Clinical-pharmacoeconomical aspects of ß-adrenoblockers use in patients with ischemic heart disease undergoing coronary artery bypass grafting

Aim of this study was to assess clinical and pharmacoeconomic effects of long term use of adrenoblockers in patients with ischemic heart disease (IHD) undergoing coronary artery bypass grafting. Patients with IHD (n=294) were included in open, prospective, randomized clinical trial. The follow up period was 3 years. It was noted that long term use of bisoprolol in comparison with atenolol and metoprolol was characterized by more pronounced increase of exercise tolerance, lower rate of angina recurrence and lower expenses for treatment of patients with IHD.     

Which method should be used to determine the obesity, in patients with coronary artery disease? (body mass index, waist circumference or waist-hip ratio)

OBJECTIVE: To determine body mass index (BMI), waist circumference and waist-hip ratio (WHR) in cases with angiographically established coronary artery disease (CAD) and to compare the obesity degrees established according to the ranges determined by the International Guidelines Committees for BMI, waist circumference and WHR. DESIGN: Cross-sectional, observational study. SUBJECTS: A total of 617 consecutive cases (516 males, mean age: 57.2+/-10.8 y) with CAD who underwent their first coronary angiography between January 2000 and May 2000. MEASUREMENTS: Before coronary angiography, their heights, weights, waist and hip circumferences were measured. Waist circumferences, BMI and WHRs were compared both as a whole and also within stratified groups as for sexes and age groups categorized in decades above 40 y of age. RESULTS: Overweight cases comprised approximately half of the patients in both sexes. In males, the percentages of obese cases with respect to BMIs were 15%, while males with action level 2 waist circumferences were detected to be 20%. Obese male patients whose WHRs were >or=0.95 were found to be 51%. In female cases, corresponding percentages of obesity were estimated to be 32, 72 and 86%, respectively. CONCLUSION: In the same patient groups, the prevalence of obesity, defined by BMI, waist circumference and WHR, could vary three-fold. Thus, some patients may not display a diagnosis of obesity. To prevent this possibility the waist circumference is an easy method, which reflects central obesity more accurately.     

Is off-pump coronary artery bypass grafting superior to drug-eluting stents for the treatment of coronary artery disease? A meta-analysis of randomized and nonrandomized studies

Background

As drug-eluting stent (DES) has almost overcome the disadvantage of frequent restenosis, off-pump coronary artery bypass grafting (OPCAB) has been introduced to avoid complications of cardiopulmonary bypass. However, which approach may promise better outcomes for patients with coronary artery disease remains controversial.

Methods

Three databases were searched. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, target vessel revascularization (TVR), repeat revascularization (RRV), myocardial infarction (MI), and cerebrovascular events (CVE). The relative risk (RR) was calculated as the summary statistic.

Results

11,452 patients from 22 studies were included, of which 4949 patients underwent OPCAB and 6503 patients received DES. The cumulative rates of MACCE (RR [95% CI] = 0.43 [0.34, 0.54], P < 0.00001), all-cause death (RR [95% CI] = 0.56 [0.33, 0.96], P = 0.03), TVR (RR [95% CI] = 0.33 [0.21, 0.53], P < 0.00001), RRV (RR [95% CI] = 0.22 [0.11, 0.42], P < 0.00001) and MI (RR [95% CI] = 0.13 [0.05, 0.29], P < 0.00001) at 3 years were all lower in OPCAB group. The incidences of in-hospital death (RR [95% CI] = 1.31 [0.81, 2.13], P = 0.27) and MI (RR [95% CI] = 1.03 [0.60, 1.78], P = 0.92) were not different between groups, but the rate of in-hospital CVE was lower (RR [95% CI] = 2.6355 [1.0033, 6.9228], P = 0.05) in DES group.

Conclusions

OPCAB presents better long-term outcomes of MACCE, all-cause mortality, TVR, RRV and MI but uncertain outcome of postoperative CVE without influencing the incidences of in-hospital death and MI.     

Is the relationship of body mass index to severity of coronary artery disease different from that of waist-to- hip ratio and severity of coronary artery disease? Paradoxical findings

Although obesity has been regarded as an independent risk factor for coronary artery disease (CAD) by the American Heart Association (AHA) and investigators of the Framingham Heart study in the 1980s and 1990s,1-3 this has not been supported by recent clinical trials. Moreover, the positive linear relationships between obesity and CAD, as reported by some studies, were as a result of univariate analysis of their data. However, by using multivariate analysis of these study data, which included other cardiovascular risk factors such as diabetes mellitus (DM), hypertension (HTN) and hyperlipidaemia, this relationship was shown to be dramatically reduced.4,5In the Munster Heart study (PROCAM) and similar studies, the positive relationship between body mass index (BMI) and cardiovascular risk factors, with cardiac mortality, which attributed obesity as an independent risk factor, appeared to be due to the associated cardiovascular risk factors that usually accompany obesity.6-10 In these studies there was also a strong positive correlation between high BMI and other cardiovascular risk factors.However, findings of recent studies in this regard were opposite to those of previous studies. According to their findings, not only was obesity not a risk factor for CAD but it also had a protective effect on the progression of CAD, which is known as the ‘obesity paradox’.11,12 On the other hand, abdominal adiposity has always been associated with increased cardiovascular disease and mortality rate, independent of patients’ weight.13,14This study was designed to evaluate not only the impact of BMI but also waist-to-hip ratio (WHR) on the severity of CAD, based on angiographic findings.     

Is the advantage of coronary bypass surgery over percutaneous coronary intervention in diabetic patients with severe multivessel disease influenced by the status of insulin requirement?

Several studies have shown that coronary artery bypass graft surgery （CABG） is superior to percutaneous coronary intervention （PCI） in patients with diabetes and multi-vessel disease. Whether this advantage of CABG over PCI is confined to diabetics who require insulin is unknown. We review the published literature comparing CABG with PCI in diabetics including 8 cohorts and 4,786 patients. There was a lower rate for all-cause mortality （Relative risk （RR）： 0.78, 95% confidence interval （CI）： 0.62-0.99）, and for major adverse cardiac and cerebrovascular events （MACCE, RR： 0.59, 95% CI： 0.47-0.75） for CABG compared to PCI. Composite outcome of mortality, myocardial infarction and stoke was similar between CABG and PCI （RR： 0.87, 95% CI： 0.54-1.42）. Visual inspection of the forest plots showed that in most analyses, the point estimates of the RR are similar between the insulin requiring group and non-insulin requiring group. On meta-regression, there was no interaction between status of insulin requirement and revascularization strategies （P 〉 0.05 for all）. The pre- sented data on the still unpublished analysis of the FREEDOM trial showed similar results. Thus, in the current era, CABG is superior to PCI with lower mortality and MACCE rates, but the state of insulin requirement had no effect on the outcomes from the two revascularization strategies.     

Does high altitude increase risks of the elderly patients with coronary artery disease？

Objective To assess the effect of altitude hypoxia on the elderly patients with coronary artery disease （CAD）. Methods Three subject groups were surveyed during their train trip on the highest railroad the Qinghai-Tibet Railway： 22 elderly individuals with documented CAD, 20 healthy elderly controls, and 20 healthy young controls, all of whom from Beijing near the sea level （76 m）, Survey questions addressed clinical features of their healthy conditions and aspects of their coronary disease. The baseline study was performed at Xining at an altitude of 2261m, and then during acute exposure to altitudes of 2808 m, 4768m, 5072 m and 4257 m by train for 24 hours. Resting pulse rate, blood pressure, oxygen saturation, electrocardiograph （ECG）, and cardiac work estimated by the heart rateblood pressure double product were obtained five times in each subject at different altitudes. Results On arrival to altitudes between 4768 m and 5072 m, the older passengers, especially those with preexisting coronary disease, had higher HR, higher BP, and lower SaO2, as well as more frequent abnormalities on ECG, as compared to the younger healthy subjects. As compared with the healthy elderly controls, incomplete right bundle branch block, left ventricular hypertrophy, and ST segment depression were more frequently seen in the elderly coronary patients （P〈0.01）. Cardiac work in group 1 was increased by 13% 12 hours after arrival to altitudes between 2808 m and 5072 m. Oxygen saturation decreased significantly with the altitude increasing by train ascent but improved after inhalation of oxygen. Most of the older subjects tolerated their sojourn at high altitude well except one who developed angina repeatedly with a significant ST segment depression. Conclusions Coronary events and ECG signs of myocardial ischemia are rare in elderly individuals with CAD who travel from sea level to moderate altitudes of 1500m to 2800 m. Patients with CAD who are well compensated at sea level generally tolerate this moderate altitude well. However, it would be prudent for patients with CAD going to altitude above 3000 m. The patients should consult their physician before undertaking a trip to such altitude （J Geriatr Cardio12009; 6：137-141）.     

Chlamydia pneumoniae in the atherosclerotic plaques of patients with unstable angina undergoing coronary artery bypass grafting: does it have prognostic implications?

Objective: This study sought to evaluate the prognostic significance of the presence of DNA of Chlamydia pneumoniae in the coronary atherosclerotic lesions of patients with unstable angina. Background: C. pneumoniae has been implicated in the pathogenesis of coronary artery disease by serological and pathological studies, but whether antichlamydial antibodies and the presence of this pathogen in the coronary atherosclerotic tissue are related to prognosis in unstable angina remains unclear. Methods: A total 76 coronary specimens from 45 patients with unstable angina undergoing bypass surgery were subjected to nested polymerase chain reaction (PCR) for C. pneumoniae. Antichlamydial immunoglobulin G (IgG), A (IgA) and M (IgM) were also examined by an enzyme immunoassay. Patients were followed during a 2-year period to determine the incidence of adverse cardiovascular events. Results: DNA of C. pneumoniae was detected in 57 (75%) of 76 atherosclerotic lesions: 39 patients showed a positive PCR result in at least one plaque. Of the 45 patients, 44 (97.7%) showed a positive serological result: IgG was positive in 39 (86.6%) patients, IgM in five (11.1%) patients and IgA in 42 (93.3%). Clinical characteristics and serologic results were similarly distributed in patients with and without infected lesions at enrollment. At least one adverse event occurred in 21 (46.6%) of the 45 patients at 2 years: death in nine (20%), recurrent angina in 12 (26.6%), revascularization in six (13.3%) and myocardial infarction in two (4.4%) patients. The composite endpoint of death, myocardial infarction, recurrent angina and revascularization at 2-year follow-up did not differ according to the PCR or serologic results. Conclusions: The presence of C. pneumoniae in coronary atherosclerotic plaques of patients with unstable angina undergoing coronary bypass grafting does not have prognostic significance. In addition, serology does not allow us to differentiate those patients with plaque infection by C. pneumoniae and also does not provide any prognostic information in these patients.     

Firebird stent for the treatment of patients with coronary heart disease： short-term clinical outcome

Objective The sirolimus-eluting stent （SES） has dramatically reduced the rate ofrestenosis in comparison to that with the baremetal stent （BMS）.This study aimed to evaluate the short-term efficacy and safety of Firebird stent implantation for patients with coronary heart disease （CHD）. Methods From Apri12006 through July 2007, 155 patients （mean age 58.93±10.27 years ） with CHD were implanted with Firebird stent or Cypher select stent at Daxing Hospital. Patients were followed up for one year. All-cause mortality, major adverse cardiac events （MACE, including cardiac death, myocardial infarction, recurrence of angina pectoris, heart failure, revascularization, and adverse arrhythmia） and stent thrombosis were compared between the 2 groups. Results Of the 155 consecutive patients, 147 patients were revascularized completely. Of these patients, 48 （with 59 lesions） were treated with Firebird stent, 59 patients （with 75 lesions） with Cypher select stent. The demographic characteristics were similar in the 2 groups. All the angiographic and procedural results were not significantly different between the 2 groups. All-cause mortality, myocardial infarction, recurrence of angina pectoris, MACE and stent thrombosis were almost identical between the 2 groups before discharge, at 6 months and at one year .Conclusion The short-term efficacy and safety of Firebird stent are similar to that of the cypher select stent for the treatment of patients with CHD （J Geriatr Cardlo12009; 6：157-161）.     

Long-term prognosis in patients with single-vessel or double-vessel coronary artery disease: does successful revascularization achieved by coronary angioplasty improve late outcome?

OBJECTIVES: It is not clear whether revascularization by coronary angioplasty improves long-term prognosis in patients with stable angina, single- or double-vessel coronary artery disease. This study investigated the extent of late revascularization achieved by percutaneous transluminal coronary angioplasty(PTCA) and evaluated the long-term effect of revascularization in patients with coronary artery disease. METHODS: This study reviewed 178 patients with single-vessel or double-vessel disease and significant coronary diameter stenosis(American Heart Association classification, 75% or more stenosis), but excluded 35 patients with failed revascularization of the target vessels because of initial failed angioplasty(n = 14) or restenosis(n = 21). The remaining 143 patients were available for assessment. Revascularization was successful at follow-up angiography after the last angioplasty in 105 patients(Group A). The remaining 38 patients received conservative medical therapy(Group B). Kaplan-Meier survival curves were used to examine absolute survival difference. RESULTS: One hundred forty-three patients(mean age 64 +/- 9 years) were followed-up for 3.8 +/- 1 years. The patients were 70.6% male, 59.4% had myocardial infarction and 76.9% had single-vessel disease. Anatomical complete revascularization in the chronic phase was accomplished in 80 patients with single-vessel disease(97.6%) and 11 patients with double-vessel disease(47.8%). The event-free survival rate was not significantly different between Group A and Group B(88.6% vs 84.2%, p = NS). Cardiac survival rate decreased significantly in Group B compared to Group A(89.5% vs 99.0%, p < 0.01). This difference in survival rate was due to sudden cardiac death in Group B(7.9% vs 0%, p < 0.05). Non-fatal myocardial infarctions occurred in seven patients(6.7%) with revascularization and in one patient(2.6%) with conservative medical therapy, but with no significant difference. Late successful revascularization improved cardiac survival rate in patients with proximal left anterior descending coronary artery involvement or single-vessel disease. CONCLUSIONS: Cardiac events decreased and long-term prognosis appeared to be a good possibility in patients with single- or double-vessel coronary artery disease if late successful revascularization of target vessel was accomplished.     

Treatment of unprotected left main coronary artery disease with drug-eluting stents: is it time for a randomized trial?

The treatment of unprotected left main coronary artery disease by percutaneous intervention represents a considerable challenge for interventional cardiologists. The American College of Cardiology/American Heart Association guidelines currently recommend surgical revascularization for this disorder and percutaneous interventions have thus far been performed only in exceptional cases, albeit with positive results in some patients. Technical limitations, however, including stent restenosis, limit the application of this technique at present. The availability of drug-eluting stents, which are associated with a reduction in angiographic restenosis, might change this situation. Preliminary results show that the implantation of drug-eluting stents for unprotected left main coronary artery lesions is a feasible and safe approach. Randomized clinical trials comparing the use of drug-eluting stents with coronary artery bypass surgery for unprotected left main coronary artery disease are the next step, but can such trials be contemplated at this stage? In this review we present an overview of the findings to date and discuss the direction that research should now take.     

Mediation of the APOE associations with Alzheimer’s and coronary heart diseases through body mass index and lipids

GeroScience - The APOE ε2/ε3/ε4 polymorphism is associated with multiple non-Mendelian traits, including high- (HDL-C) and low- (LDL-C) density lipoprotein cholesterol,...