老年非ST段抬高急性冠状动脉综合征患者早期PCI的临床疗效分析

目的 评价老年非ST段抬高急性冠状动脉综合征(ACS)患者早期行经皮冠状动脉介入治疗(PCI)的临床疗效.方法 对58例发病在48 h以内的老年非ST段抬高ACS患者早期行PCI.观察患者术后主要不良心血管事件(包括再次心肌梗死、靶血管再次血管重建和死亡)的发生情况.结果 冠状动脉造影(CAG)显示2支或2支以上血管病变的患者占74.14%,B型和C型病变占89.66%.58例患者共干预病变血管76支,靶病变87处,置入支架96个.56例患者手术成功,手术成功率96.55%(56/58).对55例患者术后随访6～14个月,无心肌梗死和死亡发生.6例(10.91%)患者术后4～10个月复发心绞痛,5例行CAG复查,发现2例支架再狭窄和3例新的血管病变,对4例病变血管狭窄程度超过75%的患者进行了靶病变再次血管成形术.结论 老年非ST段抬高ACS患者冠状动脉病变常为复杂、多支病变,对其早期行PCI成功率高,近期及远期疗效良好,主要不良心血管事件发生率低,安全可行.     

NSTE-ACS多支血管病变靶血管的判定

急性冠状动脉综合征(ACS)涵盖了不稳定性心绞痛、非ST段抬高心肌梗死和ST段抬高心肌梗死,并把不稳定性心绞痛、非ST段抬高心肌梗死合称为非ST段抬高的急性冠状动脉综合征(NSTE-ACS)。ACS的病理学特征为冠状动脉的易损斑块,斑块破裂后触发的血小板激活和凝血酶形成,最终导致血栓形成是ACS是主要发病机制。研究证明,对NSTE-ACS患者早期进行介入干预治疗可是患者获益,特别是中高危的NSTE-ACS患者。ACS的介入治疗指南推荐首先对引起症状的冠状动脉狭窄性病变,即“罪犯”血管病变行PCI。对于合并多支血管病变NSTE-ACS患者如何确定靶病变也就成为介入医生面临的问题,而对患者病史及相     

无保护左主干病变合并急性冠状动脉综合征介入与手术治疗对比研究

目的:探讨急性冠状动脉综合征(ACS)合并无保护左主干病变患者经桡动脉介入治疗(TRI)与冠状动脉旁路移植术(CABG)二者的疗效。方法:连续入选2008年3月至2010年12月,于北京安贞医院行经桡动脉介入治疗(n=236)或冠状动脉旁路移植术(n=354)的无保护左主干病变合并ACS患者。对于患者的临床基线特征及冠状动脉病变特征纳入倾向性评分模型进行匹配,得到154对患者。结果:平均随访时间27个月。经过倾向性评分模型进行校正,两组患者的基线资料及病变特征无显著差异。结果显示TRI与CABG两组全因病死率(4.5%vs.6.5%;P=0.454)及心肌梗死发生率(5.2%vs.7.8%;P=0.355)并差异无统计学意义。CABG组患者脑卒中发生率显著增加(零vs.2.6%;P=0.044),而TRI组靶血管重建率(TVR)显著增加(13.0%vs.5.2%;P=0.017)。两组患者复合终点(死亡/心肌梗死/靶血管重建),差异无统计学意义(7.1%vs.12.3%;P=0.124)。结论:对于ACS合并无保护左主干病变患者TRI与CABG的临床复合终点事件风险相似,然而尽管应用药物洗脱支架CABG组患者靶血管重建率仍显著低于介入治疗组。     

冠状动脉血管成形术治疗非ST段抬高的急性冠状动脉综合征

非ST段抬高的急性冠状动脉综合征 (ACS)是指冠心病不稳定型心绞痛 (UAP)和非Q波型急性心肌梗死 (NQMI)。2 0世纪 90年代中期以来 ,随着对非ST段抬高的ACS发病机理的深入研究 ,对它的治疗取得了较大的进步。本文对冠状动脉血管成形术治疗非ST段抬高的ACS的进展进行综述。一、冠状动脉血管成形术治疗非ST段抬高的ACS1 直接冠状动脉血管成形术治疗非ST段抬高的ACS :指在非ST段抬高的ACS患者发病早期 (2 4～ 4 8h)行常规冠状动脉造影 ,若无禁忌证 ,同时行冠状动脉血管成形术 ,包括经皮冠状动脉介入治疗 (PCI)或冠状动脉旁路移…     

介入治疗在非ST段抬高急性冠状动脉综合征中的价值

目的　比较不稳定心绞痛和非ST段抬高心肌梗死患者介入治疗和药物治疗的疗效。方法　 2 0 0 0年 1月至 2 0 0 1年 6月我院心脏科收治的不稳定心绞痛和非ST段抬高心肌梗死患者共2 4 9例 ,按治疗方法的不同分为药物保守治疗组和介入治疗组。介入治疗组在药物治疗的基础上于入院后 3～ 7d根据冠状动脉造影结果行血管重建术。随访患者的心源性死亡率和 (或 )急性心肌梗死发生率 (主要终点 ) ,心绞痛复发率、再入院率和再次血管重建率 (次要终点 )。结果　 16 3例患者接受药物治疗 ,2 4 9例患者行介入治疗。在平均 (11 0± 5 7)个月的随访中 ,介入治疗组心源性死亡率和 (或 )急性心肌梗死发生率明显低于药物保守治疗组 (3 2 %比 9 2 % ,P =0 0 1) ;心绞痛复发率(2 0 %比 5 3% ,P =0 0 0 1)、再入院率 (16 %比 4 7% ,P =0 0 0 1)和再次血管重建率 (15 %比 4 2 % ,P =0 0 0 1)也明显低于药物保守治疗组。结论　介入治疗可显著改善不稳定心绞痛和非ST段抬高心肌梗死患者的预后 ,可作为大多数患者的首选治疗策略。     

远端血栓保护装置PercuSurge用于急性冠状动脉综合征经皮冠状动脉介入治疗

目的　评价在高危急性冠状动脉综合征 (ACS)患者的经皮冠状动脉介入治疗 (PCI)过程中联合应用远端血栓保护装置PercuSurge预防远端血栓栓塞的安全性及有效性。方法　 15 4例ACS患者接受了PCI。其中 ,74例ACS患者 (男 6 5例 ,女 9例 ,平均年龄 5 7± 10岁 ,ST段抬高心肌梗死 5 3例 ,不稳定型心绞痛及非ST段抬高心肌梗死 2 1例 )在PercuSurge装置的保护下进行PCI(PercuSurge组 ) ;80例ACS患者 (男 6 8例 ,女 12例 ,平均年龄 (5 6± 10岁 ,ST段抬高心肌梗死 5 8例 ,不稳定型心绞痛及非ST段抬高心肌梗死 2 2例 )进行无保护的常规PCI(对照组 )。首要研究终点是院内和 30d的MACE。次级研究终点是PCI术后的TIMI血流和PercuSurge的临床疗效及并发症。结果　两组全部病例均成功地置入血管支架 ,PercuSurge组全部成功放置PercuSurgeGuardWire保护装置 ,平均阻滞球囊直径 4 8± 0 6mm ,平均阻滞时间 9± 7min。PercuSurge组术后TIMI 3级血流率显著高于对照组(94 5 9%与 81 2 5 % ,P <0 0 5 )。并发症包括 1例血管夹层 (1 35 % )、1例远端小血管血栓栓塞(1 35 % )、1例PercuSurge导丝所致血管穿孔 (1 35 % )。PercuSurge组院内及 30d主要不良心脏事件(MACE)显著低于对照组 (分别为 4 0 5 %与 16 2 5 %、2 70     

非ST段抬高急性冠状动脉综合征患者的早期紧急介入治疗

目的评价非ST段抬高急性冠状动脉综合征(acute coronary syndrome,ACS)患者早期应用紧急经皮冠状动脉介入治疗(PCI)的临床疗效。方法2000年1月至2005年9月我院收治的385例中、高危非ST段抬高ACS患者,根据药物治疗后病情变化,分别在入院1~2 d内(233例,紧急介入组)或3~14 d(152例,延迟介入组)行冠状动脉造影(CAG)及PCI。所有“罪犯”病变均予治疗,介入方法有经皮冠状动脉腔内成形术(PTCA) 支架、直接置入支架等。观察两组手术成功率、心绞痛缓解时间、住院时间和PCI后30 d及6个月心源性死亡、心绞痛复发等不良心脏事件发生率。结果紧急介入组手术成功率与延迟介入组相似,分别为98.1%和95.5%(P>0.05),但入院至心绞痛缓解时间分别为(2.9±1.1)d和(6.0±3.6)d(P<0.05);住院时间分别为(9.7±4.3)d和(14.2±6.6)d(P<0.05);在住院期间,两组患者均无急性心肌梗死、猝死及心功能恶化发生。30 d随访期间紧急介入组总不良心脏事件发生率较延迟介入组明显减少,二者分别为2.9%和14.1%(P<0.01)。结论在条件具备的介入中心,由经验丰富和技术娴熟的介入治疗医生施行或在其指导下,对非ST段抬高ACS患者进行早期紧急介入治疗是积极、有效的治疗措施,近、远期临床效果较满意,手术成功率及安全性较高,可作为大多数非ST段抬高ACS患者的首选治疗策略。     

急性冠状动脉综合征的介入治疗

急性冠状动脉综合征 ( ACS)是一组冠状动脉粥样硬化斑块破裂、血栓形成或血管痉挛而致急性或亚急性心肌缺血的临床综合征。目前 ,根据患者心电图 ST段是否抬高而将其分成 ST段抬高的 ACS,即 ST段抬高的急性心肌梗死( STEMI)和无 ST段抬高的 ACS,后者包括不稳定性心绞痛( U A)和无 ST段抬高的心肌梗死 ( NSTEMI)。 U A/ NSTEMI又合称为不稳定性冠状动脉疾病 ( UCAD)。1　 UA/ NSTEMI的介入治疗U A/ NSTEMI患者的处理有两种不同的策略 ,即早期保守治疗和早期有创治疗。前者的原则是 ,患者仅反复缺血 (静息时或稍活动…     

老年糖尿病合并非ST段抬高的急性冠状动脉综合征的急诊介入疗效观察

目的观察≥60岁老年糖尿病(DM)合并非ST段抬高的急性冠状动脉综合征(ACS)患者急诊介入治疗的安全性及临床效果.方法选择同期行急诊介入治疗的≥60岁DM合并非ST段抬高的ACS患者63例(DM组)与≥60岁非DM合并非ST段抬高ACS患者77例(对照组),确诊后2h内行冠状动脉造影证实病变,术中仅对"罪犯"病变介入干预.残余狭窄≤20%,前向血流TIMI 3级为手术成功标准;心绞痛复发、急性心肌梗死、心源性死亡和靶病变再次血运重建为随访终点.结果DM组PTCA 支架植入71枚,对照组PTCA 支架植入71枚,直接植入支架8枚,手术成功率(93.7%对97.4%,P＞0.05);患者症状明显减轻或消失率(88.9%对94.8%,P＞0.05);无急性闭塞和死亡病例.相同方式随访DM组47例及对照组59例2～14个月,平均(8.6±3.5)个月,心绞痛复发率(48.9%对32.2%,P＞0.05);无致死性AMI及心脏性猝死发生;对DM组29例、对照组33例冠状动脉造影复查,"罪犯"病变的再狭窄率(31.0%对21.2%,P＞0.05);DM组再狭窄者6例接受冠状动脉旁路移植术(CABG),1例再次支架植入,2例继续接受药物治疗,1例因心功能恶化于介入治疗后3个月死亡;非DM组2例接受CABG,4例再次PTCA,其中3例再次植入支架,1例接受药物治疗.结论在人力和设备有保障的心脏介入中心,对老年DM合并非ST段抬高的ACS患者行急诊介入治疗,手术安全、有效;随访期内,DM组再狭窄率及靶病变再次血运重建率比对照组略高;急诊介入干预"罪犯"病变是老年DM合并非ST段抬高的ACS患者可选择的治疗策略.     

主动脉内球囊反搏辅助高危急性冠状动脉综合征患者主要不良心血管事件危险因素分析

目的 探讨主动脉内球囊反搏术(IABP)辅助治疗高危急性冠状动脉综合征(ACS)患者住院期间发生主要不良心血管事件(MACE)的影响因素。方法 选择2014年10月～2019年12月青岛市市立医院心脏中心行IABP辅助高危冠状动脉血运重建患者350例,根据住院期间是否发生MACE分为MACE组81例,无MACE组269例。比较2组一般临床资料,采用多因素二元logistic回归分析,ROC曲线分析生物标志物和疾病严重程度评分的临床预测价值,计算曲线下面积(AUC)。结果 MACE组年龄、吸烟、高血压、高脂血症、心源性休克、ST段抬高型心肌梗死、冠状动脉狭窄程度、舒张压、心率、肌酐水平明显高于无MACE组,不稳定性心绞痛、收缩压、LVEF、IABP后CABG和住院时间明显低于无MACE组(P<0.05,P<0.01)。多因素二元logistic回归分析显示,年龄(OR=1.099,95%CI:1.026～1.178,P=0.007)、吸烟(OR=3.175,95%CI:1.250～8.067,P=0.015)、高脂血症(OR=3.430,95%CI:1.453～8.067,P...     

Predictive value of HbA1c level for in-hospital acute coronary syndrome patients with diabetes

Background Diabetes mellitus (DM) is the major risk factor of coronary artery disease (CAD), and the control status of blood sugar has direct effect on the prognosis of CAD. HbA1c is the important parameter reflecting control status of blood sugar, however, it is unclear about the value of in-hospital HbA1c in patients with acute coronary syndrome (ACS). Methods A retrospective analysis was performed for 236 in-hospital diabetic patients with ACS. Patients were stratified into two groups according to HbA1c level when admission (Well controlled group (HbA1c≤7.0%) and High HbA1c group (HbA1c > 7.0% ); major adverse cardiovascular events (MACE) group and Non-MACE group). In-hospital MACE and mortality were set as the observation target. Results 282 patients (112 in Well controlled group and 170 in High HbA1c group) were enrolled, of which 146 (51.77%), 63 (23.34%), and 73 (25.89%) patients respectively had unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Inhospital all-cause mortality and in-hospital MACE were both similar in Well controlled group and High HbA1c group (6.25% vs. 7.06% and 15.18% vs. 16.47%, P > 0.05). In MACEs, cardiac death (4.46% vs. 5.29%), recurrent myocardial infarction (2.68% vs. 2.94%), hemorrhage events (5.35% vs. 5.29%), malignant arrhyth- mia (6.25% vs. 5.29%), cardiac shock (4.46% vs. 4.12%), acute heart failure (8.93% vs. 10.0%), revascularization (4.46% vs. 5.29%) were also all similar in both two groups. In addition, there were no significant difference in HbA1c level between MACE group and Non-MACE group. Single-factor logistic regression analysis showed that HbA1c was not a risk factor for in-hospital MACE (P > 0.05) 1 . Conclusion The present study sug-gests that admission HbA1c is not the risk factor of in-hospital MACE in ACS patients with diabetes.     

Comparison of one-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease and acute coronary syndromes (from the CUSTOMIZE Registry)

Uncertainty surrounds the optimal revascularization strategy for patients with left main coronary artery disease presenting with acute coronary syndromes (ACSs), and adequately sized specific comparisons of percutaneous and surgical revascularization in this scenario are lacking. The aim of this study was to evaluate the incidence of 1-year major adverse cardiac events (MACEs) in patients with left main coronary artery disease and ACS treated with percutaneous coronary intervention (PCI) and drug-eluting stent implantation or coronary artery bypass grafting (CABG). A total of 583 patients were included. At 1 year, MACEs were significantly higher in patients treated with PCI (n = 222) compared to those treated with CABG (n = 361, 14.4% vs 5.3%, p <0.001), driven by a higher rate of target lesion revascularization (8.1% vs 1.7%, p = 0.001). This finding was consistent after statistical adjustment for MACEs (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 5.9, p = 0.01) and target lesion revascularization (adjusted HR 8.0, 95% CI 2.2 to 28.7, p = 0.001). No statistically significant differences between PCI and CABG were noted for death (adjusted HR 1.1, 95% CI 0.4 to 3.0, p = 0.81) and myocardial infarction (adjusted HR 4.8, 95% CI 0.3 to 68.6, p = 0.25). No interaction between clinical presentation (ST-segment elevation myocardial infarction or unstable angina/non-ST-segment elevation myocardial infarction) and treatment (PCI or CABG) was observed (p for interaction = 0.68). In conclusion, in patients with left main coronary artery disease and ACS, PCI is associated with similar safety compared to CABG but higher risk of MACEs driven by increased risk of repeat revascularization.     

Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II)

OBJECTIVES: The purpose of the present study is to report the five-year follow-up results of the ERACI II trial. BACKGROUND: Immediate and one-year follow-up results of the ERACI II study showed a prognosis advantage of percutaneous coronary intervention (PCI) with stents over coronary artery bypass grafting (CABG). METHODS: A total of 450 patients were randomly assigned to undergo either PCI (n = 225); or CABG (n = 225). Only patients with multi-vessel disease were enrolled. Clinical follow-up during five years was obtained in 92% of the total population after hospital discharge. The primary end point of the study was to compare freedom from major adverse cardiovascular events (MACE) at 30 days, 1 year, 3 years, and 5 years of follow-up. RESULTS: At five years of follow-up, patients initially treated with PCI had similar survival and freedom from non-fatal acute myocardial infarction than those initially treated with CABG (92.8% vs. 88.4% and 97.3% vs. 94% respectively, p = 0.16). Freedom from repeat revascularization procedures (PCI/CABG) was significantly lower with PCI compared with CABG (71.5% vs. 92.4%, p = 0.0002). Freedom from MACE was also significantly lower with PCI compared with CABG (65.3% vs. 76.4%; p = 0.013). At five years similar numbers of patients randomized to each revascularization procedure were asymptomatic or with class I angina. CONCLUSIONS: At five years of follow-up, in the ERACI II study, there were no survival benefits from any revascularization procedure; however patients initially treated with CABG had better freedom from repeat revascularization procedures and from MACE.     

Interpretation of new treatment guidelines for non-ST-segment elevation acute coronary syndromes: "ischemia-guided" versus "early invasive" strategies

The American College of Cardiology/American Heart Association Task Force on Practice Guidelines has recently published recommendations regarding the diagnosis and management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS). Conventional therapy for non-ST-segment elevation acute coronary syndrome (NSTE ACS) has traditionally employed an "ischemia-guided" approach in which diagnostic cardiac catheterization and revascularization are only used in patients with objective-evidence of residual myocardial ischemia as identified by recurrent symptoms or provocative stress testing. More recent studies, however, have demonstrated improved clinical outcomes with the use of an "early invasive" approach, employing routine coronary angiography early in the patient's hospital course, followed by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery where appropriate. Improved clinical outcomes associated with an "early invasive" strategy may have evolved as a consequence of recent advances in both adjunctive pharmacotherapy and revascularization technique. For example, use of GP IIb/IIIa inhibitors and/or low-molecular-weight heparin prior to catheterization have been shown to reduce clinical events in NSTE ACS patients, and may reduce the risk of an invasive approach by plaque passivation prior to interventional therapy. Perhaps more importantly, the combined use of GP IIb/IIIa inhibitors and intracoronary stenting may reduce the potential early hazard of an invasive approach by specifically decreasing the incidence of death and non-fatal myocardial infarction associated with percutaneous intervention. In spite of the benefits of this synergistic combination of pharmacology and mechanical revascularization, risk stratification remains important in identifying high-risk individuals most likely to benefit from an "early invasive" approach.     

Atorvastatin pretreatment improves outcomes in patients with acute coronary syndromes undergoing early percutaneous coronary intervention: results of the ARMYDA-ACS randomized trial.

OBJECTIVES: This study sought to investigate potential protective effects of atorvastatin in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). BACKGROUND: Randomized studies have shown that pretreatment with atorvastatin may reduce periprocedural myocardial infarction in patients with stable angina during elective PCI; however, this therapy has not been tested in patients with ACS. METHODS: A total of 171 patients with non-ST-segment elevation ACS were randomized to pretreatment with atorvastatin (80 mg 12 h before PCI, with a further 40-mg preprocedure dose [n = 86]) or placebo (n = 85). All patients were given a clopidogrel 600-mg loading dose. All patients received long-term atorvastatin treatment thereafter (40 mg/day). The main end point of the trial was a 30-day incidence of major adverse cardiac events (death, myocardial infarction, or unplanned revascularization). RESULTS: The primary end point occurred in 5% of patients in the atorvastatin arm and in 17% of those in the placebo arm (p = 0.01); this difference was mostly driven by reduction of myocardial infarction incidence (5% vs. 15%; p = 0.04). Postprocedural elevation of creatine kinase-MB and troponin-I was also significantly lower in the atorvastatin group (7% vs. 27%, p = 0.001 and 41% vs. 58%, p = 0.039, respectively). At multivariable analysis, pretreatment with atorvastatin conferred an 88% risk reduction of 30-day major adverse cardiac events (odds ratio 0.12, 95% confidence interval 0.05 to 0.50; p = 0.004). CONCLUSIONS: The ARMYDA-ACS trial indicates that even short-term pretreatment with atorvastatin may improve outcomes in patients with ACS undergoing early invasive strategy. These findings may support routine use of high-dose statins before intervention in patients with ACS.     

12-month outcomes of percutaneous and surgical revascularization in acute coronary syndromes without ST-segment elevation in patients with multivessel coronary artery disease

Early invasive strategy is one of two methods of treatment of acute coronary syndromes without ST-segment elevation (NSTEACS). We aimed at assessing 12-month outcomes and quality of life in patients with NSTEACS and multivessel coronary artery disease (CAD) who underwent percutaneous or surgical revascularization. Analyzed group comprised 412 patients (92%) who were qualified for invasive treatment based on coronary angiography performed 24 hours after admission and in whom long-term follow up data was available. The inclusion criteria were: rest angina within 24 hours prior to admission and at least one of the following: ST segment depression (> or = 0.5 mm), transient (< 20 min) ST-segment elevation, negative T-waves (> or = 1 mm)in at least 2 contiguous leads, positive serum cardiac markers. Patients with single-vessel CAD or qualified for conservative treatment were excluded from the study. We analysed the rate of adverse cardiac events (death, non-fatal myocardial infarction, unstable angina, repeated revascularization, cardiovascular hospitalization) at one year. The quality of life was assessed using Short-Form-36 (SF-36) questionnaire. The rate of death was 5.3% vs 9.3% (NS), myocardial infarction 3.4% vs 0% (p = 0.054), unstable angina 20.9% vs 2.8% (p = 0.0000), repeated revascularization 12.6% vs 0% (p = 0.0001) and cardiovascular hospitalization 36% vs 22.7% (p = 0.001) in the PCI and CABG group respectively. Physical Component Summary scores were 38.7 +/- 11.6 vs 43.08 +/- 9.5, p = 0.001 in the PCI and CABG group respectively. Mental Component Summary Scores were similar in both groups (46.34 +/- 13.05 vs 45.97 +/- 11.9, NS). Conclusions: Overall mortality rate was similar in both groups. PCI patients had more frequent rate of unstable angina, rate of hospitalization and repeat revascularization. This study has shown that there is a significant difference in health-related quality of life 12 months after PCI and CABG. This difference arises from better physical function (Physical Component) for CABG surgery patients compared with PCI patients. Despite impairment of the physical health status, the mental health status (Mental Component) remained similar in both groups.     

Outcomes of patients with acute coronary syndrome and previous coronary artery bypass grafting (from the Pravastatin or Atorvastatin Evaluation and Infection Therapy [PROVE IT-TIMI 22] and the Aggrastat to Zocor [A to Z] trials)

We examined the effects of intensive statin therapy in patients with acute coronary syndromes (ACSs) and previous coronary artery bypass graft surgery (CABG) participating in the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE-IT TIMI 22) and the Aggrastat to Zocor (A to Z) trials. Of the 8,655 patients enrolled in PROVE IT-TIMI 22 or A to Z, 640 (7.4%) had undergone CABG before enrollment. After a median follow-up of 2 years, compared with patients without previous CABG, those with previous CABG had a higher risk of cardiovascular death (6.2% vs 2.8%), myocardial infarction (14.2% vs 6.6%), and readmission for ACS (7.9% vs 4.4%, p <0.001 for all comparisons) but a lower rate of repeat coronary revascularization (22.7% vs 26.9%, p = 0.01). Compared with moderate statin therapy, intensive statin therapy appeared to decrease the composite of cardiovascular death, myocardial infarction, stoke, and readmission for an ACS (A to Z primary end point) to a similar extent in patients with (26.1% vs 21.6%, hazard ratio 0.84, p = 0.27) and without (13.9% vs 12.0%, hazard ratio 0.86, p = 0.016) previous CABG, although the decrease was not statistically significant in the previous CABG group, likely due to the small number of patients with previous CABG. In conclusion, compared with patients with ACS without previous CABG, those with previous CABG have a higher risk for adverse cardiac events and may derive similar benefit from intensive statin therapy.     

New-onset conduction defects and their relationship with in-hospital major cardiac events in unstable angina pectoris

BACKGROUND: The aim of this prospective cohort study was to describe the incidence and the risk factors for the development of intraventricular conduction defects and the relationship of these defects with in-hospital major cardiac events (MACE) in unstable angina pectoris. METHODS: Two-hundred-and-seventy consecutive patients presenting with Braunwald class IIIB angina without a conduction defect at admission were included in the study and followed up during the in-hospital period. RESULTS: Fifty-one patients who developed non-ST-elevation myocardial infarction during the first day were excluded from the study. Of the remaining 219 patients, 40 (18%) had a new permanent conduction defect (group 1) and 179 (82%) did not have a conduction defect (group 2) during the in-hospital period. The patients in group 1 were significantly older (mean age of 63.5 +/- 11 years compared with 59 +/- 10 years, P = 0.01) and a history of previous coronary artery bypass grafting (CABG) was more frequent in this group (12.5% compared with 1.6%, P = 0.004). By logistic regression analysis, age (P = 0.01, odds ratio (OR) = 1.473, 95% confidence interval (CI) = 1.108-2.612) and previous CABG (P = 0.005, OR = 3.995, 95% CI = 1.811-7.383) were also found to be risk factors for the development of a conduction defect. In-hospital total MACE, death and heart failure were more frequently observed in group 1 (P = 0.005, P = 0.02, P = 0.001, respectively). The incidences of recurrent refractory angina, acute myocardial infarction and urgent revascularization were not different between the groups. ST-segment depression at admission (P = 0.009, OR = 1.654, 95% CI = 1.228-2.675) and a new-onset conduction defect (P = 0.02, OR = 1.625, 95% CI = 1.244-2.754) were found to be predictors of the development of in-hospital MACE. CONCLUSIONS: In unstable angina pectoris, patients with a new-onset conduction defect are relatively older and have more frequently undergone previous CABG. Because in-hospital MACE, death and heart failure are more common in patients with a new conduction defect, they should be considered as high risk and treated more aggressively.     

Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.

OBJECTIVES: This study sought to systematically determine whether early invasive therapy improves survival and reduces adverse cardiovascular events in the management of non-ST-segment elevation acute coronary syndromes. BACKGROUND: Although early invasive therapy reduces recurrent unstable angina, the magnitude of benefit on other important adverse outcomes is unknown. METHODS: Clinical trials that randomized non-ST-segment elevation acute coronary syndrome patients to early invasive therapy versus a more conservative approach were included for analysis. RESULTS: In all there were 7 trials with 8,375 patients available for analysis. At a mean follow-up of 2 years, the incidence of all-cause mortality was 4.9% in the early invasive group, compared with 6.5% in the conservative group (risk ratio [RR] = 0.75, 95% confidence interval [CI] 0.63 to 0.90, p = 0.001), and at 1 month (RR = 0.82, 95% CI 0.50 to 1.34, p = 0.43). At 2 years of follow-up, the incidence of nonfatal myocardial infarction was 7.6% in the invasive group, versus 9.1% in the conservative group (RR = 0.83, 95% CI 0.72 to 0.96, p = 0.012), and at 1 month (RR = 0.93, 95% CI 0.73 to 1.19, p = 0.57). At a mean of 13 months of follow-up, there was a reduction in rehospitalization for unstable angina (RR = 0.69, 95% CI 0.65 to 0.74, p < 0.0001). CONCLUSIONS: Managing non-ST-segment elevation acute coronary syndromes by early invasive therapy improves long-term survival and reduces late myocardial infarction and rehospitalization for unstable angina.