Impact of body mass index on in-hospital outcomes following percutaneous coronary intervention (report from the New York State Angioplasty Registry)

Although obesity traditionally has been considered a risk factor for coronary revascularization, recent data from registry studies have shown a possible protective effect of obesity on outcomes after percutaneous coronary intervention (PCI). Using data from the New York State Angioplasty database over a 4-year period, we analyzed 95,435 consecutive patients who underwent PCI. Classification of body mass index (BMI) was: underweight (<18.5 kg/m(2)), healthy weight (18.5 to 24.9 kg/m(2)), overweight (25 to 29.9 kg/m(2)), moderate obesity (class I) (30 to 34.9 kg/m(2)), severe obesity (class II) (35 to 39.9 kg/m(2)), and very severe obesity (class III) (>40 kg/m(2)). In-hospital postprocedural mortality and complications were compared among these groups. Compared with healthy weight patients, patient with class I or II obesity had lower in-hospital mortality and major adverse cardiac events (MACE) (combined death, myocardial infarction, and emergency surgery), whereas patients at the extremes of BMI (underweight and class III obese patients) had significantly higher mortality and MACE rates. Adjusted hazards ratios for in-hospital mortality according to BMI were: underweight (2.69), healthy weight (1.0), overweight (0.90), class I obese (0.74), class II obese (0.67), and class III obese (1.63). Patients at the extremes of BMI (<18.5 and >40 kg/m(2)) were at increased risk of MACEs, including mortality after PCI, whereas patients who were moderately to severely obese (BMIs 30 to 40 kg/m(2)) were at lower risk than healthy weight patients.     

Outcome of coronary revascularization in patients on renal dialysis

Previous retrospective studies showed high periprocedure mortality rate and poor outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) among renal dialysis patients. The purpose of this study was to compare mortality and clinical event rates in renal dialysis patients after PTCA or CABG. We identified 252 patients from the Emory Cardiovascular Database who were on dialysis and who received PTCA (122 patients) or CABG (130 patients) at Emory University Hospital and Crawford W. Long Hospital between March 1987 and December 1997. Baseline and angiographic characteristics, in-hospital, and 1-year outcome were compared between the 2 groups. Left main disease and 3-vessel coronary artery disease were significantly more common in the CABG group. There was a higher periprocedure and in-hospital mortality in the CABG group (6.9% vs 1.6%, p = 0.04). Patients in the PTCA group underwent repeat revascularization 11 times more frequently within 1 year (22% vs 2%). At 1 year, mortality was 23% in the PTCA group and 27% in the CABG group, with no statistical difference between the 2 groups. This nonrandomized comparison reveals that PTCA and CABG can be performed in selected renal dialysis patients with an acceptable in-hospital major complication rate; however, 1-year mortality remains high in dialysis patients after coronary revascularization. Therefore, attempts at improving outcome in dialysis patients should focus on the prevention and treatment of coronary artery disease before they require coronary revascularization.     

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.     

Impact of body mass index on in-hospital outcomes after percutaneous coronary intervention for ST segment elevation acute myocardial infarction.

BACKGROUND: The impact of body mass index (BMI) on outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) remains unclear. METHODS AND RESULTS: A total of 3,076 patients undergoing PCI for AMI within 48 h after symptom onset were studied. Patients were divided into 4 groups according to baseline BMI: lean (<20 kg/m(2)), normal weight (20.0-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)) and obese (>or=30.0 kg/m(2)). Obese patients were younger and had a higher frequency of diabetes mellitus, hyperlipidemia, hypertension and smoking. Lean patients were older, usually women and had a lower frequency of the aforementioned risk factors. Killip class on admission, renal insufficiency, and final Thrombolysis In Myocardial Infarction (TIMI) flow grade did not differ among the 4 groups. In lean, normal weight, overweight and obese patients, in-hospital mortality was 9.2%, 4.4%, 2.5% and 1.8%, respectively (p<0.01). Multivariate analysis showed that compared with normal weight patients, odds ratios for in-hospital death in lean, overweight and obese patients were 1.92, 0.79 and 0.40, respectively (p=NS). Independent predictors were age, Killip class on admission, renal insufficiency and final TIMI flow grade. CONCLUSION: BMI itself had no impact on in-hospital mortality in patients undergoing primary PCI for AMI. The phenomenon ;obesity paradox' may be explained by the fact that obese patients were younger at presentation.     

Clinical trials of revascularization therapy in diabetics

Diabetic patients are a high-risk group for cardiovascular morbidity and mortality, with poorer long-term outcomes, with or without revascularization, than non-diabetic patients. Results from the Bypass Angioplasty Revascularization Investigation (BARI) trial, the largest randomized study of coronary revascularization strategies, showed that diabetic patients with multivessel coronary disease who were undergoing an initial revascularization procedure had a significant long-term survival advantage with coronary artery bypass graft surgery (CABG) compared with percutaneous transluminal coronary angioplasty (PTCA). The 8-year follow-up data from the Emory Angioplasty Versus Surgery Trial (EAST) study, the other major US trial of CABG versus PTCA, and results of other clinical trials that enrolled similar patients are consistent with an advantage for CABG in diabetic patients but not for nondiabetic patients. This benefit is entirely a result of improved cardiac mortality. It is limited to patients receiving an internal mammary artery (IMA) graft and is apparent earlier in insulin-treated patients. The benefit of CABG in diabetic patients may be significantly related to a protective effect on mortality after myocardial infarction, because CABG greatly reduced the risk of death after spontaneous Q-wave myocardial infarction in BARI-eligible diabetic patients (relative risk 0.09, P<0.001), an effect not seen in non-diabetic patients.     

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes

OBJECTIVES: We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes. BACKGROUND: Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published. METHODS: We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. RESULTS: We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.     

The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox?

OBJECTIVES: The purpose of this study was to assess the impact of body mass index (BMI) on the short- and long-term outcomes after percutaneous coronary intervention (PCI). BACKGROUND: Obesity is associated with advanced coronary artery disease (CAD). However, the relation between BMI and outcome after PCI remains controversial. METHODS: We studied 9,633 consecutive patients who underwent PCI between January 1994 and December 1999. Patients were divided into three groups according to BMI: normal, BMI between 18.5 and 24.9 (n = 1,923); overweight, BMI between 25 and 30 (n = 4,813); and obese, BMI >30 (n = 2,897). RESULTS: Obese patients were significantly younger and had consistently worse baseline clinical characteristics than normal or overweight patients, with a higher incidence of hypertension, diabetes, hypercholesterolemia and smoking history (p < 0.0001). Despite similar angiographic success rates among the three groups, normal BMI patients had a higher incidence of major in-hospital complications, including cardiac death (p = 0.001). At one-year follow-up, overall mortality rates were significantly higher for normal BMI patients compared with overweight or obese patients (p < 0.0001). Myocardial infarction and revascularization rates did not differ among the three groups. By multivariate Cox regression analysis, diabetes, hypertension, age, BMI and left ventricular function were independent predictors of long-term mortality. CONCLUSIONS: In patients with known CAD who undergo PCI, very lean patients (BMI <18.5) and those with BMI within the normal range are at the highest risk for in-hospital complications and cardiac death and for increased one-year mortality.     

Staged revascularization in critically ill patients with coronary artery disease

BACKGROUND: Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity. HYPOTHESIS: The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock. METHODS: We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock. RESULTS: Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management. CONCLUSIONS: Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.     

The consequences of under-use of coronary revascularization; results of a cohort study in Northern Italy.

AIM: To assess whether under-use of coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) affects patient outcome. PATIENTS AND METHODS: A prospective observational study was performed following up a cohort of patients, candidates for a revascularization procedure (either CABG or PTCA) after an index angiogram. A total of 1258 patients, candidates -- according to explicit criteria -- for either CABG or PTCA entered the study enrolled by 16 hospitals located in a Northern Italian region (Lombardia). Information on demographic and clinical characteristics, type of care received (i.e. CABG or PTCA performed Yes/No) and vital status was obtained from revascularization laboratories, patients' hospital medical records and local census offices of the town of patients' residence. The main outcome measure was total unadjusted and adjusted mortality at a minimum follow-up of 9 months after the index cardiac angiogram. RESULTS: Patients who received CABG or PTCA (n=863) had lower mortality than those who did not (n=350) (4.8% vs 10.6%, P=0.001). This held true after adjustment for relevant risk factors between the two groups such as extent of coronary artery disease, clinical symptoms, and cardiac surgical risk index (adjusted odds ratio=0.48; 95% confidence intervals=0.30--0.77) and after performing a survival analysis (adjusted hazard ratio=0.31; 95% confidence intervals=0.19--0.50). CONCLUSIONS: Failure to perform a revascularization procedure when it was indicated led, in this study, to a significantly increased mortality showing that under-use of effective procedures may represent a significant quality of care problem even in areas where health care systems are well developed. Although the study was not specifically designed to identify determinants of under-use (i.e. reduced capacity leading to waiting lists, physicians' competence or patients' refusal to undergo a recommended procedure) our data suggest that limited capacity could have been the most important reason. Our findings also provide further evidence of the validity of the RAND method to assess the impact of under-use of coronary revascularization procedures.     

Impact of body mass index on the outcome of patients with multivessel disease randomized to either coronary artery bypass grafting or stenting in the ARTS trial: The obesity paradox II?

The effect of body mass index (BMI) on outcomes after coronary artery revascularization remains controversial. We studied 1,203 patients who had multivessel coronary artery disease and underwent stenting (n = 599) or coronary artery bypass grafting (CABG; n = 604) in the Arterial Revascularization Therapies Study. Patients were assigned to 1 of 3 groups according to BMI: <25, 25 to 30, and >30 kg/m(2). At 3-year follow-up, the incidence of death, cerebrovascular events, or myocardial infarction was similar for these BMI categories regardless of the revascularization technique used. Rates of repeat revascularization procedures were significantly higher among patients who had been randomized to stenting but were similar across BMI groups. For patients who had been randomized to undergo CABG, there was a significant decrease in repeat revascularization procedures in obese patients (p = 0.03). Among patients who underwent stenting, BMI had no effect on the 3-year combined end point of rate of major adverse cardiac or cerebrovascular events. Among patients who underwent CABG, major adverse cardiac or cerebrovascular event rates were significantly lower for patients who were obese (11%) or overweight (16%) compared with patients who had a normal BMI (24%; p = 0.008). Thus, in a large cohort of patients who had multivessel coronary artery disease and underwent surgical or percutaneous revascularization, BMI had no effect on 3-year outcome of those who underwent stenting. Conversely, among patients who underwent CABG, those who were overweight or obese had a significantly better outcome than did those who had a normal BMI with regard to survival without major adverse cardiac or cerebrovascular events, mainly due to lower rates of repeat revascularization procedures.     

Impact of body mass index on the one-year clinical outcome of patients undergoing multivessel revascularization with sirolimus-eluting stents (from the Arterial Revascularization Therapies Study Part II)

The differential safety and efficacy profiles of sirolimus-eluting stents when implanted in patients with multivessel coronary artery disease who have increased body mass indexes (BMIs) compared with those with normal BMIs are largely unknown. This study evaluated the impact of BMI on 1-year outcomes in patients with multivessel coronary artery disease treated with sirolimus-eluting stents as part of the Arterial Revascularization Therapies Study Part II (ARTS II). From February to November 2003, 607 patients were included at 45 centers; 176 patients had normal BMIs (<25 kg/m(2)), 289 were overweight (> or =25 and < or =30 kg/m(2)), and 142 were obese (>30 kg/m(2)). At 30 days, the cumulative incidence of the primary combined end point of death, myocardial infarction, cerebrovascular accident, and repeat revascularization (major adverse cardiac and cerebrovascular events) was 3.4% in the group with normal BMIs, 3.1% in overweight patients, and 2.8% in obese patients (p = 0.76). At 1 year, the cumulative incidence of major adverse cardiac and cerebrovascular events was 10.8%, 11.8%, and 7.0% in the normal BMI, overweight, and obese groups, respectively (p = 0.31). In conclusion, BMI had no impact on 1-year clinical outcomes in patients with multivessel coronary artery disease treated with sirolimus-eluting stents in ARTS II.     

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.     

Impact of obesity on disease-specific health status after percutaneous coronary intervention in coronary disease patients

OBJECTIVE: Several investigators have focused on obesity as a specific risk factor for mortality in patients undergoing bypass surgery, but few have examined it as a risk factor among patients undergoing percutaneous coronary interventions (PCI). In addition, none have evaluated the impact of obesity on post-PCI quality of life or disease-specific health status. This study examined whether obesity is a risk factor for poor quality of life or diminished health status 12-months postprocedure among a large cohort of PCI patients. RESEARCH METHODS AND PROCEDURES: A total of 1631 consecutive PCI patients were enrolled into the study and classified as underweight (BMI <20 kg/m2), normal weight range (BMI >/=20 and <25 kg/m2), overweight (BMI >/=25 and <30 kg/m2), class I obese (BMI >/=30 kg/m2), or class II and III obese (BMI >/=35 kg/m2). The 12-month postprocedure outcomes included need for repeat procedure, survival, quality of life and health status, assessed using the Seattle Angina Questionnaire (SAQ) and the Short Form-12. RESULTS: Obese patients with and without a history of revascularization were significantly younger than overweight, normal weight range, or underweight patients at the time of PCI. However, obese patients demonstrated similar long-term recovery and improved disease-specific health status and quality of life when compared to patients in the normal weight range after PCI. In addition, mortality and risk for repeat procedure was similar to those patients in the normal weight range patients at 12-months postrevascularization. Underweight patients who had no previous history of revascularization reported lower quality of life (F=3.02; P=0.018) and poorer physical functioning (F=2.82; P=0.024) than other BMI groups. CONCLUSION: Obese patients presenting for revascularization were younger when compared to patients in the normal weight range, regardless of previous history of revascularization. However, weight status was not a significant predictor of differences in long-term disease-specific health status, quality of life, repeat procedures, or survival. Underweight patients demonstrated less improvement in quality of life and physical functioning than other BMI groups.     

Long-term outcome of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in patients with end-stage renal disease

This study was conducted to investigate therapeutic methods for end-stage renal disease (ESRD) by retrospectively analyzing in-hospital outcome and long-term outcome in patients who underwent either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Ninety-two patients underwent PTCA and 47 underwent CABG, and the initial success rates were 87% and 85%, respectively. As major in-hospital complications, in the PTCA group 1 died (1%), 2 required emergency CABG (2%), and 2 had Q-wave myocardial infarction (2%); in the CABG group, 7 died (15%) and 3 had Q-wave myocardial infarction (6%). As for the long-term outcome, although there were no differences in the incidence of death or the incidence of cardiac death between the 2 groups, the cumulative proportion of patients free of death, myocardial infarction, CABG and repeat PTCA was lower in the PTCA group, which was mainly due to a higher incidence of repeat PTCA in that group. The incidence of cardiac death was low for both groups among the patients attaining complete revascularization. Twenty-three percent of the patients required cross-over implementation of PTCA and CABG. In conclusion, it is necessary to aim for complete revascularization using both treatments for a better prognosis in patients with ESRD.     

Medical therapies and invasive treatments for coronary artery disease by body mass: the "obesity paradox" in the Get With The Guidelines database

Previous studies of hospitalized patients have suggested an "obesity paradox" with lower short-term mortality as weight increases. We hypothesized that some of this difference might be related to more aggressive management. To evaluate the effect of body mass index (BMI) on treatments and outcomes in patients with coronary artery disease (CAD), the Get With The Guidelines database was investigated. From 409 United States hospitals, 130,139 hospitalizations for CAD were identified with documented height and weight. Patients were stratified by BMI, with 3,305 (2.5%) underweight (BMI <18.5 kg/m(2)), 34,697 (27%) of healthy weight (BMI 18.5 to 24.9 kg/m(2)), 47,883 (37%) overweight (BMI 25 to 29.9 kg/m(2)), 37,686 (29%) obese (BMI 30 to 39.9 kg/m(2)), and 6,568 (5%) extremely obese (BMI > or =40 kg/m(2)). As BMI increased, patients were significantly younger but more likely to be men and have hypertension, diabetes, and hyperlipidemia. Unadjusted in-hospital mortality was highest in the underweight group (10.4%) and significantly lower in the healthy-weight (5.4%), overweight (3.1%), obese (2.4%), and extremely obese (2.9%) patients. Higher BMI was associated with increased use of standard medical therapies such as aspirin, beta blockers, inhibitors of the renin-angiotensin system, and lipid-lowering therapy in the hospital and at discharge. In adjusted analyses, compared with the healthy-weight group, overweight and obese patients were more likely to undergo invasive procedures and had lower mortality (p <0.01 for all odds ratios). In conclusion, increasing BMI appears to be associated with better use of guideline-recommended medical treatment and invasive management of CAD, which may explain the observed lower rates of in-hospital mortality.     

The relationship of body mass index to outcomes after percutaneous coronary intervention

OBJECTIVES: To evaluate the effect of body mass index (BMI) on in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI) at a tertiary care hospital center in Ontario, Canada. BACKGROUND: Obesity is present in a large population of patients undergoing revascularization with PCI. METHODS: Retrospective analysis of 4,631 patients aged 62.0 +/- 12 years, stratified by BMI into five groups: nonobese (<25 kg/m2); overweight (25-29.9 kg/m2); class I obese (30-34.9 kg/m2); class II obese (35-39.9 kg/m2); and class III obese (> or =40 kg/m2). RESULTS: A BMI >25 kg/m2 was present in 79% of patients, and 35% were obese (BMI > or =30 kg/m2). Obese patients, particularly the class III obese, were significantly younger and had higher prevalence of diabetes, hypertension, and dyslipidemia (P < 0.0001). After adjustment for several covariates, lower BMI was independently associated with higher risk of major bleeding requiring transfusion (adjusted odds ratio [OR]= 1.40, 95% confidence interval [CI] 1.04-1.88, P = 0.025), and femoral hematoma (adjusted OR = 1.14, 95% CI 1.05-1.25, P = 0.003) in lean (<20 kg/m2) and normal BMI (20-24.9 kg/m2) patients. Obesity was not associated with death, myocardial infarction, repeat PCI, coronary artery bypass grafting, or major adverse cardiac event. CONCLUSIONS: Obesity is not associated with increased risk of adverse postprocedural in-hospital outcomes. These findings, however, do not discount the need for sustained efforts in secondary prevention of obesity and its consequences.     

Physicians' judgments of survival after medical management and mortality risk reduction due to revascularization procedures for patients with coronary artery disease

STUDY OBJECTIVE:s: To assess the accuracy of physicians' judgments of survival probability for medically managed patients with coronary artery disease (CAD), and of the absolute risk reduction of mortality due to coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for such patients; and relationships among these judgments and the physicians' propensity to perform revascularization. DESIGN: Two surveys (for three-vessel or two-vessel CAD) for patients presenting with stable CAD, currently managed medically, and without other life-limiting problems. SETTING: Multiple educational conferences, 1996-1997. PARTICIPANTS: Conference attendees. MEASUREMENTS AND RESULTS: Main outcomes were proportions of patients for whom the physicians would recommend revascularization (CABG for three-vessel CAD, CABG or PTCA for two-vessel CAD), and judgments of the proportions of medically managed patients who would be alive after 5 years, 7 years, and 11 years, and of absolute risk reduction of mortality due to CABG (or PTCA for two-vessel CAD). At least one half of the participants judged the survival rate of medically managed patients with three-vessel or two-vessel CAD to be less than the lowest rates supported by the best available evidence. More than one fourth judged the absolute risk reduction due to CABG to be higher than the highest values based on such evidence. Physicians' propensity to perform revascularization correlated inversely with their judgments of survival given medical management, and with their judgments of absolute risk reduction due to revascularization. CONCLUSIONS: Physicians may overuse revascularization because of excessive pessimism about survival of medically managed patients, and excessive optimism about the survival benefits of revascularization.     

Effect of body mass index on early outcomes in patients undergoing coronary artery bypass surgery

OBJECTIVES: This study sought to quantify the effect of body mass index (BMI) on early clinical outcomes following coronary artery bypass grafting (CABG). BACKGROUND: Obesity is considered a risk factor for postoperative morbidity and mortality after cardiac surgery, although existing evidence is contradictory. METHODS: A concurrent cohort study of consecutive patients undergoing CABG from April 1996 to September 2001 was carried out. Main outcomes were early death; perioperative myocardial infarction; infective, respiratory, renal, and neurological complications; transfusion; duration of ventilation, intensive care unit, and hospital stay. Multivariable analyses compared the risk of outcomes between five different BMI groups after adjusting for case-mix. RESULTS: Out of 4,372 patients, 3.0% were underweight (BMI <20 kg/m(2)), 26.7% had a normal weight (BMI >or=20 and <25 kg/m(2)), 49.7% were overweight (BMI >or=25 and <30 kg/m(2)), 17.1% obese (BMI >or=30 and <35 kg/m(2)) and 3.6% severely obese (BMI >or=35 kg/m(2)). Compared with the normal weight group, the overweight and obese groups included more women, diabetics, and hypertensives, but fewer patients with severe ischemic heart disease and poor ventricular function. Underweight patients were more likely than normal weight patients to die in hospital (odds ratio [OR] = 4.0, 95% CI 1.4 to 11.1), have a renal complication (OR = 1.9, 95% confidence interval [CI] 1.0 to 3.7), or stay in hospital longer (>7 days) (OR = 1.7, 95% CI 1.1 to 2.5). Overweight, obese, and severely obese patients were not at higher risk of adverse outcomes than normal weight patients, and were less likely than normal weight patients to require transfusion (ORs from 0.42 to 0.86). CONCLUSIONS: Underweight patients undergoing CABG have a higher risk of death or complications than normal weight patients. Obesity does not affect the risk of perioperative death and other adverse outcomes compared to normal weight, yet obese patients appear less likely to be selected for surgery than normal weight patients.     

Early and late results of coronary angioplasty and bypass in octogenarians

Early and late results were evaluated for octogenarians undergoing first time revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The study group consisted of 142 patients with CABG and 53 with PTCA. The groups with PTCA and CABG differed with respect to number of patients with angina class III to IV (92 and 67%, respectively; p less than 0.001), number with 3-vessel disease (34 and 77%, respectively; p less than 0.001), presence of left main trunk disease (2 and 24%, respectively; p less than 0.001) and number with normal or mildly impaired left ventricular function (82 and 65%, respectively; p less than 0.034). The groups with PTCA and CABG had similar procedural complications, including myocardial infarction (6 and 4%, respectively) and stroke (0 and 4%, respectively). Hospital mortality was low (6% with CABG and 2% with PTCA). Three year survival, excluding hospital mortality, was 87% in patients with CABG and 81% in those with PTCA (p = 0.493). Octogenarians underwent revascularization procedures with relatively low morbidity and mortality. In regard to the excellent long-term survival, "very" elderly patients with severe coronary artery disease should be considered for revascularization despite advanced age.     

Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome.

AIMS: The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making. METHODS AND RESULTS: The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences. RESULTS: The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1.28; 95% CI: 1.10-1.49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1.03; 95% CI: 0.87-1.24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group. CONCLUSION: When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7-8 years, reintervention was greater in patients who had initial CABG.