Frequency, predictors, and outcomes of drug-eluting stent utilization in patients with high-risk non-ST-segment elevation acute coronary syndromes

Despite the established benefit of drug-eluting stents (DESs) in improving clinical and angiographic outcomes in pivotal, randomized trials, relatively little is known regarding the frequency and patterns of DES use in clinical practice. To characterize DES use in a broad, unselected high-risk non-ST-segment elevation acute coronary syndrome population, we evaluated the frequency, patterns, and predictors of DES use among patients in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Quality Improvement Initiative who were selected to undergo percutaneous coronary intervention. Of 8,852 patients with high-risk non-ST-segment elevation acute coronary syndromes who underwent percutaneous revascularization at 262 hospitals between October 2003 and June 2004, 5,858 (66.2%) were treated with DESs and 2,994 (33.8%) were not. During a 9-month period, DES use increased considerably from 52.6% of cases in October 2003 to 78.5% in June 2004. Compared with the bare metal stent cohort, patients receiving DESs were more likely to be women and to have private insurance, but were less likely to present with positive cardiac markers or ST-segment depression. In adjusted analysis, death and recurrent infarction were significantly lower among the patients with a DES, yet early revascularization and treatment with guideline-recommended therapies were less frequent. In a multivariate model, significant (p <0.05) predictors of DES use included hyperlipidemia, elevated systolic blood pressure, private insurance, and treatment at a larger hospital. In conclusion, these findings not only identified differences in the selection and treatment of patients receiving bare metal stents versus DESs, but also demonstrated the increasing use of DESs in higher risk patients who have previously been excluded from randomized, pivotal trials.     

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.     

Percutaneous coronary intervention versus coronary artery bypass grafting as primary revascularization in patients with acute coronary syndrome

New European Society of Cardiology/American College of Cardiology guidelines classify patients with acute coronary syndrome and increased cardiac troponins as non-ST-segment elevation myocardial infarction (NSTEMI) who would have been classified as unstable angina pectoris (UAP) using the older World Health Organization (WHO) definition. The optimal revascularization strategy in these patients is poorly defined. This prospective cohort study included 1,024 consecutive patients with acute coronary syndrome classified as UAP, NSTEMI according to the WHO definition (WHO NSTEMI), and NSTEMI additionally identified by the novel European Society of Cardiology/American College of Cardiology definition (additional NSTEMI). All patients underwent coronary angiography within 24 hours and were treated with immediate percutaneous coronary intervention (PCI) or early coronary artery bypass grafting (CABG). The primary end point was all-cause mortality during follow-up of 36 months. Patients with additional NSTEMI showed excessive cumulative 3-year mortality if undergoing CABG (hazard ratio 5.9, 95% confidence interval 2.7 to 13.1, p <0.001). In patients with UAP or WHO NSTEMI, mortality was similar in the CABG and PCI groups. In conclusion, in the absence of randomized trials specifically including patients with additional NSTEMI, the excessive mortality observed with CABG in this cohort study suggested that PCI may be the preferable revascularization strategy in this subgroup.     

Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non-ST-segment elevation acute coronary syndromes

In the case of non-ST-segment elevation acute coronary syndromes (NSTE-ACSs), the acute use of certain antiplatelet agents is complicated by concerns about perioperative bleeding risks in patients requiring coronary artery bypass grafting (CABG) during the index hospitalization. As a result, clinicians often withhold potentially useful agents, such as clopidogrel, before determining patients' coronary anatomy. An accurate predictive model could allow for a better balance of this safety concern with the demonstrated benefits of agents such as clopidogrel. To create an accurate decision-making tool that would assess, at hospital presentation, the need for CABG in patients with NSTE-ACSs, we studied 61,974 high-risk patients with NSTE-ACS admitted to 311 CABG-capable hospitals participating in Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) from 2001 to 2003. A total of 8,395 patients (14%) underwent CABG during their initial hospital stay. A multivariate model was developed and identified 13 presenting clinical characteristics significantly associated with the likelihood of CABG (previous CABG, male gender, previous heart failure, diabetes, hyperlipidemia, renal insufficiency, ST depression and transient ST elevation, age > or = 75 years, previous percutaneous coronary intervention, family history of coronary artery disease, hypertension, trends in CABG rates, and previous stroke). This model had only modest predictive accuracy and calibration (c-index = 0.67). In conclusion, although certain presenting clinical features are associated with an increased likelihood of CABG in patients with NSTE-ACSs during the index hospitalization, it remains difficult to reliably identify, before diagnostic angiography, those who will subsequently undergo surgical revascularization.     

Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality

OBJECTIVES: The goal of this study was to assess the long-term impact of creatine kinase-MB isoform (CK-MB) elevation after percutaneous or surgical revascularization. BACKGROUND: The long-term impact of CK-MB elevation after coronary artery bypass grafting (CABG) is not as well characterized as that following percutaneous coronary intervention (PCI). METHODS: The three-year cumulative survival of consecutive patients who underwent their first percutaneous or surgical revascularization procedure between January 1, 1995 and August 31, 2000 and had CK-MB determination was assessed using the Social Security Death Index. RESULTS: The 3,812 patients undergoing CABG had a less favorable coronary risk profile than the 3,573 patients undergoing PCI. The incidence of CK-MB elevation above normal range was 90% and 38% for the CABG and PCI groups (p < 0.001). In 6% and 5%, respectively, the elevation surpassed 10x the upper limit of normal (ULN). At an average follow-up of three years, there were 712 deaths, 83 of which occurred within 30 days of procedure. The cumulative survival was 92% and 90% for CABG and PCI, respectively (p = 0.003). Chronic renal insufficiency (adjusted hazard ratio [HR] 3.8, [95% confidence interval 3.1 to 4.6]), age (HR 1.5 per decade [1.3 to 1.6]), ejection fraction <40% (HR 1.3 [1.1 to 1.5] and PCI (HR 1.6 [1.3 to 1.9]) were the main predictors of increased mortality. Creatine kinase-MB isoform elevation only above 10 x ULN was independently predictive of mortality in the CABG (HR 1.3 [1.1 to 1.5]) and PCI (HR 1.1 [1.0 to 1.2]) groups, p < 0.001. CONCLUSIONS: Creatine kinase MB isoform elevation after revascularization is very common, particularly in CABG patients. When extensive, it is independently correlated with increased mortality over a three-year period. Identification and aggressive management of patients with high levels of CK-MB after revascularization may improve their outcome.     

Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group

OBJECTIVES: We sought to assess survival among patients with diabetes and multivessel coronary artery disease (MVD) after percutaneous coronary intervention (PCI) and after coronary artery bypass grafting surgery (CABG). BACKGROUND: The Bypass Angioplasty Revascularization Investigation (BARI) demonstrated that diabetics with MVD survive longer after initial CABG than after initial PCI. Other randomized trials or observational databases have not conclusively reproduced this result. METHODS: A large, regional database was linked to the National Death Index to assess five-year mortality. Of 7,159 consecutive patients with diabetes who underwent coronary revascularization in northern New England during 1992 to 1996, 2,766 (38.6%) were similar to those randomized in the BARI trial. Percutaneous coronary intervention was the initial revascularization strategy in 736 patients and CABG in 2,030. Cox proportional hazards regression was used to calculate risk-adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%). RESULTS: Patients who underwent PCI were younger, had higher ejection fractions and less extensive coronary disease. After adjusting for differences in baseline clinical characteristics, patients with diabetes treated with PCI had significantly greater mortality relative to those undergoing CABG (HR = 1.49; CI 95%: 1.02 to 2.17; p = 0.037). Mortality risk tended to increase more among 1,251 patients with 3VD (HR = 2.02; CI 95%: 1.04 to 3.91; p = 0.038) than among 1,515 patients with 2VD (HR = 1.33; CI 95%: 0.84 to 2.1; p = 0.21). CONCLUSIONS: In this analysis of a large regional contemporary database of patients with diabetes selected to be similar to those enrolled in the BARI trial, five-year mortality was significantly increased after initial PCI. This supports the BARI conclusion on initial revascularization of patients with diabetes and MVD.     

Comparisons of guideline-recommended therapies in patients with documented coronary artery disease having percutaneous coronary intervention versus coronary artery bypass grafting versus medical therapy only (from the REACH International Registry)

To evaluate current compliance with recommendations for medical therapy in patients with coronary artery disease (CAD), the relation between previous revascularization and use of guideline-recommended therapies was investigated. From 5,400 outpatient practices in 44 countries, we compared baseline characteristics and medical therapy of 40,450 patients with documented CAD (all with previous myocardial infarction, percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], or angina pectoris) by previous revascularization status. Approximately 33% of patients had previous CABG, 33% had previous PCI, and 33% had no previous revascularization. Patients with previous CABG were older and often men and diabetic. Patients with previous PCI were the youngest. Guideline-recommended medical therapy use was significantly higher in those with previous revascularization. Antiplatelet therapy in medically managed patients was 80% versus 86% and 91% for those with previous CABG or PCI, respectively. Use of any lipid-lowering agent in those with previous CABG or PCI was 86% in the 2 groups versus 70% in patients who were medically managed. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were used in similar ratios among groups. Previous revascularization appears to be associated with better use of guideline-recommended medical treatment. These trends were similar for patients from the United States versus everywhere else. In conclusion, use of evidence-based, guideline-recommended therapies in outpatients with CAD needs to improve, especially in medically managed patients.     

The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: the Euro Heart Survey of acute coronary syndrome experience

AIM: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p=0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p=nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59-1.61). CONCLUSIONS: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.     

Early invasive strategies for acute coronary syndromes

Early coronary angiography and percutaneous or operative revascularization is now the treatment of choice for both ST- and non-ST-segment elevation acute coronary syndromes (ACS). In non-ST-segment elevation ACS this strategy produces a 18% to 22% reduction in ischemic outcomes at 6 months and prevents 1.7 deaths, 2.0 nonfatal infarcts and 20 readmissions per 100 treated patients at 1-year follow-up. Early angiography allows definition of coronary anatomy and assessment of left ventricular function, both important predictors of long-term risk. Intracoronary stenting and intravenous glycoprotein IIb/IIIa antagonists have improved outcome in percutaneous revascularization and should be used in the majority of ACS patients undergoing PCI. Initial costs are higher with an early invasive strategy; however, these are offset by reductions in rehospitalizations and later ischemic complications.     

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.     

Comparison of outcomes for patients receiving drug-eluting versus bare metal stents for non-ST-segment elevation myocardial infarction

The outcomes for patients undergoing percutaneous coronary interventions (PCI) with drug-eluting stents (DESs) and bare metal stents (BMSs) have been compared in many studies for patients with ST-segment elevation myocardial infarction. However, little is known about the relative outcomes for patients with non-ST-segment elevation myocardial infarction (NSTEMI). The aim of the present study was to compare the NSTEMI outcomes for PCI with DESs and BMSs. New York's PCI registry was used to propensity-match 4,776 pairs of patients with NSTEMI who had received DESs and BMSs from January 1, 2003 to December 31, 2007. These patients were followed up through December 31, 2008 to test for differences in mortality, target vessel revascularization, and total repeat revascularization. The outcomes were also compared for various patient subsets. At a median follow-up period of 3.68 years, the patients receiving DESs had significantly lower mortality (16.58% vs 14.52%, difference 2.06%, p<0.001), target vessel revascularization (13.08% vs 11.04%, p=0.009), and total repeat revascularization (22.16% vs 18.77%, p<0.001). The patients receiving paclitaxel-eluting and sirolimus-eluting stents both experienced superior outcomes compared to patients receiving BMSs. The patients receiving DESs had significantly lower mortality rates than their propensity-matched counterparts receiving BMSs when they were ≥65 years (difference 2.29%, p=0.01) and male (difference 2.77%, p=0.003). In conclusion, patients with NSTEMI undergoing PCI experienced lower 4-year mortality, target vessel revascularization, and repeat revascularization rates when they had received DESs than when they had received BMSs, and patients who were >65 years old, and men received notable benefits.     

Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting

BACKGROUND

The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear.

OBJECTIVES

To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG]).

METHODS

The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared.

RESULTS

Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125).

CONCLUSIONS

The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients.     

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

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

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.     

Revascularization of left main coronary artery disease

Coronary artery disease with left main stenosis is associated with the highest mortality of any coronary lesion. Studies in the 1970s and 1980s comparing coronary artery bypass grafting (CABG) and medical therapy showed a significant survival benefit with revascularization. In the angioplasty era, initial experience with percutaneous intervention was associated with poor clinical outcomes. As a result, percutaneous coronary intervention (PCI) was restricted to patients who were considered inoperable, or those with prior CABG with a functional graft to the left anterior descending or circumflex artery ("protected left main disease"). With the introduction of drug-eluting stents, there are new studies demonstrating comparable survival in patients who were revascularized using PCI and CABG, although percutaneous revascularization is associated with a higher rate of repeat revascularization. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial, the combined incidence of death, myocardial infarction, and stroke was similar between the CABG and PCI groups; however, the stroke rate was higher in the CABG group. The degree and extent of disease as defined by the SYNTAX scoring system has allowed for stratification of risk and improved assignment of patients with left main stenosis to either PCI or CABG.     

无保护左主干病变冠状动脉搭桥术与雷帕霉素洗脱支架治疗的对比研究

目的:回顾性分析无保护左主干病变患者使用雷帕霉素洗脱支架(DES)的经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植手术(CABG)治疗的中、远期疗效,并探讨应用SYNTAX SCORE来评估病变风险与临床事件的相关性。方法:本研究回顾性收集了176例无保护左主干病变患者,其中CABG组80例,PCI-DES组96例。收集患者的基本情况、左主干病变特点及SYNTAX评分、CABG和PCI手术情况,随访患者术后3年的主要不良心脑血管事件(MACCE)的发生率。结果:术后3年随访,PCI-DES组与CABG组的MACCE发生率及无MACCE生存率比较差异无统计学意义,但PCI组靶血管再次血运重建率(TVR)明显高于CABG组(P<0.05)。用SYNTAX SCORE把PCI-DES和CABG两组患者分为高积分组(≥30.0)和低积分组(<30.0):高积分组,术后3年PCI-DES亚组MACCE事件发生率高于CABG亚组(23.53%∶18.05%,P<0.05),无MACCE事件生存率低于CABG亚组(51.47%∶70.83%,P<0.05)。低积分组,术后3年MACCE事件发生率CABG亚组高于PCI-DES亚组(12.50%∶7.14%,P>0.05),而无MACCE事件生存率低于PCI-DES亚组(75.00%∶82.14%,P<0.05)。结论:PCI-DES与CABG治疗无保护左主干病变患者总体疗效相似。用SYNTAX SCORE指导无保护左主干病变血管重建方式的选择有重要价值,但在不同的患者人群中,仍应结合临床特征和冠状动脉病变特点选择恰当的血运重建术。     

The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal: A systematic review

Introduction and ObjectivesReperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates. We aimed to describe the use of these therapies for the treatment of acute coronary syndrome (ACS) patients over time in Portugal.MethodsPubMed was searched in July 2012. The proportion of patients treated with fibrinolysis, primary percutaneous coronary intervention (PCI), any PCI and coronary artery bypass grafting (CABG) was described according to type of ACS: STEMI (≥90% patients with ST-segment elevation or Q-wave myocardial infarction), NSTE-ACS (≥90% patients with non-ST-segment elevation ACS) and mixed ACS (all others).ResultsWe identified 41 eligible studies, published between 1989 and 2011. Twenty-eight reported on samples considered representative of ACS patients treated in Portugal. The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend. In the last 20 years, the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased, while the use of CABG did not change.ConclusionsThe general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries, reflecting a favorable trend in the quality of care of ACS patients. The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions, and highlights the need for systematic approaches to monitor the use of treatments over time.     

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.     

Integrating antithrombin and antiplatelet therapies with early invasive management for non-ST-segment elevation acute coronary syndromes

Non-ST-segment elevation acute coronary syndromes are a dramatic manifestation of coronary artery disease. Multiple clinical trials have shown that early cardiac catheterization improves clinical outcomes in patients with non-ST-segment elevation acute coronary syndromes. Many antithrombotic agents effectively manage unstable coronary syndromes and serve as adjuncts to percutaneous coronary intervention. Yet, the growing number of pharmacologic agents makes early management of non-ST-segment elevation acute coronary syndromes increasingly complex. We review the current evidence regarding the optimal integration of early antithrombotic and antiplatelet therapies with early coronary angiography and subsequent revascularization.     

The Association of Previous Revascularization With In-Hospital Outcomes in Acute Myocardial Infarction Patients: Results From the National Cardiovascular Data Registry

ObjectivesThe aim of this study was to compare outcomes of ST-segment elevation myocardial infarction (STEMI) patients with a history of coronary artery bypass graft surgery (CABG), previous percutaneous coronary intervention (PCI), or no previous revascularization undergoing primary PCI.BackgroundLimited data exist regarding door-to-balloon times and clinical outcomes of STEMI patients with a history of CABG or PCI undergoing primary PCI.MethodsWe examined 15,628 STEMI patients who underwent primary PCI at 297 sites in the United States. We used multivariable logistic regression analyses to compare door-to-balloon time delays >90 min and in-hospital major adverse cardiovascular or cerebrovascular events (MACCE).ResultsPatients with previous CABG were significantly older and more likely to have multiple comorbidities (p < 0.0001). Previous CABG was associated with a lower likelihood of a door-to-balloon time ≤90 min compared with patients with no previous revascularization. However, no significant differences in door-to-balloon times were noted between patients with previous PCI and those without previous revascularization. The unadjusted MACCE risk was significantly higher in patients with a history of CABG compared with patients without previous revascularization (odds ratio: 1.68, 95% confidence interval: 1.23 to 2.31). However, after multivariable risk adjustment, there were no significant differences in MACCE risk between the 2 groups. No significant differences in in-hospital outcomes were seen in patients with a previous PCI and those without previous revascularization.ConclusionsIn a large cohort of STEMI patients undergoing primary PCI, patients with previous CABG were more likely to have reperfusion delays, yet risk-adjusted, in-hospital outcomes were similar to those without previous revascularization. No significant differences in reperfusion timeliness and in-hospital outcomes were seen in patients with a history of PCI compared with patients without previous revascularization.