Asymptomatic carotid artery disease in valvular heart surgery: impact of systematic screening on surgical strategy and neurological outcome

We evaluated the prevalence of asymptomatic carotid artery disease in patients scheduled for valvular cardiac surgery. Preoperative screening of the carotid arteries was performed. Among 1012 patients scheduled for valvular cardiac surgery, 267 (26.4%) had carotid stenosis graded >50%; 37 had carotid stenosis >70% and underwent combined valvular surgery and carotid endarterectomy (CEA); and 230 (86%) had carotid stenosis >50% to ≤ 69% and received valvular cardiac surgery under hypothermic cardiopulmonary bypass. Operative mortality and the rate of perioperative adverse neurological events were comparable among the groups. During 6.8 years of follow-up, patients with carotid stenosis not exceeding 69% at the time of surgery had CEA more frequently (P < .05) and stroke/transient ischemic attack ([TIA] P < .05) versus patients treated with combined surgery. The prevalence of asymptomatic carotid stenosis is not negligible in patients undergoing isolated valvular surgery. Combined valvular and carotid surgery is safe and reduces the incidence of CEA and stroke/TIA during follow-up.     

The impact of coronary revascularization on long-term outcomes after surgical repair of abdominal aortic aneurysm]

BACKGROUND: Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA. METHODS: Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months. RESULTS: CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up. CONCLUSIONS: Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.     

Prognostic significance of myocardial ischemia during dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus and no prior history of coronary events

The prognostic significance of myocardial ischemia assessed by dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus who have no previous coronary artery disease remains unclear. We assessed the value of dobutamine stress echocardiography for risk stratification in 161 asymptomatic patients with type 2 diabetes (mean 62 +/- 12 years of age; 96 men) who had no previous myocardial infarction or revascularization. End point during follow-up was hard cardiac events (cardiac death and nonfatal myocardial infarction). Ischemia was detected in 45 patients (28%). During a median follow-up of 5 years, 40 patients (25%) died (18 cardiac deaths) and 7 patients had nonfatal myocardial infarction (25 hard cardiac events). An abnormal dobutamine stress echocardiogram was associated with a higher mortality compared with a normal dobutamine stress echocardiogram (p = 0.03). In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age and hypercholesterolemia. Ischemia was incremental to the clinical parameters. In conclusion, myocardial ischemia is an independent predictor of cardiac events in asymptomatic diabetic patients with no previous coronary artery disease.     

Simultaneous carotid and coronary artery surgery: indications and perioperative outcome

BACKGROUND: A significant number of patients with coronary artery disease is diagnosed with additional carotid artery disease. This subset of patients has been identified as a high-risk group for cardiac and cerebral complications following surgical intervention. METHODS: In a retrospective analysis we investigated the perioperative outcome of combined single-stage carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in 63 patients operated between January 1989 and August 1998. In all of these patients, CEA was performed prior to CABG and before initiation of cardiopulmonary bypass. RESULTS: Perioperative mortality rate was 7.9% (5/63) for simultaneous CEA and CABG and was due to cardiac complications in all patients. Postoperative unilateral neurological symptoms were diagnosed in 1 patient (1.7%) and were completely reversible. No neurologic events suggestive for permanent cerebral damage were observed during the 30 d postoperative period. CONCLUSIONS: In our study combined single-stage CEA and CABG was associated with low cerebral morbidity and patient outcome was mainly determined by cardiac complications. In this subset of patients, simultaneous CEA and CABG appears to be a safe method.     

Simultaneous Carotid Endarterectomy and Coronary Revascularization is Safe Using Either On-Pump or Off-Pump Technique

The appropriate surgical strategy for patients with combined carotid and coronary artery disease remains controversial. We retrospectively compared our surgical results for 2 types of approaches in this disorder. The records of 76 patients consecutively operated on for carotid and coronary artery disease between August 1993 and October 2004 were reviewed. There were 18 males (66.6%) and 9 females (33.3%) in group I. Group II consisted of 35 males (71.4%) and 14 females (28.5%). The patients were divided into two groups: patients with combined off-pump coronary artery bypass and carotid endarterectomy (group I, n = 27), and those with one-stage on-pump coronary artery bypass and carotid endarterectomy (group II, n = 49). Surgical mortality and morbidity and late outcome were compared among the two groups. The average number of grafts was 1.2 +/- 0.4, with the average operative time of 3.3 +/- 0.3 hours in group I, and 2.3 +/- 0.5 grafts with operative time of 4.6 +/- 0.4 hours in group II (P < 0.001 and P < 0.001, respectively). There was 1 death (3.7%) in group I and 2 deaths (4.8%) in group II (P = 0.937). No patient from either group I or group II had postoperative stroke. Mean hospital stay was 7.4 +/- 1.9 days in group I and 11.3 +/- 1.7 days in group II (P < 0.001). At a mean follow-up of 5.5 +/- 3.3 years in group I, 1 patient had contralateral carotid endarterectomy (3.7%). Group II had a mean follow-up of 5.2 +/- 3.0 years and contralateral carotid endarterectomy was performed in 1 patient (2.0%). There were no late strokes or deaths in either group. Combined coronary artery bypass grafting and carotid endarterectomy using 2 different types of technique is a safe and effective procedure in patients with significant concomitant monolateral carotid and coronary artery disease.     

Metabolic syndrome is associated with severe coronary artery disease and poor cardiac outcome in end-stage renal disease patients with acute coronary syndrome

OBJECTIVE: People with either end-stage renal disease or metabolic syndrome (MS) are at increased risk for developing coronary artery disease. The impact of MS on coronary artery disease in end-stage renal disease patients, however, remained unclear. We therefore evaluated whether the presence of MS is associated with more coronary lesions and a worse cardiac outcome in end-stage renal disease patients with acute coronary syndrome. METHODS: We retrospectively examined 76 consecutive end-stage renal disease patients who experienced acute coronary syndrome and underwent cardiac catheterization. Cardiovascular events were compared between the MS and non-MS group. RESULTS: MS was found in 58 patients and coronary artery disease was found in 63 patients [52 with MS (accounting for 90% of the MS group); 11 without MS (61% of the non-MS); MS vs. non-MS, P=0.01]. Patients with MS had more multi-vessel coronary artery disease (P<0.001) than those without MS. Sixty-nine (MS, 51; non-MS, 18) patients survived the acute coronary syndrome. During the follow-up period (MS, 17.6+/-13.8; non-MS, 19.9+/-11.7 months), 12 patients with MS (24%) and none without MS died owing to cardiovascular events (MS vs. non-MS, P=0.028). Regarding major cardiac events, including cardiac death, repeat non-fatal myocardial infarction, and repeat revascularization, the non-MS group had a higher probability of event-free survival (P<0.0001). CONCLUSIONS: In patients with end-stage renal disease complicated by acute coronary syndrome, MS is frequently seen and associated with a higher probability of coronary artery disease involving multiple coronary branches and a higher probability of cardiac death and major cardiac events. Therefore, detection of MS in such patients is useful for risk stratification.     

Prognostic value of dipyridamole thallium-201 imaging in elderly patients.

The prognostic value of intravenous dipyridamole myocardial perfusion imaging has not been studied in a large series of elderly patients. Patients greater than or equal to 70 years of age with known or suspected coronary artery disease were evaluated to determine the predictive value of intravenous dipyridamole thallium-201 imaging for subsequent cardiac death or nonfatal myocardial infarction. Of the 348 patients, 207 were symptomatic and 141 were asymptomatic; 52% of the asymptomatic group had documented coronary artery disease. During 23 +/- 15 months of follow-up, there were 52 cardiac deaths, 24 nonfatal myocardial infarctions and 42 revascularization procedures (percutaneous transluminal coronary angioplasty in 20; coronary artery bypass surgery in 22). Clinical univariate predictors of a cardiac event included previous myocardial infarction, congestive heart failure symptoms, hypercholesterolemia and diabetes (all p less than 0.05). The presence of a fixed, reversible or combined thallium-201 defect was significantly associated with the occurrence of cardiac death or myocardial infarction during follow-up (p less than 0.05). Cardiac death or nonfatal myocardial infarction occurred in only 7 (5%) of 150 patients with a normal dipyridamole thallium-201 study (p less than 0.001). Stepwise logistic regression analysis of clinical and radionuclide variables revealed that an abnormal (reversible or fixed) dipyridamole thallium-201 study was the single best predictor of cardiac events (relative risk 7.2, p less than 0.001). As has been demonstrated in younger patients, previous myocardial infarction (relative risk 1.8, p less than 0.001) and symptoms of congestive heart failure at presentation (relative risk 1.6, p = 0.02) were also significant independent clinical predictors of cardiac death or myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of coronary heart disease on morbidity and mortality after carotid endarterectomy: a population-based study in Olmsted County, Minnesota (1970-1988)

To evaluate the prognostic importance of coronary artery disease among patients undergoing carotid endarterectomy, 177 residents of Olmsted County, Minnesota who underwent carotid endarterectomy during the period 1970 through 1988 were followed up to July 1, 1989. Patients were stratified as to the presence (n = 64) or absence (n = 93) of overt coronary artery disease or prior myocardial revascularization (n = 20) at the time of endarterectomy. At 30 days after carotid endarterectomy, there were no significant differences between patients with or without coronary artery disease in the occurrence of death, myocardial infarction or stroke. Kaplan-Meier estimate of 8-year relative survival after carotid endarterectomy (assessed as a percent of survival in age- carotid endarterectomy (assessed as a percent of survival in age- and gender-matched control subjects) was 89% in those without and 75% in those with overt coronary artery disease. Of the 59 total deaths, 29 (49%) had a cardiac cause and 4 (7%) were due to stroke (p less than 0.0001). The cumulative incidence of a cardiac event at 8 years after carotid endarterectomy was greater in those with than in those without overt coronary artery disease (61% vs. 25%, p less than 0.0001). In multivariable analysis, uncorrected coronary artery disease and diabetes were the only independent predictors of subsequent cardiac events, whereas age was the only independent predictor of death. These population-based data suggest that carotid endarterectomy can be safely undertaken in patients with stable coronary artery disease. In long-term follow-up of these patients, coronary rather than cerebral vascular disease is the most frequent cause of morbidity and mortality. Thus, these data lend strong support to the concept of early identification and management of coronary artery disease in patients undergoing carotid endarterectomy.     

Outcomes following extracranial carotid artery stenting in high-risk patients

BACKGROUND: Carotid artery angioplasty and stenting has become a viable alternative to carotid endarterectomy (CEA), especially for patients considered at high risk for post-operative complications. This study investigated the feasibility, safety and long-term outcome of carotid artery stenting (CAS) in high-risk patients. METHODS: From July 1995 to November 2000, sixty-two consecutive patients considered to be at high risk for post-operative complications of CEA were followed prospectively after undergoing extracranial CAS procedures. RESULTS: Sixty-two patients [37 men (60%) and 25 women (40%)] underwent a total of 69 CAS procedures. The mean age was 67 +/- 9 years (range, 32-89 years). Comorbid conditions included hypertension in 95% and severe coronary artery disease in 58%. Sixteen patients (26%) had a previous ipsilateral CEA, twenty-one percent had a history of neck radiation and 32% had a history of significant contralateral carotid artery disease. Fifty-two patients (84%) were symptomatic. All 69 CAS procedures were technically successful. The major post-operative complications were two minor strokes (2.8%), one major stroke (1.4%) and one fatal major stroke (1.4%). The mean length of follow-up was 17 months (range, 4 months to 5.6 years). Two patients (2.8%) have suffered ipsilateral neurologic events following CAS. Long-term follow-up revealed restenosis at 6 months in 4 patients (5.7%). CONCLUSIONS: Carotid artery angioplasty and stenting is safe and feasible. This procedure produces satisfactory outcomes in patients who are at high risk for post-operative complications of CEA.     

Early and late outcomes of percutaneous transluminal angioplasty of cephalad arteries

BACKGROUND: Efficacy of carotid endarterectomy (CEA) in prevention of stroke in patients with carotid artery stenosis has been confirmed in randomised trials. Carotid artery stenting (CAS) is a routine clinical practice and recent results of CAS are not worse than CEA. Moreover, percutaneous transluminal angioplasty (PTA) techniques allow other cephalad arteries to be dilated. AIM: To assess early and long-term outcome of PTA of cephalad arteries and to determine risk factors of early and late major adverse cardiovascular and cerebral events (MACCE). METHODS: The study group consisted of 223 consecutive patients (151 males, 67.7%, mean age 65.3+/-8.6) in whom 256 PTA procedures of cephalad arteries were performed. Two hundred and forty-two internal carotid, 7 common carotid and 15 vertebral arteries were dilated. Thirty-four patients underwent one-stage carotid and coronary procedures, while in 46 patients one-stage carotid and peripheral procedures were performed. Neuroprotection with a distal protection device was used in 51.5% of cases. The procedures were divided into two groups: with high (n=181) and low (n=75) risk of cardiovascular events. Early and late events were recorded and analysed subsequently. RESULTS: In hospital 30-day MACCE occurred in 12 (4.6%) patients, including 7 (2.7%) strokes, 3 (1.1%) myocardial infarctions and two (0.8%) deaths. Transient ischaemic attacks were observed in 8 patients, pulmonary oedema in 3 cases, as well as a single episode of retinal artery embolisation and acute renal insufficiency. The incidence of 30-day MACCE was not significantly higher in the high-risk group (6.07 vs. 1.33%; NS), but the risk of any adverse event was significantly higher (p=0.03). There was no difference in stroke incidence between procedures with or without neuroprotection (2.27 vs. 3.22%; NS). There was no difference in risk of MACCE between angioplasty of cephalad artery and one-stage cephalad and coronary artery angioplasty procedure (3.6 vs. 5.5%; NS). During 50.3+/-20 months of follow-up there were 16 (7.1%) deaths, 9 (3.5%) strokes and 6 (2.3%) re-stenoses confirmed angiographically. One-year total survival and one-year MACCE-free survival rates according to the Kaplan-Meier analysis were 94.9% and 89.0%, showing a trend towards better outcome in the low-risk group (F-Cox=2.46; p=0.19 and F-Cox=2.17; p=0.09 respectively). CONCLUSIONS: Percutaneous transluminal angioplasty of cephalad arteries is safe and feasible, with a low periprocedural complication rate and good late outcome. Carotid artery stenting is an alternative method to CEA.     

Intraoperative duplex ultrasonography in carotid endarterectomy: the impact on indication for immediate revision and intermediate-term outcome

BACKGROUND: Thromboembolic complications in relation to carotid endarterectomies (CEA) are frequently associated with technical errors. We analyzed prospectively the impact of intraoperative duplex ultrasonography (IODS) in CEA on immediate revision and postoperative results. PATIENTS AND METHODS: We have observed 70 patients with 74 CEA. Indications for surgery were asymptomatic high grade stenosis (70-99%) or symptomatic stenosis of > 50%. IODS findings were rated as "relevant", "minor" or "normal". Relevant findings were immediately repaired. Peri- and postoperative neurological events were analyzed in Duplex Scans controls in a median length of follow-up of 17.3 months. Outcome of patients with "minor" findings (group A) were compared with patients having "normal" or corrected "relevant" findings (group B). RESULTS: In 8/74 cases (11%) we found relevant findings leading to immediate revision. In 25/74 (34%) cases minor findings were detected which were not revised. In group A (n = 25, 34%) two asymptomatic occlusions and one recurrent high grade stenosis were found during follow-up. In group B (n = 49, 66%) we detected two high and two low grade stenosis. The 30 day death and stroke rate was 1.4% (n = 1). CONCLUSIONS: IODS is a sensitive method to detect immediately pathological findings. Its correction seems to reduce the incidence of early occlusions and therefore early neurological events.     

Thirty-day outcomes of direct carotid artery stenting with cerebral protection in high-risk patients.

BACKGROUND: Implantation of a carotid artery stent after predilation is a standard approach in the endovascular treatment of carotid artery stenoses. Stenting without predilation may be an alternative approach in a certain subset of patients. The present prospective, single-center registry was designed to evaluate the feasibility and safety of direct carotid artery stenting (DCAS) in high-risk patients. METHODS AND RESULTS: Symptomatic patients with stenosis >50% and asymptomatic patients with stenosis >70% were eligible for enrolment. Criteria for high-risk patients included: need or history of open heart surgery, history of myocardial infarction, multivessel coronary artery disease, left ventricular dysfunction (ejection fraction < or =40%), severe pulmonary or renal disease, significant contralateral carotid disease, previous endarterectomy, and age > or =80 years. All procedures were performed using a filter protection device. Patients underwent complete clinical examination before and after DCAS and at 30-day follow-up. A total of 83 consecutive patients (45 males, 68+/-9 years, 33% symptomatic) underwent 100 procedures and 103 stents were deployed successfully. The technical success rate of stenting was 100%. Predilation of carotid stenosis was necessary in 1 (1%) procedure. Carotid-artery stenoses before and after DCAS were 80+/-9% and 7+/-9%, respectively. The median fluoroscopic time for DCAS was 7 min. The overall rate of in-hospital major adverse cerebrovascular events (death, stroke, myocardial infarction) was 5% (2 minor strokes, 3 transient attacks). There was 1 (1%) minor stroke within the 30-day follow-up. CONCLUSION: DCAS is feasible and can be performed with an acceptable risk in high-risk patients.     

Combined carotid and coronary artery surgery: early and late results.

Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high incidence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascular disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic carotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged procedures in 45 patients (including carotid endarterectomy followed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined procedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of patients with diffuse atherosclerosis much more.     

Off-pump coronary surgery improves in-hospital and early outcomes in octogenarians.

BACKGROUND: A retrospective study on octogenarians who underwent off-pump (OPCAB) or conventional (CCAB) coronary artery bypass surgery undertaken to evaluate the in-hospital and early outcomes in terms of survival and cardiac and neurological events. METHODS: The design of the study was single-institutional, retrospective and comparative. Between January 1997 and May 2003, 114 patients were included and 73 underwent OPCAB, while 41 underwent CCAB. Uni- and multivariate analyses were used to determine the correlation between the pre- and intraoperative data and hospital death or complications. The overall survival and freedom from cardiac events were determined using Kaplan-Meier analysis. The linearized rates of follow-up complications were compared between the two groups. RESULTS: Overall, comparison of CCAB to OPCAB revealed differences in the operative mortality (6 deaths for CCAB, 14.6% vs 5 deaths for OPCAB, 6.8%; p = 0.05). Postoperative complication variables showed that there was no significant difference in the number of patients who suffered from cardiac events and stroke (2.4% CCAB vs 1.4% OPCAB, p = NS) whereas there was a significant difference for minor neurological events (12.2% CCAB vs 2.8% OPCAB, p = 0.04). The mean follow-up was 2.1 +/- 1.8 years, for a total follow-up of 234 patient-years. There were 12 late deaths, 6 in the CCAB group and 6 in the OPCAB group. The linearized rate of overall death was 9.5 +/- 2.6%/year in the CCAB group and 13.3 +/- 3.9%/year in the OPCAB group (p = NS). The actuarial survival at 24 months was 84 +/- 7% for OPCAB and 81 +/- 12% for CCAB (p = NS). The actuarial freedom from cardiac events at 24 months was 89 +/- 4% for OPCAB and 90 +/- 6% for CCAB (p = NS). The linearized rate of neurological events was 0.7 +/- 0.7%/year for the CCAB group and 1.1 +/- 1.1%/year for the OPCAB group (p = NS). CONCLUSIONS: Our analysis shows that OPCAB improves the early outcome and that octogenarians can lead event-free lives after cardiac surgery.     

Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results.

AIMS: To assess risk factors for early and late outcome after concurrent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). METHODS AND RESULTS: Records of all 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 were reviewed, and follow-up obtained (100% complete). In the group (mean age 67 years; 74% males), 62% had triple-vessel disease, 57% unstable angina, 31% left main coronary stenosis, 19% congestive heart failure, and 35% either a history of vascular procedures or existing vasculopathies. Preoperative assessment revealed transient ischaemic attack in 16%, stroke in 7%, and bilateral carotid disease in 20%. There were 7% emergent and 19% urgent operations, and ascending aorta was described as atheromatous or calcified in 21%. Hospital death occurred in 19 patients, myocardial infarction in seven, and permanent stroke in 12. Significant multivariable predictors of hospital death were aortic calcifications, coexisting vasculopathy, and emergent procedure. Significant predictors of postoperative stroke were calcified or dilated aorta, and of prolonged hospital stay were advanced age, unstable angina, and coexisting vascular disease. For hospital survivors, 10-year actuarial late event-free rates were: death, 50%; myocardial infarction, 84%; stroke, 93%; percutaneous angioplasty, 95%; redo CABG, 98%; and all morbidity and mortality, 48%. Significant multivariable predictors of late deaths were coexisting vasculopathy, age, renal insufficiency, previous cardiac surgery, tobacco abuse, calcified or atheromatous aorta, and duration of intensive care unit stay. CONCLUSION: Concurrent CEA and CABG can be performed with acceptable operative mortality and morbidity, and good long-term freedom from coronary and neurologic events. Atheromatous aortic disease is a harbinger of poor operative and long-term outcome.     

Effects of high-dose statin administered prior to coronary angioplasty on the incidence of cardiac events in patients with acute coronary syndrome

INTRODUCTION: Statins given after acute coronary syndrome without ST elevation (NSTE-ACS) reduce the incidence of major adverse cardiac events (MACE) in long-term follow-up. AIM: To evaluate the effects of high-dose statin administered in patients with NSTE ACS and increased CRP level prior to percutaneous coronary intervention (PCI) on the incidence of MACE in long-term follow-up. METHODS: The study involved 140 consecutive patients with NSTE ACS and increased CRP level at baseline. Patients from group A (n=54) did not receive statin before PCI, whereas subjects in group B (n=86) were given 80 mg of atorvastatin. Patients in both groups received typical cardiological therapy including aspirin, thienopyridine and low molecular weight heparin. After PCI all patients received 40 mg of atorvastatin. Incidence of MACE (death, myocardial infarction (MI), re-PCI) during long-term followup was evaluated in both groups. RESULTS: Study groups did not differ with respect to demographic parameters and rate of ischaemic heart disease risk factors. Also, no differences occurred regarding CRP level (group A vs. B: hsCRP 10.8+/-1.8 mg/l vs. 8.2+/-2.8 mg/l; p=NS) and TIMI Risk Score (group A vs. B: 4.3+/-0.71 vs. 4.37+/-0.79; p=NS). During long-term follow-up the incidence of MI (9.25% vs. 1.2%, p=0.03), composite endpoint: death + MI (14.8% vs. 2.32%, p=0.013) and death + MI + re PCI (25.9% vs. 8.1%, p=0.006) was significantly higher in group A than group B. CONCLUSIONS: Administration of high-dose statin in NSTE ACS patients before PCI was associated with significant reduction of MACE in long-term follow-up. This effect was observed despite the same therapy given after PCI.     

Contemporary management of concomitant carotid and coronary artery disease

The best approach to the management of concomitant severe carotid and coronary artery disease remains unanswered. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend carotid endarterectomy (CEA) in asymptomatic carotid stenosis of ≥ 80% either prior to or combined with coronary artery bypass surgery (CABG). Currently, there is no consensus as to which surgical approach is superior. More recently, carotid artery stenting (CAS) prior to CABG is emerging as an alternative option with promising results in asymptomatic patients considered 'high risk' for CEA. A <3% composite event rate has been set as a benchmark for isolated CAS or CEA in asymptomatic patients by the ACC/AHA; however, most CEA or CAS studies in patients requiring concomitant CABG have shown event rates ranging from 10-12%. This review examines the available data on carotid revascularisation in relation to CABG surgery to aid in the risk-benefit decision analysis in this controversial area.     

Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. MRC asymptomatic carotid surgery trial (ACST) collaborative group. Lancet 2004; 363: 1491-502

QUESTION: Is carotid endarterectomy (CEA) an effective and safe treatment for the prevention of stroke among patients with >60% internal carotid artery stenosis who had no neurologic symptoms in the previous 6 months. POPULATION: Men and women with severe (>60%) unilateral or bilateral carotid artery stenosis not associated with neurologic symptoms in the past 6 months, where both doctor and patient were uncertain whether to choose or to defer immediate CEA. DESIGN AND METHODS: During 1993-2003, 3120 asymptomatic patients with >60% carotid stenosis were randomized equally to immediate CEA versus indefinite deferral of CEA, and were followed for up to 5 years. The primary end point was risk of stroke or death at 5 years. Analysis was by intention to treat. The treatment of patients with antiplatelet agents, antihypertensive and lipid-lowering therapies was left to the discretion of the clinician. RESULTS: Among patients randomized to immediate CEA (50% had CEA by 1 month, 88% by 1 year) versus deferred, the incidence of stroke or death at 5 years was 6.4% versus 11.8% (95% CI: 3.0-7.7, p < 0.0001); 3.5% versus 6.1% for fatal or disabling strokes (95% CI: 0.8-4.3, p = 0.004), and 2.1% versus 4.2% for fatal strokes (95% CI: 0.6-3.6, p = 0.006). The perioperative stroke incidence was marginally higher in the delayed group versus the immediate group (4.5% versus 2.8%) and overall the risk per CEA of perioperative stroke or death was 3.1%. After excluding the perioperative events from the analysis, the 5-year stroke risks were 3.8% versus 11% (95% CI: 5.0-9.4], p < 0.0001). Surgery primarily prevented carotid territory ischemic strokes (2.7% vs 9.5%; gain 6.8% [4.8-8.8], p < 0.0001). The impact of immediate surgery was consistent in all age groups, among men and women, and across the spectrum of carotid stenosis (i.e. 70%, 80% and 90% carotid stenosis). CONCLUSION: In asymptomatic patients younger than 75 years of age with carotid stenosis of 70% or more on ultrasound, immediate CEA reduces the 5-year incidence of stroke and death.     

Value of programmed ventricular stimulation in the evaluation and management of patients with nonsustained ventricular tachycardia associated with coronary artery disease

Programmed ventricular stimulation with up to 3 extrastimuli at the right ventricular apex was performed in 52 patients with spontaneous nonsustained ventricular tachycardia (VT) associated with coronary artery disease. There were 44 men and 8 women, aged 66 +/- 9 years (range 45 to 86). The mean left ventricular ejection fraction was 41 +/- 14%. Nonsustained VT was asymptomatic in 10 patients (19%), while the arrhythmia was detected during evaluation of palpitations in 5 patients (10%), presyncope in 11 (21%) and syncope in 26 patients (50%). All patients were tested in the drug-free state and were classified as having no inducible arrhythmia (31 patients, group I), or an inducible arrhythmia (21 patients, group II). The age, gender, type of heart disease, symptoms and left ventricular ejection fraction were similar in both groups. Group I patients had a higher overall incidence of syncope. Group I patients received no therapy, while group II patients received antiarrhythmic therapy guided by electropharmacologic testing. At 21 +/- 17 months there was no sustained VT in either group. There were 3 deaths in group I patients, including 1 sudden, 1 nonsudden cardiac and 1 noncardiac death. In group II patients 6 deaths occurred including 4 nonsudden cardiac and 2 noncardiac deaths. In patients with nonsustained VT and coronary artery disease undergoing programmed ventricular stimulation, the incidence of significant arrhythmic events is low in those without therapy with no inducible arrhythmia, and in those with an inducible arrhythmia with therapy guided by electrophysiologic testing.     

Carotid angioplasty and stenting under protection. State of the art

A carotid stenosis is responsible for about 30% of strokes occurring. Carotid endarterectomy (CEA) is considered to be the gold standard treatment of a carotid stenosis. Carotid angioplasty and stenting (CAS) is emerging as a new alternative treatment for a carotid artery stenosis, but the risk of neurological complications and brain embolism remain the major drawback to this procedure. So as to reduce the risk, we need: good indications, good patient and lesion selection; correct techniques; brain protection devices (cerebral protection devices should be routinely used and are mandatory for any procedure. Three types of protection devices are available: filters are the most commonly used. Nevertheless, all protection devices have limitations and cannot prevent from embolic events. However neurological complications can be reduced by 60%. New protection devices will be discussed); good choice of the stent and correct implantation (all stents are not equivalent and have different geometrical effects); pharmacological adjuncts; good team. Indications are well accepted for high-risk patients and recent studies have shown that CAS has superior short-term outcomes than CEA in this group of patients. Indications for low-risk and asymptomatic patients are controversial. New selection criteria have to be discussed. But there are enough reported data to conclude that CAS is also not inferior to CEA in low-risk and asymptomatic patients. In our series of 844 procedures, without protection (n = 187) 30-day death and stroke rate was 3.7% and with protection (n = 657) 1% (1.3% for symptomatic patients, 0.9% for asymptomatic patients, 1.4% in high-risk patients, 0.4% in low-risk patients). CAS under protection is the standard of care and is maybe becoming the gold standard treatment of a carotid stenosis at least in some subgroups of patients.