Progression to Overt or Silent CAD in Asymptomatic Patients With Diabetes Mellitus at High Coronary Risk: Main Findings of the Prospective Multicenter BARDOT Trial With a Pilot Randomized Treatment Substudy

ObjectivesThe purpose of this study was to evaluate prevalence, progression, treatment, and outcome of silent coronary artery disease (CAD) in asymptomatic patients with diabetes (DM) at high coronary risk.BackgroundDespite the close association of diabetes and CAD, general CAD screening in asymptomatic patients with DM is discouraged even though outcome data in patients at high coronary risk are lacking.MethodsProspective multicenter outcome study—with a pilot randomized treatment substudy. The study comprised 400 asymptomatic patients with DM (type 2) without history or symptoms of CAD at high CAD risk. They underwent clinical evaluation and myocardial perfusion single-photon emission computed tomography (MPS) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management.ResultsAn abnormal MPS was found in 87 of 400 patients (22%). In patients with normal MPS, MACE occurred in 2.9% and ischemia or new scar in 3.2%. Patients with abnormal MPS had more MACE (9.8%; hazard ratio: 3.44; 95% confidence interval [CI]: 1.32 to 8.95; p = 0.011) and ischemia or new scar (34.2%; odds ratio: 15.91; 95% CI: 7.24 to 38.03; p < 0.001) despite therapy, resulting in “overt or silent CAD progression” of 35.6% versus 4.6% (odds ratio: 11.53; 95% CI: 5.63 to 24.70; p < 0.001). Patients with abnormal MPS randomized to medical versus invasive-medical strategies had similar event rates (p = 0.215), but more ischemic or new scar findings (54.3% vs. 15.8%; p < 0.001).ConclusionsHigh-risk asymptomatic patients with DM and normal MPS (78%) have a low rate of first manifestations of CAD. Patients with abnormal MPS at baseline (22%) have a 7-fold higher rate of progression to “overt or silent CAD,” despite therapy. Randomized patients’ outcomes suggest that a combined invasive and medical strategy for silent CAD may reduce scintigraphic but not symptomatic CAD progression versus medical therapy alone. (Trial of Invasive versus Medical therapy of Early coronary artery disease in Diabetes Mellitus ISRCTN87953632).     

Validation and Comparison of the Long-Term Prognostic Capability of the SYNTAX Score-II Among 1,528 Consecutive Patients Who Underwent Left Main Percutaneous Coronary Intervention

ObjectivesThis study sought to evaluate the long-term prognostic capacity of the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score II (SS-II) and compare it with other risk scores among patients undergoing left main percutaneous coronary intervention (LM-PCI).BackgroundRecently, the SS-II was developed in an attempt to individualize and help the decision-making process between PCI and coronary artery bypass graft (CABG) surgery in the management of complex coronary artery disease (CAD). However, there is a paucity of data regarding the utility of SS-II in patients undergoing LM-PCI.MethodsData from 1,528 consecutive patients from a single center undergoing unprotected LM-PCI were prospectively collected. The SS-II and other scores were then derived using patients’ baseline clinical characteristics. Patients were stratified according to tertiles of SS-II for PCI: SS-II ≤21 (n = 508), SS-II >21 and ≤28 (n = 480), and >28 (n = 540). Predictive capability for long-term mortality was compared between angiographic scores and scores combining both angiographic and clinical variables.ResultsAt a mean follow-up of 4.4 years, mortality in the first, second, and third SS-II tertiles was 1.8%, 3.5%, and 9.4%, respectively (p < 0.0001). Multivariate analysis showed SS-II to be a strong independent predictor of mortality (hazard ratio: 1.76, 95% confidence interval: 1.10 to 2.82; p = 0.02) after LM-PCI. When compared with the angiographic SS, scores combining both clinical and angiographic variables, such as the SS-II, were superior in terms of long-term prognostication.ConclusionsResults of this large series of consecutive patients who underwent unprotected LM-PCI suggested that the SS-II has better long-term prognostic power in terms of mortality compared with the original purely angiographic SS.     

Survival of Transcatheter Mitral Valve Repair Compared With Surgical and Conservative Treatment in High-Surgical-Risk Patients

ObjectivesThe goal of this study was to compare survival between transcatheter mitral valve (MV) repair using MitraClip system (Abbott Vascular, Santa Clara, California), MV-surgery, and conservative treatment in high-surgical-risk patients symptomatic with severe mitral valve regurgitation (MR).BackgroundUp to 50% of patients with symptomatic severe MR are denied for surgery due to high perioperative risk. Transcatheter MV repair might be an alternative.MethodsConsecutive patients (n = 139) treated with transcatheter MV repair were included. Comparator surgically (n = 53) and conservatively (n = 59) treated patients were identified retrospectively. Surgical risk was based on the logistic European System for Cardiac Operative Risk Evaluation (log EuroSCORE) or the presence of relevant risk factors, as judged by the heart team.ResultsThe log EuroSCORE was higher in the transcatheter MV repair group (23.9 ± 16.1%) than in the surgically (14.2 ± 8.9%) and conservatively (18.7 ± 13.2%, p < 0.0001) treated patients. Left ventricular ejection fraction was higher in surgical patients (43.9 ± 14.4%, p = 0.003), with similar values for the transcatheter MV repair (36.8 ± 15.3%) and conservatively treated (34.5 ± 16.5%) groups. After 1 year of follow-up, the transcatheter MV repair and surgery groups showed similar survival rates (85.8% and 85.2%, respectively), whereas 67.7% of conservatively treated patients survived. The same trend was observed after the second and third years. After weighting for propensity score and controlling for risk factors, both the transcatheter MV repair (hazard ratio [HR]: 0.41, 95% confidence interval [CI]: 0.22 to 0.78, p = 0.006) and surgical (HR: 0.52, 95% CI: 0.30 to 0.88, p = 0.014) groups showed better survival than the conservatively treated group. The transcatheter MV repair and surgical groups did not differ (HR: 1.25, 95% CI: 0.72 to 2.16, p = 0.430).ConclusionsDespite a higher log EuroSCORE, high-surgical-risk patients with symptomatic severe MR treated with transcatheter MV repair show similar survival rates compared with surgically treated patients, with both displaying survival benefit compared with conservative treatment.     

免疫性血小板减少症(ITP)合并胸闷1例

免疫性血小板减少症（immune thrombocytopenia,ITP）是一种因免疫系统介导的血小板破坏过多进而导致血小板减少的疾病,具有高出血风险。冠心病（coronary artery disease,CAD）和经皮冠状动脉介入（percutaneous coronary intervention,PCI）术后的患者需要常规抗血小板治疗,与ITP的治疗相矛盾。本文报道1例ITP合并急性冠脉综合征（acute coronary syndrome,ACS）行PCI术的老年男性,因血小板数量低下、出血风险高而未行充分抗血小板治疗,导致ACS数次发作,于原冠脉支架内形成血栓,病程中数次行PCI术并调整抗血小板治疗方案和激素治疗剂量,以期为这类患者的临床处理提供参考。     

钛基台支持的CAD/CAM全瓷单冠不同载荷位置的三维有限元应力分析

目的分析钛基台支持的CAD/CAM全瓷单冠在载荷位置不同时全冠的应力情况,为种植上部结构的临床设计提供理论参考。方法建立钛基台以及粘接固位的下颌第二前磨牙牙冠的三维有限元模型,在基台上方偏颊侧(a)、基台正上方(b)、基台上方偏舌侧(c)的牙冠■面3个不同部位分别施加300N的轴向静载荷,计算分析全冠的应力情况。结果对于玻璃陶瓷全冠,当载荷作用于位置a时,最大拉应力在舌侧颈缘处,约为13MPa;最大压应力位于颊侧颈缘处,约为-45MPa。载荷作用于位置b时,最大拉应力在与基台顶部中心区域接触处的牙冠组织面,约为20MPa。载荷作用于位置c时,最大拉应力在牙冠颊侧颈缘处约为15MPa;舌侧颈缘处最大压应力值为-40MPa。氧化锆全冠在三种载荷类型时的应力场分布与玻璃陶瓷全冠类似,应力值大小不同。结论钛基台支持的CAD/CAM全瓷单冠,当载荷作用于位置a时,牙冠颊侧颈缘应增加强度以防止折裂,牙冠舌侧颈缘处应防止脱粘接;载荷作用于位置b时,基台上方牙冠■面需要增加强度;载荷作用于位置c时,牙冠颊侧颈缘处易发生脱粘接,舌侧颈缘处容易折裂。     

不同基牙设计对CAD/CAM全瓷修复体抗折强度的影响

目的 研究不同CAD/CAM全瓷修复体修复根充后前磨牙的抗折强度。方法 收集21颗因正畸拔除的上颌第一前磨牙,制备近面及舌尖缺损洞型。样品分为3组,第1组为直接树脂充填组;第2组为保留缺损组;第3组为纤维桩核组,然后利用IPS e.max CAD全瓷修复体进行修复,采用Rely X U200树脂黏结剂进行黏固。对所有样品进行抗折强度测试,采用光学显微镜观察样品的断裂类型。采用SPSS 15.0软件包对数据进行统计学分析。结果 纤维桩核组全瓷修复体的抗折强度显著大于树脂充填组和保留缺损组。第1组和第2组以修复体破裂为主,第3组除修复体破裂外,还发生牙体组织破裂。结论 对于伴有功能牙尖缺损的前磨牙,建议采用纤维桩核+全瓷冠进行修复。