Health-related quality of life outcomes of patients with coronary artery disease treated with cardiac surgery, percutaneous coronary intervention or medical management

BACKGROUND: Given the repeated findings of little or no difference in mortality outcomes between percutaneous coronary intervention (PCI) with or without stent and coronary artery bypass graft surgery (CABG), there is a need to assess the health-related quality of life (HRQOL) outcomes associated with revascularization decisions. OBJECTIVE: To compare risk-adjusted HRQOL outcomes by treatment strategy one year following cardiac catheterization. METHODS: Using an inception cohort study design, the sample included all Alberta residents, 18 years of age or older, referred for cardiac catheterization, from January 1, 1996, to December 31, 1998, with two or more diseased coronary vessels at catheterization. Patients received a follow-up questionnaire including the Seattle Angina Questionnaire (SAQ), one year following their index catheterization. The SAQ comprises five dimensional scales measuring exertional capacity, anginal stability, anginal frequency, treatment satisfaction and quality of life. RESULTS: Three thousand three hundred ninety-two (78.1%) patients responded to the follow-up survey. Responders who were revascularized consistently reported significantly better HRQOL compared with responders treated with medical management. Responders undergoing CABG reported significantly better HRQOL in all but one SAQ dimension compared with responders who had either a PCI with or without stent. Responders who had a PCI with stent reported better HRQOL compared with responders who underwent a PCI without a stent. CONCLUSION: The treatment decision to revascularize the coronary vessels, whether with PCI with or without a stent or with CABG, was consistently associated with significantly better HRQOL at one-year follow-up compared with patients treated with medical therapy.     

Comparison of patient-reported outcomes after elective coronary artery bypass grafting in patients aged greater than or equal to and less than 65 years.

Older patients represent a growing proportion of patients undergoing coronary artery bypass grafting (CABG). Although functional benefits after CABG have been demonstrated, most assessments of outcomes have involved patients aged less than 65 years. Therefore, little is known concerning the impact of CABG on older patients compared with that on younger ones. A number of postsurgical (6 months) health-related quality-of-life outcomes (e.g., symptoms, cardiac functional class, instrumental activities of daily living, and emotional and social functioning) reported by patients aged less than 65 (n = 169) and greater than or equal to 65 (n = 99) years who underwent elective CABG at 4 major teaching hospitals in Massachusetts and California were compared. The proportion of patients reporting cardiac-related symptoms after surgery did not vary by age, and quality-of-life outcome scores of younger and older patients did not differ even after adjustment for clinical and demographic characteristics. The exception to this was mental health status, an outcome for which older patients reported better functioning than did younger ones. On average, patients in the 2 age groups reported equivalent improvement over preadmission status in instrumental activities of daily living, and emotional and social functioning. The independent relation of clinical and sociodemographic factors to quality-of-life outcomes was also investigated. Patients who functioned better before admission, those with less severe co-morbid disease, and married patients reported better functioning after discharge. In general, older patients who underwent elective CABG reported functional benefits similar to those reported by younger ones, and the factors associated with better functioning did not vary by age group.     

Revascularization use and survival outcomes after cardiac catheterization in British Columbia and Alberta

BACKGROUND: Alberta and British Columbia have comprehensive cardiac databases that provide detailed demographic, clinical and procedural data, including coronary anatomy, on all patients undergoing cardiac catheterization. OBJECTIVES: To examine the baseline clinical characteristics of patients undergoing cardiac catheterization, describe the use of revascularization treatments (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) following catheterization, and describe survival after cardiac catheterization, stratified by treatment strategy received and proposed, using cardiac databases from Alberta and British Columbia. PATIENTS AND METHODS: All patients between 20 and 105 years of age, admitted to hospital for their first coronary angiography between April 1, 1995, and March 31, 2001, with angiographic evidence of coronary disease were included in the study. Procedure volumes, baseline characteristics and therapy received within one year of cardiac catheterization are described by province. Stepwise, multivariate logistic regression analysis was used to model determinants of the revascularization modality. Kaplan-Meier curves of one-year survival after index cardiac catheterization were estimated for the therapy received (Alberta and British Columbia) and the therapy proposed (British Columbia only). RESULTS: Patients were predominantly men (70%), commonly presented with two- or three-vessel disease, and frequently had hypertension, a history of myocardial infarction and dyslipidemia. Within one year of catheterization, 21% to 26% underwent CABG and 32% to 42% underwent PCI. Emergency or urgent status at the time of catheterization was associated with receiving PCI, while three-vessel and left main disease were associated with receiving CABG. Patients who did not undergo revascularization within one year (presumed medical therapy) had the lowest one-year survival rate (93.4%; 95% CI 92.1% to 94.7%); this group comprised patients receiving medical therapy as proposed (one-year survival rate of 95.7%, 95% CI 94.6% to 96.8%), as well as patients receiving medical therapy at variance with the proposal for revascularization (84.6%; 95% CI 80.5% to 88.9%). CONCLUSIONS: Between 53.1% and 67.5% of patients presenting for cardiac catheterization undergo revascularization within one year. Urgent status increased the probability of PCI, and anatomy (ie, three-vessel and left main) increased the probability of CABG. Patients not undergoing proposed revascularization by one year had poorer outcomes, in contrast with those proposed for medical therapy, who had excellent outcomes.     

Multicenter experience in revascularization of very elderly patients

Background

Very elderly patients are increasingly referred for revascularization yet have been underrepresented in both prior percutaneous coronary intervention (PCI) and coronary bypass surgery (CABG) clinical trials. We pooled the largest PCI and CABG clinical registries in the United States to better understand revascularization procedure use, risks and outcomes in patients aged ≥75 years.

Methods

Six PCI registries (n = 48,439) and 8 CABG registries (n = 180,709) voluntarily contributed all procedural data in patients aged ≥75 years from 1990 through 1999. Patient characteristics, procedural process, and inhospital mortality and morbidity outcomes were evaluated. Risk factors for mortality in elderly patients were identified and compared across registries using standardized multivariable logistic regression.

Results

Between the years 1991 and 1999, the proportion of patients aged ≥75 years undergoing revascularization was on the rise (10% increase). Pooled estimates of inhospital mortality following PCI during this decade was 3.0% (range 1.5%-5.2% among databases), and following CABG was 5.9% (range 4.9%-8.4% among databases). Mortality rates declined significantly in older patients for both PCI and CABG over this decade. While process measures varied across registries, the most significant predictors of inhospital death (procedural urgency, left ventricular dysfunction, prior CABG) seemed consistent across all sites.

Conclusion

Over the last decade, the use of coronary revascularization in elderly patients increased and outcomes improved. While age remains a determinant of procedural risk, this risk varies markedly among elderly patients, emphasizing the need for individualized risk assessments.     

The elderly: health status benefits and recovery of function one year after coronary artery bypass surgery

OBJECTIVES: The purpose of this study was to describe the health status (symptoms, function, and quality of life) changes of elderly patients undergoing coronary artery bypass grafting (CABG) and compare these to younger patients. BACKGROUND: Despite increasing use of CABG in the elderly, few data exist about elderly patients' health status benefits from CABG. METHODS: A total of 690 consecutive patients (n = 156, >75 years of age; n = 534, 相似文献   

老年无保护左主干病变置人药物洗脱支架与行冠状动脉旁路移植术的预后比较

目的 对比老年无保护左主干病变患者置入药物洗脱支架(DES)和行冠状动脉旁路移植术(CABG)后2年的临床预后.方法 入选2004年1月至2006年6月因无保护左主干病变置入DES或行CABG的老年患者(≥70岁)共295例.随访2年,记录患者发生全因死亡、非致死性心肌梗死及靶病变血管重建的情况.结果 共206例患者行CABG,89例患者置入DES.随访2年的累积死亡率CABG组为10.2%,DES组为13.3%,两组之间差异无统计学意义(P=0.428).生存分析表明2年生存率CABG组为89.2%,DES组为86.4%,两组之间差异无统计学意义(P=0.668).2年心肌梗死发生率CABG组为10.1%,DES组为7.8%,两组之间差异无统计学意义(P=0.501).DES组2年内靶病变血管重建的发生率明显高于CABG组(13.5%比4.9%,P=0.015).多因素分析表明,年龄(HR:1.04,95% CI:1.01～1.09,P=0.024)、左心室功能不全(LVEF<30%)(HR:4.97,95%CI:1.22～24.85,P=0.018)以及2型糖尿病(HR:2.22,95%CI:1.31～4.86,P=0.001)均是死亡的独立危险因素.结论 对于≥170岁的老无保护左主干病变患者,行CABG和置入DES后2年的生存率相当,但置入DES的患者靶病变血管重建发生率明显高于行CABG的患者.     

Comparison of frail patients versus nonfrail patients ≥65 years of age undergoing percutaneous coronary intervention

Frailty is a geriatric syndrome characterized by functional impairments and is associated with poor outcomes; however, the prevalence of frailty and its association with health status in patients treated with percutaneous coronary intervention (PCI) are unknown. To assess the prevalence of frailty and its association with health status in PCI-treated patients, we studied 629 patients ≥65 years old undergoing PCI from October 2005 through September 2008. Frailty was characterized using the Fried criteria: weight loss >10 lbs. in previous 1 year, exhaustion, low physical activity, poor gait speed, and poor grip strength (3 features = frail; 1 feature to 2 features = intermediate frailty; 0 feature = not frail). Health status was assessed using the Short-Form 36 and the Seattle Angina Questionnaire (SAQ). Multivariable linear regression models were used to estimate the independent association between frailty and health status. Complete data on 545 patients demonstrated that 19% (n = 117) were frail, 47% (n = 298) had intermediate frailty, and 21% (n = 130) were not frail. Frail patients had more co-morbidities and more frequent left main coronary artery or multivessel disease after adjusting for age and gender (p <0.05 across groups). Multivariable linear regression demonstrated poorer health status in frail patients compared to nonfrail patients as evidenced by lower Short-Form 36 scores, lower SAQ scores for physical limitation, and lower SAQ scores for quality of life (p <0.001 for each health status domain). In conclusion, 1/5 of older patients are frail at the time of PCI and have greater comorbid burden, angiographic disease severity, and poorer health status than nonfrail adults.     

冠状动脉多支血管病变伴慢性肾功能不全患者血管重建策略与预后的关系

目的对比多支血管病变伴慢性肾脏疾病（CKD）患者经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）的2年临床预后。方法根据改良MDRD公式对北京安贞医院2004年到2006年因多支冠状动脉病变接受药物洗脱支架（DES）或CABG的患者的肾小球滤过率（GFR）进行计算,GFR＆lt;60mL/min诊断为CKD。共入选CKD患者1069例,其中724例接受DES,345例接受CABG。首要终点为2年内死亡、心肌梗死（MI）以及脑血管事件（CVE）的复合终点,次级终点为再次血管重建。结果在2年随访中,CABG组首要终点的发生率为9.9%,DES组为11.3%（P=0.528）。两组之间死亡率差异也无统计学意义（CABG组与DES组分别为3.5%比4.7%,P=0.422）。而DES组2年再次血管重建的比例显著高于CABG组（9.0%比4.1%,P=0.004）。Cox多因素回归分析表明,年龄、糖尿病、左心室功能不全（LVEF＆lt;30%）和急性冠状动脉综合征是复合终点发生的独立预测因素。结论在冠状动脉多支病变伴CKD患者中,CABG和DES两种血管重建策略显示出相同的死亡率和MI、CVE发生率。但DES组患者再次血管重建的发生率依然高于CABC组患者。     

老年冠心病患者多支病变PCI与CABG治疗的远期疗效比较

目的:比较老年多支冠状动脉病变患者雷帕霉素洗脱支架植入(DES)与冠状动脉搭桥术(CABG)的远期疗效。方法:随机入选我院年龄大于75岁,并成功行择期血运重建的,有多支冠状动脉病变的住院患者322例,分为CABG组(160例),DES组(162例)。随访5年的主要不良心脑血管事件(MACE)。采用Kaplan-Meier方法估计无事件生存率。采用Logistic多元回归方法分析治疗对终点事件的影响。结果:322例随访率100%,与DES组比较,CABG组5年MACE发生率明显减低(18.52%比3.75%,P<0.05),再次血运重建率明显减低(12.3%比0.63%,P<0.01);两组间5年生存率无明显差异(98.8%比98.1%,P>0.05)。结论:高龄老年多支冠脉病变患者CABG与雷帕霉素洗脱支架植入比较,二者生存率无显著差异;但CABG组的远期心脑血管事件发生率、血运重建率显著低于雷帕霉素洗脱支架植入组。     

Comparison of quality of life after repeat versus initial coronary artery bypass grafting

One-year health status improvements in 62 patients with previous coronary artery bypass grafting (CABG) were compared with those of 628 patients undergoing initial CABG using the Seattle Angina Questionnaire (SAQ). Adjusted analyses revealed that repeat CABG conferred similar 1-year improvements in health status compared with patients undergoing a first CABG (changes in SAQ Physical Limitation score [SAQ-PL: repeat CABG 25 +/- 27 vs first CABG 20 +/- 27; p = 0.30], Quality of Life score [SAQ-QoL: 34 +/- 24 vs 35 +/- 5; p = 0.87], and Angina Frequency score (SAQ-AF: 35 +/- 40 vs 25 +/- 24; p = 0.03]).     

Outcomes of repeat revascularization in diabetic patients with prior coronary surgery

OBJECTIVES: This study evaluated both short- and long-term outcomes of diabetic patients who underwent repeat coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) after initial CABG. BACKGROUND: Although diabetic patients who have multivessel coronary disease and require initial revascularization may benefit from CABG as compared with PCI, the uncertainty concerning the choice of revascularization may be greater for diabetic patients who have had previous CABG. METHODS: Data were obtained over 15 years for diabetic patients undergoing PCI procedures or repeat CABG after previous coronary surgery. Baseline characteristics were compared between groups, and in-hospital, 5-year, and 10-year mortality rates were calculated. Multivariate correlates of in-hospital and long-term mortality were determined. RESULTS: Both PCI (n = 1,123) and CABG (n = 598) patients were similar in age, gender, years of diabetes, and insulin dependence, but they varied in presence of hypertension, prior myocardial infarction, angina severity, heart failure, ejection fraction, and left main disease. In-hospital mortality was greater for CABG, but differences in long-term mortality were not significant (10 year mortality, 68% PCI vs. 74% CABG, p = 0.14). Multivariate correlates of long-term mortality were older age, hypertension, low ejection fraction, and an interaction between heart failure and choice of PCI. The PCI itself did not correlate with mortality. CONCLUSIONS: The increased initial risk of redo CABG in diabetic patients and the comparable high long-term mortality regardless of type of intervention suggest that, except for patients with severe heart failure, PCI be strongly considered in all patients for whom there is a percutaneous alternative.     

主动脉内球囊反搏在70岁以上冠心病患者手术的临床应用

目的探讨主动脉内球囊反搏(IABP)在年龄≥70岁冠心病患者手术应用的临床效果。方法选择冠状动脉旁路移植术应用IABP的患者1 21例,将年龄≥70岁的43例作为老年组,70岁的78例作为对照组,回顾性分析2组患者手术后并发症的发生率。结果与对照组比较,老年组在IABP应用时间,术后并发症和早期病死率等方面无显著差异(P0.05)。老年组术后合并其他器官功能衰竭的比例显著高于对照组(P0.05),并发呼吸功能衰竭的比例显著高于对照组(P0.05)。结论在年龄≥70岁患者的冠心病手术中,应用IABP安全有效,围手术期需注意呼吸道的管理和多器官功能的保护。     

Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter study with 4-year follow-up

We evaluated transmyocardial laser revascularization (TMLR) with coronary artery bypass grafting (CABG) versus CABG alone for severe coronary artery disease involving 21 myocardial region unsuited for CABG. At 4 centers, 44 consecutive patients were randomized for CABG+TMLR (n = 23) or CABG alone (n = 21). Operative and in-hospital mortality and morbidity rates were monitored. Clinical status was evaluated at hospital discharge, 1 year, and 4 years. Success was characterized by relief of angina and freedom from repeat revascularization and death. Preoperatively, 20 patients (47%) were at high risk. The CABG technique, number of grafts, and target vessels were similar in both groups. Patients undergoing CABG+TMLR received 25 +/- 11 laser channels. Their < or = 30-day mortality was 13% (3/23) compared with 28% (6/21) after CABG alone (P = 0.21). There were no significant intergroup differences in the number of intraoperative or in-hospital adverse events. The follow-up period was 50.3 +/- 17.8 months for CABG alone and 48.1 +/- 16.8 months for CABG+TMLR. Both groups had substantially improved angina and functional status at 1 and 4 years, with no significant differences in cumulative 4-year mortality. The incidence of repeat revascularization was 24% after CABG alone versus none after CABG+TMLR (P < 0.05). The 4-year event-free survival rate was 14% versus 39%, respectively (P < 0.064). In conclusion, CABG+TMLR appears safe and poses no additional threat for high-risk patients. Improved overall success and repeat revascularization rates may be due to better perfusion of ischemic areas not amenable to bypass. Further studies are warranted to determine whether these trends are indeed significant.     

Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry)

Although great interest exists in the relative efficacy of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary artery stenosis, data comparing the 2 strategies are scant. Furthermore, no comparison has ever been performed between CABG and drug-eluting stents in this setting. From January 2002 to June 2005, 154 patients with unprotected left main coronary artery stenosis underwent CABG and 157 underwent PCI. Ninety-four patients received a drug-eluting stent in the left main artery. After a median follow-up of 430 days, the rate of mortality, acute myocardial infarction, and target lesion revascularization was 12.3%, 4.5%, and 2.6%, respectively, in the CABG group and 13.4%, 8.3%, and 25.5%, respectively, in the PCI group (death and myocardial infarction p = NS, target lesion revascularization p = 0.0001). Although patients treated with drug-eluting stents had a 25% relative risk reduction in the rate of death, myocardial infarction, and target lesion revascularization compared with patients treated with bare stents, event-free survival was still better for patients treated with CABG. In the multivariate analysis, age >or=70 years, New York Heart Association classes III and IV, acute coronary syndromes, and peripheral vascular disease were the only independent predictors of mortality. In conclusion, our results have indicated that at long-term follow-up no difference exists in the rate of mortality and myocardial infarction between PCI and CABG for the treatment of unprotected left main coronary artery stenosis. However, the rate of target lesion revascularization was higher in the PCI group.     

Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.

AIMS: The SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) Trial showed no benefit of early revascularization in patients aged >/=75 years with acute myocardial infarction and cardiogenic shock. We examined the effect of age on treatment and outcomes of patients with cardiogenic shock in the SHOCK Trial Registry. METHODS AND RESULTS: We compared clinical and treatment factors in patients in the SHOCK Trial Registry with shock due to pump failure aged <75 years (n=588) and >/=75 years (n=277), and 30-day mortality of patients treated with early revascularization <18 hours since onset of shock and those undergoing a later or no revascularization procedure. After excluding early deaths covariate-adjusted relative risk and 95% confidence intervals were calculated to compare the revascularization strategies within the two age groups. Older patients more often had prior myocardial infarction, congestive heart failure, renal insufficiency, other comorbidities, and severe coronary anatomy. In-hospital mortality in the early vs. late or no revascularization groups was 45 vs. 61% for patients aged <75 years (p=0.002) and 48 vs. 81% for those aged >/=75 years (p=0.0003). After exclusion of 65 early deaths and covariate adjustment, the relative risk was 0.76 (0.59, 0.99; p=0.045) in patients aged <75 years and 0.46 (0.28, 0.75; p=0.002) in patients aged >/=75 years. CONCLUSIONS: Elderly patients with myocardial infarction complicated by cardiogenic shock are less likely to be treated with invasive therapies than younger patients with shock. Covariate-adjusted modeling reveals that elderly patients selected for early revascularization have a lower mortality rate than those receiving a revascularization procedure later or never.     

Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter,randomized trial

BACKGROUNDPercutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are being applied to high-risk populations, but previous randomized trials comparing revascularization methods have excluded a number of important high-risk groups.OBJECTIVESThis five-year, multicenter, randomized clinical trial was designed to compare long-term survival among patients with medically refractory myocardial ischemia and a high risk of adverse outcomes assigned to either a CABG or a PCI strategy, which could include stents.METHODSPatients from 16 Veterans Affairs Medical Centers were screened to identify myocardial ischemia refractory to medical management and the presence of one or more risk factors for adverse outcome with CABG, including prior open-heart surgery, age >70 years, left ventricular ejection fraction <0.35, myocardial infarction within seven days or intraaortic balloon pump required. Clinically eligible patients (n = 2,431) underwent coronary angiography; 781 were angiographically acceptable; 454 (58% of eligible) patients consented to random assignment between CABG and PCI.RESULTSA total of 232 patients was randomized to CABG and 222 to PCI. The 30-day survivals for CABG and PCI were 95% and 97%, respectively. Survival rates for CABG and PCI were 90% versus 94% at six months and 79% versus 80% at 36 months (log-rank test, p = 0.46).CONCLUSIONSPercutaneous coronary intervention is an alternative to CABG for patients with medically refractory myocardial ischemia and a high risk of adverse outcomes with CABG.     

Effects of revascularization within 14 days of hospital admission due to acute coronary syndrome on 1-year mortality in patients with previous coronary artery bypass graft surgery.

AIMS: To determine whether revascularization within 14 days reduces 1-year mortality in patients with a previous CABG admitted for non-ST-elevation ACS. Current guidelines for patients with acute coronary syndrome (ACS) include early revascularization. The evidence is derived from studies, in which patients with previous coronary artery by-pass graft (CABG) surgery often were excluded and thus insufficient to support a similar strategy in these high-risk patients in whom coronary interventions are associated with lower success and higher complication rates. METHODS AND RESULTS: A cohort of 10 469 patients < 80 years old from a national registry, admitted to coronary care units in Sweden, was studied. We obtained 1-year mortality data from the Swedish National Cause of Death Registry. Relative risk (RR) in patients undergoing revascularization within 14 days (n = 4269) of admission compared to those who did not (n = 6200) was calculated by using multivariable logistic regression analyses and propensity scores for the likelihood of early revascularization. At 1-year, unadjusted mortality was 5.4% in the revascularized group and 13.1% in the conservatively treated group. In multiple regression analyses, revascularization was associated with a reduction of 1-year mortality (RR 0.67; 95% CI, 0.56-0.81; P < 0.001). CONCLUSION: In patients with a previous CABG admitted for ACS, revascularization within 14 days of hospital admission was associated with a marked reduction in 1-year mortality, supporting an early invasive approach also in this subset of patients.     

Neuropsychological and psychiatric outcomes following coronary surgery or angioplasty: a comparative study

BACKGROUND: Medical outcomes following coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) are similar, but few studies have compared neuropsychological outcomes after these procedures. METHODS: A retrospective study compared detailed neurocognitive and psychosocial functioning in 32 patients (CABG, n = 16; PTCA, n = 16) aged 61 +/- 6 years, 9-15 months after coronary revascularisation. Subjects were tested for executive functioning, speed of processing/attention and learning/memory, significant psychopathology (General Health Questionnaire, GHQ) and psychosocial functioning (Short Form (SF)-36 health survey). In the prospective study, 55 patients completed GHQ and SF-36 surveys, the day prior to and 6 months following PTCA. RESULTS: There were no significant differences between the CABG and PTCA groups for neuropsychological or psychosocial end-points (P > 0.20). Executive functioning in both groups, however, was worse than for healthy population controls (P < 0.01). The PTCA patients were significantly more likely than CABG patients to have psychiatric abnormality (GHQ Score >4; P < 0.01). After PTCA, however, there was a significant improvement in the GHQ and SF-36 scores (P < 0.05). CONCLUSIONS: Although executive function is often impaired after coronary revascularisation, neuropsychological status appears equivalent after CABG or PTCA. Psychiatric pathology is common in patients undergoing PTCA, but improves after this intervention.     

Resource utilization,cost, and health status impacts of coronary stent versus "optimal" percutaneous coronary angioplasty: results from the OPUS-I trial

In the OPUS-I trial, primary coronary stent implantation reduced 6-month composite incidence of death, myocardial infarction, cardiac surgery, or target vessel revascularization relative to a strategy of initial PTCA with provisional stenting in patients undergoing single vessel coronary angioplasty. The purpose of this research was to compare the economic and health status impacts of each treatment strategy. Resource utilization data were collected for the 479 patients randomized in OPUS-I. Itemized cost estimates were derived from primary hospital charge data gathered in previous multicenter trials evaluating coronary stents, and adjusted to approximate 1997 Medicare-based costs for a cardiac population. Health status at 6 months was assessed using the Seattle Angina Questionnaire (SAQ). Initial procedure related costs for patients treated with a primary stent strategy were higher than those treated with optimal PTCA/provisional stent ($5,389 vs $4,339, P < 0.001). Costs of initial hospitalization were also higher for patients in the primary stent group ($9,234 vs $8,434, P < 0.01) chiefly because of the cost differences in the index revascularization. Mean 6-month costs were similar in the two groups; however, there was a slight cost advantage associated with primary stenting. Bootstrap replication of 6-month cost data sustained the economic attractiveness of the primary stent strategy. There were no differences in SAQ scores between treatment groups. In patients undergoing single vessel coronary angioplasty, routine stent implantation improves important clinical outcomes at comparable, or even reduced cost, compared to a strategy of initial balloon angioplasty with provisional stenting.     

Outcomes of coronary revascularization (percutaneous or bypass) in patients with diabetes mellitus and multivessel coronary disease

Clinical outcomes in patients with diabetes mellitus and multivessel disease (MVD) undergoing coronary revascularization have not been extensively evaluated, we sought to examine outcomes in a diabetic cohort of 195 consecutive patients with MVD characterized by SYNTAX scores (SSs) undergoing nonrandomized revascularization, 102 (52%) by percutaneous intervention (PCI) and 93 (48%) by coronary artery bypass grafting (CABG) at Liverpool Hospital (Sydney, Australia) from June 2006 to March 2010. Clinical outcomes were assessed at a median term of 14 months. The overall median SS was 44, with significantly higher SSs in CABG- than PCI-treated patients (48 vs 39, p <0.0001). There was a similar incidence of all-cause death, nonfatal myocardial infarction and stroke in PCI- and CABG-treated patients (6.1% vs 8.3%, p = 0.383; 12% vs 4.9%, p = 0.152; 3.1% vs 3.5%, p = 0.680 respectively). However, the rates of target vessel revascularization and major adverse coronary and cerebral event were significantly higher in PCI-treated patients than in those undergoing CABG (20% vs 1.2%, p <0.0001; 29% vs 15%, p = 0.034). Despite a much higher SS, patients who underwent PCI achieved comparable outcomes at 1 year to those with diabetes mellitus and a SS ≥33 as reported in the SYNTAX trial. In conclusion, in this single-center nonrandomized observational study, coronary revascularization by PCI is associated with increased major adverse coronary and cerebral events at 1-year follow-up, predominantly driven by a high rate of target vessel revascularization. Thus, CABG should remain the revascularization procedure of choice for diabetic patients with MVD and high SSs.