulting fees from Pfizer and Boston Scientific, lecture fees from Pfizer, and grant support from Cordis
Sources
1. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V pilot study. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2006.11.052. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
2. Moscucci M, Jones N. Coronary revascularization before noncardiac vascular surgery: One more step forward in understanding its role. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2007.01.068 . Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
3. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Eng J Med 2004; 351:2795-2804.
Related links
Risk for death, stroke increased with combined CABG and CEA [Other News > Medscape Medical News; Jan 16, 2007]
Higher risk of stroke and death in patients undergoing combined CEA-CABG surgery vs CABG alone [HeartWire > Other News; Apr 25, 2005]
No benefit from revascularization before vascular surgery: CARP published [HeartWire > Other News; Dec 29, 2004]
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