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Whether moderate-intensity statins plus ezetimibe could be an alternative to high-intensity statins in patients with atherosclerotic cardiovascular disease is unclear. We compared the risk of adverse cardiovascular events in patients receiving moderate-intensity statins plus ezetimibe vs. high-intensity statins after a coronary revascularization procedure using data from a large cohort study. Population-based cohort study using nationwide medical insurance data from Korea. Study participants (n = 20,070) underwent percutaneous coronary intervention or coronary artery bypass graft surgery between January 1, 2015, and December 31, 2016, and received moderate-intensity statins (atorvastatin 10–20 mg or rosuvastatin 5–10 mg) plus ezetimibe (n = 922) or high-intensity statins (atorvastatin 40–80 mg or rosuvastatin 20 mg; n = 19,148). The primary outcome was a composite of cardiovascular mortality, hospitalization for myocardial infarction (MI), hospitalization for stroke, or revascularization. At 12 months, the incidence rates of the primary outcome were 138.0 vs. 154.0 per 1000 person-years in the moderate-intensity stains plus ezetimibe and the high-intensity statins group, respectively. The fully adjusted hazard ratio [HR] for the primary outcome was 1.11 (95% confidence interval [CI] 0.86–1.42; p = 0.43). The multivariable-adjusted HR for a composite of cardiovascular mortality, hospitalization for MI, or hospitalization for stroke was 1.05 (95% CI 0.74–1.47; p = 0.80). During follow-up, the proportion of patients maintaining their initial lipid-lowering therapy was significantly higher in the moderate-intensity statins plus ezetimibe group than in the high-intensity statins group. Patients undergoing a coronary revascularization procedure who received moderate-intensity statins plus ezetimibe showed similar rates of major adverse cardiovascular events as patients who received high-intensity statins.

Percutaneous coronary intervention is a coronary revascularization procedure that may rarely result in thromboembolic events. Although infrequent, ophthalmological complications of percutaneous interventions include a wide range of clinical presentations, with differing severity and outcomes. In this case report, an 83-year-old woman, with multiple cardiovascular risk factors, presents with horizontal diplopia after a percutaneous transluminal coronary angioplasty. After ophthalmological evaluation and a head computed tomography scan, the diagnosis of isolated ischemic internuclear ophthalmoplegia was established. After six months of follow-up, the patient showed complete recovery of her symptoms and ocular movements. We discuss the post-percutaneous intervention ophthalmic complications that, although uncommon, must be recognized by health care providers.A intervenção coronária percutânea é um procedimento de revascularização coronária que pode, raramente, resultar em eventos tromboembólicos. Apesar de incomuns, as complicações oftalmológicas da intervenção percutânea incluem um largo espectro de manifestações clínicas com diferentes prognósticos. Reportamos um caso clínico de uma mulher de 83 anos, com múltiplos fatores de risco cardiovascular, que apresenta diplopia horizontal após uma angioplastia coronária percutânea. O diagnóstico de oftalmoplegia internuclear isquémica isolada foi estabelecido após avaliação oftalmológica e realização de tomografia computorizada cranioencefálica. Seis meses após a apresentação, a doente apresentava recuperação completa dos sintomas e dos movimentos oculares. Os autores discutem as complicações oftalmológicas da intervenção percutânea que, apesar de incomuns, devem ser reconhecidas pelos profissionais de saúde.

Background Coronary artery disease (CAD) remains one of the leading causes of mortality worldwide and is associated with multiple inherited and environmental risk factors. This study is designed to identify, design, and develop a panel of genetic markers that combined with clinical and angiographic information, will facilitate the creation of a personalized risk prediction algorithm (GEnetic Syntax Score—GESS). GESS score could be a reliable tool for predicting cardiovascular risk for future adverse events and for guiding therapeutic strategies. Methods GESS (ClinicalTrials.gov Identifier: NCT03150680) is a prospective, non-interventional clinical study designed to enroll 1080 consecutive patients with no prior history of coronary revascularization procedure, who undergo scheduled or emergency coronary angiography in AHEPA, University General Hospital of Thessaloniki. Next generation sequencing (NGS) technology will be used to genotype specific single-nucleotide polymorphisms (SNPs) across the genome of study participants, which were identified as clinically relevant to CAD after extensive bioinformatic analysis of literature-based SNPs. Enrichment analyses of Gene Ontology-Molecular Function, Reactome Pathways and Disease Ontology terms were also performed to identify the top 15 statistically significant terms and pathways. Furthermore, the SYNTAX score will be calculated for the assessment of CAD severity of all patients based on their angiographic findings. All patients will be followed-up for one-year, in order to record any major adverse cardiovascular events. Discussion A group of 228 SNPs was identified through bioinformatic and pharmacogenomic analysis to be involved in CAD through a wide range of pathways and was correlated with various laboratory and clinical parameters, along with the patients' response to clopidogrel and statin therapy. The annotation of these SNPs revealed 127 genes being affected by the presence of one or more SNPs. The first patient was enrolled in the study in February 2019 and enrollment is expected to be completed until June 2021. Hence, GESS is the first trial to date aspiring to develop a novel risk prediction algorithm, the GEnetic Syntax Score, able to identify patients at high risk for complex CAD based on their molecular signature profile and ultimately promote pharmacogenomics and precision medicine in routine clinical settings. Trial registration GESS trial registration: ClinicalTrials.gov Number: NCT03150680. Registered 12 May 2017- Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03150680.

Introduction Coronary artery bypass graft (CABG) is the most effective coronary revascularization procedure, and it has been endorsed by many trials and studies over the years. However, due to CABG's immediate adverse effects, patients tend to prefer percutaneous coronary intervention (PCI) for coronary revascularization over it. This article focuses on the recent downtrend in CABG procedures for revascularization among patients for whom it is indicated. This study’s main objective was to identify the factors responsible for the downtrend in patients undergoing CABG despite a clear indication for it in those with multivessel diseases. Methods This study was conducted at the Lady Reading Hospital, Peshawar, Pakistan, from August 1, 2020, to January 1, 2021. A total of 340 patients with a class-I indication (presence of conditions regarding which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective) for CABG were enrolled in the study. Data related to all the variables were collected from patients and hospital records through an adequately designed proforma. For analysis, we applied the chi-square test to elaborate on the data for information and point biserial correlation to rule out the effect of age and weight on CABG’s downward trend. Results The mean age of the patients was 58.77 ± 9.54 years; 65.88% were male, and 34.12% were female. Only 17.65% of the patients underwent CABG; 71.47% opted for medical treatment, and 9.41% underwent PCI. Out of the 280 patients who did not undergo CABG, 26.76% had financial issues; 23.82% were high-risk patients and hence refused surgeries by the surgeons; 20.59% of patients were not willing to undergo surgery; 7.94% were on the waiting list, and 3.24% had deranged renal function tests (RFTs). Conclusions A limited number of patients underwent revascularization therapy even though they had clear indications for CABG. The high-risk status of patients, patients' unwillingness, and the cost of the procedure were the primary reasons behind the downtrend in CABG procedures among patients with a clear indication for the same.

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with increased cardiovascular events, especially in high-risk populations.This study sought to evaluate the influence of LDL-C on the incidence of cardiovascular events either following a coronary revascularization procedure (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) or optimal medical therapy alone in patients with established coronary heart disease and type 2 diabetes (T2DM).Patient-level pooled analysis of 3 randomized clinical trials was undertaken. Patients with T2DM were categorized according to the levels of LDL-C at 1 year following randomization. The primary endpoint was major adverse cardiac or cerebrovascular events ([MACCE] the composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke).A total of 4,050 patients were followed for a median of 3.9 years after the index 1-year assessment. Patients whose 1-year LDL-C remained ≥100 mg/dl experienced higher 4-year cumulative risk of MACCE (17.2% vs. 13.3% vs. 13.1% for LDL-C between 70 and 100 mg/dl and LDL-C 70 mg/dl, respectively; p = 0.016). When compared with optimal medical therapy alone, patients with PCI experienced a MACCE reduction only if 1-year LDL-C was 70 mg/dl (hazard ratio: 0.61; 95% confidence interval: 0.40 to 0.91; p = 0.016), whereas CABG was associated with improved outcomes across all 1-year LDL-C strata. In patients with 1-year LDL-C ≥70 mg/dl, patients undergoing CABG had significantly lower MACCE rates as compared with PCI.In patients with coronary heart disease with T2DM, lower LDL-C at 1 year is associated with improved long-term MACCE outcome in those eligible for either PCI or CABG. When compared with optimal medical therapy alone, PCI was associated with MACCE reductions only in those who achieved an LDL-C 70 mg/dl.

Objectives The authors sought to describe the incidence, determinants, and outcome of elective coronary revascularization (ECR) in patients with stable coronary artery disease (CAD). Background Observational data are lacking regarding the practice of ECR in patients with stable CAD receiving modern secondary prevention. Methods The authors analyzed coronary revascularization procedures performed during a 5-year follow-up in 4,094 stable CAD outpatients included in the prospective multicenter CORONOR (Suivi d'une cohorte de patients COROnariens stables en region NORd-Pas-de-Calais) registry. Results Secondary prevention medications were widely prescribed at inclusion (antiplatelet agents 96.4%, statins 92.2%, renin-angiotensin system antagonists 81.8%). A total of 481 patients underwent ≥1 coronary revascularization procedure (5-year cumulative incidences of 3.6% [0.7% per year] for acute revascularizations and 8.9% [1.8% per year] for ECR); there were 677 deaths during the same period. Seven baseline variables were independently associated with ECR: prior coronary stent implantation (p Conclusions These real-life data show that ECR is performed at a rate of 1.8% per year in stable CAD patients widely treated by secondary medical prevention. ECR procedures performed in patients without noninvasive stress tests are not rare. Having an ECR was not associated with the risk of ischemic adverse events.

Background Many patients report adverse reactions to, and may not tolerate, statin therapy. These patients may be at increased risk for coronary heart disease (CHD) events and mortality. Objectives This study evaluated the risk for recurrent myocardial infarction (MI), CHD events, and all-cause mortality in Medicare beneficiaries with statin intolerance and in those with high adherence to statin therapy. Methods We studied 105,329 Medicare beneficiaries who began a moderate- or high-intensity statin dosage after hospitalization for MI between 2007 and 2013. Statin intolerance was defined as down-titrating statins and initiating ezetimibe therapy, switching from statins to ezetimibe monotherapy, having International Classification of Diseases, 9th revision, diagnostic codes for rhabdomyolysis or an antihyperlipidemic adverse event, followed by statin down-titration or discontinuation, or switching between ≥3 types of statins within 1 year after initiation. High statin adherence over the year following hospital discharge was defined as proportion of days covered ≥80%. Recurrent MI, CHD events (recurrent MI or a coronary revascularization procedure), and mortality were identified from 1 year after hospital discharge through December 2014. Results Overall, 1,741 patients (1.65%) had statin intolerance, and 55,567 patients (52.8%) had high statin adherence. Over a median of 1.9 to 2.3 years of follow-up, there were 4,450 recurrent MIs, 6,250 CHD events, and 14,311 deaths. Compared to beneficiaries with high statin adherence, statin intolerance was associated with a 36% higher rate of recurrent MI (41.1 vs. 30.1 per 1,000 person-years, respectively), a 43% higher rate of CHD events (62.5 vs. 43.8 per 1,000 person-years, respectively), and a 15% lower rate of all-cause mortality (79.9 vs. 94.2 per 1,000 person-years, respectively). The multivariate-adjusted hazard ratios (HR) comparing beneficiaries with statin intolerance versus those with high statin adherence were 1.50 (95% confidence interval [CI]: 1.30 to 1.73) for recurrent MI, 1.51 (95% CI: 1.34 to 1.70) for CHD events, and 0.96 (95% CI: 0.87 to 1.06) for all-cause mortality. Conclusions Statin intolerance was associated with an increased risk for recurrent MI and CHD events but not all-cause mortality.

Rotational atherectomy (RA) is a safe and effective percutaneous technique utilized in a treatment of calcified lesions to modify as a primary therapy. Even though the procedural success rate with RA is 90%, RA is associated with higher rate of no flow/slow flow which occurs as a result of micro debris and/or bubbles than other coronary revascularization procedure (1).

Procedure-related myocardial infarction (pMI) is directly associated with a coronary revascularization procedure, such as percutaneous coronary intervention (PCI) or CABG surgery. In contrast to spontaneous myocardial infarction (MI), the prognostic relevance of pMI is the subject of ongoing debate. Data from retrospective analyses of large, randomized clinical trials, and large, contemporary cohort studies have several shortcomings that limit their extrapolation to clinical practice. In our opinion, the currently available evidence is insufficient to conclude that pMI during PCI, as currently defined, always has important prognostic implications. Until further evidence is available, we recommend adopting the definition for MI given in the third universal definition of MI, which differentiates between pMI and spontaneous MI. This is important not only for clinical decision-making but also for the interpretation of pMI as a surrogate end point in clinical trials. Further studies are essential to understand the pathophysiology and consequences of pMI.

Although eliminating angina is a primary goal in treating patients with chronic coronary artery disease (CAD), few contemporary data quantify prevalence and severity of angina across US cardiology practices. The authors hypothesized that angina among outpatients with CAD managed by US cardiologists is low and its prevalence varies by site. Among 25 US outpatient cardiology clinics enrolled in the American College of Cardiology Practice Innovation and Clinical Excellence (PINNACLE) registry, we prospectively recruited a consecutive sample of patients with chronic CAD over a 1- to 2-week period at each site between April 2013 and July 2015, irrespective of the reason for their appointment. Eligible patients had documented history of CAD (prior acute coronary syndrome, prior coronary revascularization procedure, or diagnosis of stable angina) and ≥1 prior office visit at the practice site. Angina was assessed directly from patients using the Seattle Angina Questionnaire Angina Frequency score. Among 1257 patients from 25 sites, 7.6% (n = 96) reported daily/weekly, 25.1% (n = 315) monthly, and 67.3% (n = 846) no angina. The proportion of patients with daily/weekly angina at each site ranged from 2.0% to 24.0%, but just over half (56.3%) were on ≥2 antianginal medications, with wide variability across sites (0%-100%). One-third of outpatients with chronic CAD managed by cardiologists report having angina in the prior month, and 7.6% have frequent symptoms. Among those with frequent angina, just over half were on ≥2 antianginal medications, with wide variability across sites. These findings suggest an opportunity to improve symptom control.

Percutaneous coronary revascularization was introduced over 30 years ago by Dr Andreas Grüntzig. This event catapulted adult invasive cardiology from a diagnostic entity to a therapeutic modality, which has since become the most frequently performed coronary revascularization procedure worldwide. This success has been built on several key concepts-problem identification, targeted solutions, applied technology, populations-based testing, postmarket surveillance, and education. These concepts will continue to be of paramount importance as novel percutaneous innovations and strategies are brought to bear on an increasingly broader group of patients with cardiovascular disease. In this review, we trace the history, review current practices, and also provide insight into future potential innovations, as it pertains to percutaneous coronary revascularization.

Percutaneous coronary intervention with implantation of a stent has become the most widely accepted coronary revascularization procedure. It effectively relieves ischemic symptoms, as well as improves survival in a selected group of high-risk patients. Yet, dilemmas arise when patients have to undergo noncardiac surgery after stent implantation. On the one hand, premature discontinuation of antiplatelet therapy has been found to be an important predictor of stent thrombosis. On the other hand, continuation of antiplatelet therapy might increase the risk of bleeding complications during the perioperative period. The issue is further complicated by the impact of timing of the noncardiac surgery on clinical outcomes. This article reviews the perioperative management of patients with coronary stent implantation, with special emphasis on the optimal timing of noncardiac surgery and perioperative use of antiplatelet therapy. Optimization of surgical risk by various pharmacological and nonpharmacological measure...

OBJECTIVE To test the hypothesis that exenatide twice daily reduces the relative incidence of cardiovascular disease (CVD) events among patients with type 2 diabetes compared with other glucose-lowering agent(s). RESEARCH DESIGN AND METHODS A retrospective database analysis was performed of the LifeLink database of medical and pharmaceutical insurance claims for June 2005 through March 2009. Patients with no history in the preceding 9 months of myocardial infarction, ischemic stroke, or coronary revascularization procedure were assigned to the exenatide-initiated or non–exenatide-initiated cohorts based on the first new prescription filled and reassigned if exenatide was prescribed or discontinued. Incident CVD events (myocardial infarction, ischemic stroke, or coronary revascularization procedure) were identified by ICD-9-CM diagnosis codes. Patient outcomes were adjusted for differences in clinical and demographic characteristics and compared using propensity score–weighted discrete time survival analysis with time-varying exposure to exenatide. RESULTS A total of 39,275 patients with type 2 diabetes were treated with exenatide twice daily, and 381,218 patients were treated with other glucose-lowering therapies. Patients who initiated exenatide were more likely to have prior ischemic heart disease, obesity, hyperlipidemia, hypertension, and/or other comorbidities at baseline. Exenatide-treated patients were less likely to have a CVD event than non–exenatide-treated patients (hazard ratio 0.81; 95% CI 0.68–0.95; P = 0.01) and lower rates of CVD-related hospitalization (0.88; 0.79–0.98; P = 0.02) and all-cause hospitalization (0.94; 0.91–0.97; P < 0.001). CONCLUSIONS Exenatide twice-daily treatment was associated with a lower risk of CVD events and hospitalizations than treatment with other glucose-lowering therapies.

Background: This paper investigates the extent to which sociodemographic factors are associated with knowledge of cardiac procedures in a sample of study participants treated for coronary heart disease (CHD). Research indicates the importance of knowledge of CHD and its associated risks in order to prevent CHD. However, quantification of knowledge levels among individuals undergoing cardiac procedures to treat CHD has not been well documented. Method: Using a cross-sectional design, 156 participants, diverse in race/ethnicity, age, and sex, underwent elective cardiac catheterization for the evaluation of chest pain and/or angina. Participants completed surveys regarding medical history, sociodemographic information, and knowledge of cardiac procedures. Ninety-five of these individuals, with clinically significant CHD, were recommended by their physician to undergo a coronary revascularization procedure [percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG)]. These individuals completed additional knowledge assessment surveys. Results: The overall knowledge scores for those undergoing coronary angiography were suboptimal (M score = 4.6 out of 8). Older aged (> 65), male, married, white, college-educated participants demonstrated greater knowledge of cardiac catheterization procedures (all p values < 0.05). Knowledge scores were greater among those revascularized than among participants undergoing coronary angiography. Conclusions: Health professionals should provide general information about CHD treatment and interventions, especially among women and ethnic minorities.

The ESC/EASD (European Society of Cardiology/European Association for the Study of Diabetes) joint Guidelines on diabetes, pre-diabetes, and cardiovascular diseases have, for the first time, addressed diabetes mellitus and cardiovascular diseases (CVD) as a pathophysiological entity in Europe. Based on these guidelines, diabetes mellitus is regarded from the outset to be a cardiovascular disease, whose life-threatening complications myocardial infarction and stroke can only be avoided by an interdisciplinary concerted action. The most important information of these guidelines for the interdisciplinary cooperation of primary-care physicians, diabetologists and cardiologists are the postulations that patients with the main diagnosis diabetes mellitus with or without known CVD should, at regular intervals, be referred to a cardiologist, and patients with the main diagnosis CVD with or without diabetes mellitus should, at regular intervals, be referred to a diabetologist. Of fundamental importance is the prevention of diabetes and CVD by a comprehensive lifestyle modification including smoking cessation, regular physical activity and weight control, flanked by an evidence-based drug therapy. Within the framework of a multimodal risk management, an optimal antihypertensive therapy of a concomitant elevated blood pressure; a statin therapy in case of elevated LDL cholesterol or regardless of an elevated LDL in proven CVD; ACE inhibitors, angiotensin II receptor blockers, or beta-blockers in case of heart failure; and an anticoagulant therapy for the prevention of cardioembolic stroke in patients with atrial fibrillation all have class I recommendations. Concerning the preferred coronary revascularization procedure in diabetics, today no rigid general recommendation can be given in favor of or against coronary bypass surgery, or in favor of or against percutaneous coronary intervention. The decision for a specific revascularization procedure should, in any case, be based on a detailed analysis of the individual coronary anatomy.

September 2007 marked the 30-year anniversary of the first human percutaneous coronary intervention, an index event that changed the course of modern-day cardiovascular care. Before that first procedure, adult invasive cardiology focused on diagnostic angiography as well as hemodynamic assessment of structural heart disease. Since that initial procedure, percutaneous coronary intervention has become the most frequently performed coronary revascularization procedure worldwide. Several factors have been responsible for this dramatic paradigm shift, the most prominent being identification of opportunities for technical improvement and the application of innovation and investigation in concert with colleagues, professional societies, and industry. These approaches will continue to be of paramount importance as new technologies are brought to bear on an increasingly broader group of patients with cardiovascular disease.

Inflammation plays an important role on every stage of atherosclerosis. Myeloperoxidase (MPO), a leukocyte-derived enzyme that participates in the innate immunity, probably is involved in many stages of atherothrombosis. According to the recent studies, MPO is related with unfavorable outcome in patients with chest pain and acute coronary syndromes. Its role in prediction of outcomes after ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of the study was to assess if elevated MPO level is a predictor of long-term adverse cardiac events in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Material and methods We evaluated data of 127 patients with STEMI. Plasma levels of MPO collected on admission and the 3rd–4th day of hospitalization were measured by ELISA method. C-reactive protein (CRP) and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) were also determined. All patients were followed-up prospectively for the occurrence of major adverse cardiovascular events (MACE) defined as unscheduled coronary revascularization procedure, stroke, reinfarction or all-cause death. Results After 14months of follow-up 20% of patients developed MACE. Elevated MPO levels collected on the 3rd–4th day of STEMI were the predictor of death, reinfarction, the need for coronary revascularization and all adverse events taken together. In multivariate analysis, MPO and CRP levels assessed on the 3rd–4th day of hospitalization revealed to be significant predictors of MACE. MPO demonstrated to be significantly better predictor of MACE than NT-proBNP level. Conclusions Myeloperoxidase is a prognostic marker in patients with STEMI treated with pPCI.

Aim This study aimed to assess the short-term predictive value of a pharmacologic stress echocardiography test performed with accelerated high-dose dipyridamole (0.84 mg/kg over 6 minutes). Methods In all, 301 patients (161 men, mean age 61.41 ± 11.62 years) were scheduled for accelerated high-dose dipyridamole stress test. A total of 22 tests were interrupted prematurely because of side effects (overall feasibility 92.7%). The patients were followed up for nonfatal myocardial infarction, unstable angina, myocardial revascularization, and sudden death at first and third months and each 6 months (maximum 18 months). Results A positive echocardiographic response was found in 25 patients. Six patients with negative stress test experienced events. Eight patients with positive stress test went to coronary revascularization procedure. Negative predictive value was 97.8%, positive predictive value was 32%, sensitivity was 57%, and specificity was 94%. Conclusions Risk stratification with accelerated high-dose dipyridamole stress echocardiography is effective. A negative test predicts favorable short-term cardiovascular prognosis.

Objective: The mid-term patency rates for individual and sequential grafts as coronary bypass conduits for diagonal arteries were angiographically compared; the impact of native coronary vessel and type of the conduit characteristics are investigated. Methods: Between March 1992 and April 2000, we performed a total number of 811 distal anastomosis on diagonal arteries of left anterior descending (LAD) artery in 296 patients who underwent coronary artery bypass surgery (CABG) distal anastomosis in our clinic. The patients were divided into two groups in this prospective study. In group A (n = 195) individual anastomosis technique, in group B (n = 101) sequential anastomosis technique was chosen as the myocardial revascularization strategy. At an average of 49.4 ± 13.2 months after coronary revascularization procedure coronary angiographies were evaluated. Individual and sequential grafting techniques were compared by graft patency rates. Results: The patency rates of sequential conduits were markedly higher than those of individual conduits (66.7% vs. 89.2%, p = 0.0001). This difference was also clear in coronary arteries with poor quality and small (

Background The prognosis associated with metabolic syndrome and high-sensitivity C-reactive protein (hs-CRP) in patients with stable coronary artery disease has not been well established. Methods The WIZARD study was to determine the effects of 12 weeks of antibiotic therapy on coronary heart disease events in patients with stable coronary artery disease and known Chlamydia pneumoniae exposure. Baseline metabolic risk factors were available for 3319 patients enrolled from 1997 to 1998. The primary outcome was the first occurrence of death, recurrent myocardial infarction, coronary revascularization procedure, or hospitalization for angina. Results Of the 3319 subjects, 825 patients experienced the primary outcome during the mean follow-up of 37 months. For the composite outcome, there was an increased hazard ratio (HR) for metabolic syndrome (HR 1.40, 95% CI 1.22-1.61) (unadjusted) and for hs-CRP (HR 1.60, 95% CI 1.38-1.85) (unadjusted). Both the metabolic syndrome and hs-CRP indicated, in a multivariable model including age and sex, an increased HR for the primary outcome (metabolic syndrome: HR 1.33, 95% CI 1.15-1.53; hs-CRP: HR 1.52, 95% CI 1.30-1.76). Conclusions Although related, the presence of the metabolic syndrome and increased levels of hs-CRP were associated with increased risk of adverse cardiovascular outcomes.

Objectives This study sought to assess the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in patients with coronary heart disease and preserved left ventricular (LV) function. Background The ACEIs have been shown to improve outcomes in patients with heart failure and myocardial infarction (MI). However, there is conflicting evidence concerning the benefits of ACEIs in patients with coronary artery disease (CAD) and preserved LV systolic function. Methods An extensive search was performed to identify randomized, placebo-controlled trials of ACEI use in patients with CAD and preserved LV systolic function. Of 61 potentially relevant articles screened, 6 trials met the inclusion criteria. They were reviewed to determine cardiovascular mortality, nonfatal MI, all-cause mortality, and revascularization rates. We performed random-effect model meta-analyses and quantified between-studies heterogeneity with I2. Results There were 16,772 patients randomized to ACEI and 16,728 patients randomized to placebo. Use of ACEIs was associated with a decrease in cardiovascular mortality (relative risk [RR] 0.83, 95% confidence interval [CI] 0.72 to 0.96, p = 0.01), nonfatal MI (RR 0.84, 95% CI 0.75 to 0.94, p = 0.003), all-cause mortality (RR 0.87, 95% CI 0.81 to 0.94, p = 0.0003), and revascularization rates (RR 0.93, 95% CI 0.87 to 1.00, p = 0.04). There was no significant between-studies heterogeneity. Treatment of 100 patients for an average duration of 4.4 years prevents either of the adverse outcomes (one death, or one nonfatal myocardial infarction, or one cardiovascular death or one coronary revascularization procedure). Conclusions The cumulative evidence provided by this meta-analysis shows a modest favorable effect of ACEIs on the outcome of patients with CAD and preserved LV systolic function.

Background— Retrospective studies in dialysis patients have reported increased survival after coronary artery bypass (CAB) compared with coronary artery stenting and PTCA. The purpose of this study was to compare the long-term outcome of renal transplant recipients after stent, PTCA, or CAB with or without internal mammary grafting (CAB [IMG+] or CAB [IMG−]). Methods and Results— Renal transplant recipients hospitalized from 1995 to 1999 for first coronary revascularization procedure were retrospectively identified from the United States Renal Data System database. Event-free survival for the end points of all-cause death, cardiac death, acute myocardial infarction (AMI), and the combined end point of cardiac death or AMI was estimated by the life-table method. The impact of independent predictors on survival was examined in a comorbidity-adjusted Cox model. In-hospital mortality rate was 2.3% for 909 stent patients, 4.3% for 652 PTCA patients, 9.4% for 288 CAB (IMG−) patients, and 5.0% for 812 CAB (IMG+) patients. Two-year all-cause survival (±SE) was: stent, 82.5±2.8%; PTCA, 81.6±3.1%; CAB (IMG−), 74.4±5.4%; and CAB (IMG+), 82.7±2.8%. The relative risks of all-cause and cardiac death were not significantly different among revascularization groups. The relative risk of cardiac death or AMI (versus PTCA) was 0.90 (95% CI, 0.69 to 1.17) for stent, 0.80 (95% CI, 0.55 to 1.17) for CAB (IMG−), and 0.57 (95% CI, 0.42 to 0.76) for CAB (IMG+). Conclusions— Renal transplant recipients in the United States have comparable long-term survival after percutaneous and surgical coronary revascularization procedures. The most favorable long-term outcome occurs after surgical coronary revascularization.

Background— This study reports on the trends in the volume and outcomes of coronary revascularization procedures performed on Medicare beneficiaries between 2008 and 2012. Methods and Results— This retrospective study identifies all Medicare beneficiaries undergoing a coronary revascularization procedure: coronary artery bypass graft surgery or percutaneous coronary intervention (PCI) performed in either the nonadmission or inpatient setting. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes (inpatient setting) and Current Procedural Terminology and Ambulatory Payment Classification codes (nonadmission) were used to identify revascularizations. The study population consists of 2 768 007 records. This study finds that the rapid growth in nonadmission PCIs performed on Medicare beneficiaries (60 405–106 495) has been more than offset by the decrease in PCI admissions (363 384–295 434) during the study period. There also were >18 000 fewer coronary artery bypass graft admissions in 2012 than in 2008. This study finds lower observed mortality rates (3.7%–3.2%) among Medicare beneficiaries undergoing any coronary artery bypass graft surgery and higher observed mortality rates (1.7%–1.9%) for Medicare beneficiaries undergoing any PCI encounter. This study also finds a growth in the number of facilities performing revascularization procedures during the study period: 268 (20.2%) more sites were performing nonadmission PCIs; 136 (8.2%) more sites were performing inpatient PCIs; and 19 (1.6%) more sites were performing coronary artery bypass graft surgery. Conclusions— The total number of revascularization procedures performed on Medicare beneficiaries peaked in 2010 and declined by >4% per year in 2011 and 2012. Observed mortality rates among all Medicare beneficiaries undergoing any coronary revascularization remained between 2.1% and 2.2% annually during the study period.

The left internal mammary artery (LIMA) graft is considered the "gold standard" of coronary artery bypass grafting (CABG). This conduit provides increased survival, symptomatic relief, increased freedom from myocardial infarction, and increased freedom from re-intervention when compared to saphenous venous grafting. It has a remarkable long term patency rate with clinical and angiographic outcomes that are unmatched by other conduits. Given the fact that patients often require more than one graft during a coronary revascularization procedure, the prospect of bilateral internal mammary artery (BIMA) grafting has been very appealing to some surgeons. BIMA grafting has been extensively studied via multiple retrospective and prospective cohort studies and findings have indicated that BIMA grafting can have an increased survival benefit when compared to LIMA grafting alone. As a result, this technique has accrued increasing popularity over the course of the last decade. Yet, questions still remain on whether BIMA grafting is the optimal treatment modality for patients in terms of long-term prognosis. There is limited data at the present time from randomized controlled trials and only 4-12% of CABGs performed today utilize BIMA grafting. Concerns regarding perioperative complications, which patient subsets are at higher risks for complications from the technique, and the technical challenges involved in utilizing and teaching the technique have limited its widespread use.

To assess the prognostic significance of a normal dobutamine-atropine stress echocardiogram in relation to the pretest probability of coronary artery disease (CAD), 200 consecutive patients (86 men and 114 women, mean [SD] age 59 [13] years) with a stable chest pain syndrome and a normal dobutamine-atropine stress echocardiogram were followed-up for 21 +/- 16 months. Outcome events were cardiac death, non-fatal myocardial infarction, and coronary revascularization procedures. Low (10%), intermediate (10% to 80%), and high (80%) pretest probabilities of CAD were present in 27 (14%), 108 (54%), and 65 (33%) patients, respectively. During follow-up, 2 patients (annual event rate 0.6%) had cardiac death, none had nonfatal myocardial infarction, and 4 patients (annual event rate 1.1%) underwent a coronary revascularization procedure. All patients with cardiac events had high pretest probabilities of CAD. Patients with cardiac death (but unproven significant CAD) had maximal tests without angina or ischemic electrocardiographic changes. In contrast, all patients with subsequent coronary revascularization had dobutamine-induced angina or ischemic electrocardiographic changes, and all except one study were submaximal. We conclude that patients with a stable chest pain syndrome and normal findings on dobutamine-atropine stress echocardiograms have an excellent cardiac prognosis. However, patients with typical angina, high pre-test probabilities of CAD, and stress-induced angina or ischemic electrocardiographic changes, and in particular those with submaximal stress, still appear to be at risk for functionally important CAD despite a normal dobutamine-atropine stress echocardiogram.

Objective To identify factors predictive of smoking cessation after successful percutaneous coronary revascularization. Material and Methods We undertook a case-control study of the smoking status of ail patients at Mayo Clinic Rochester from September 1979 through December 1995 who were smokers at the time of an index percutaneous coronary revascularization procedure in the non-peri infarction setting (no myocardial infarction within 24 hours). Maximal duration of prospective follow-up was 16 years. Patients were classified into those who permanently quit smoking immediately after the procedure (N = 435; mean follow-up, 5.1 ± 3.7 years) or (hose who continued to smoke at some time during follow-up (N = 734; mean follow-up, 5.3 ± 3.7 years). Logistics regression models were formulated to determine independent predictors of smoking cessation. Results Predictors of continued smoking were greater prior cigarette consumption (odds ratio |OR] −1.009 for each pack-year; 95% confidence interval [CI] = 1.004 to 1.014) and having one or more risk factors for coronary artery disease other than cigarette smoking (OR = 1.49; 95% CI= 1.15 to 1.93). Older age (OR = 0.98 for each additional year; 95% CI=0.97 to 0.99) and unstable angina at time of initial assessment (OR = 0.69; 95% CI=0.52 to 0.91) were associated with less likelihood of continued smoking. Conclusion Younger patients with a worse risk profile and greater prior cigarette consumption were more likely than other patients to continue smoking after percutaneous coronary revascularization in the non-peri-infarction setting. Patients who had unstable angina were more likely to quit smoking than those who had stable angina. Despite the proven benefits of smoking cessation after percutaneous coronary revascularization, a substantial proportion of smokers (63%) continue to smoke; thus, smoking-cessation counseling should be addressed in this population.

Excellent long-term graft patency remains the primary goal of any surgical coronary revascularization procedure, irrespective of how the operation itself is performed. Inter- and intra-surgeon variability in the surgical technique and in the subsequent quality of the anastomosis have the potential to significantly impact not only on graft patency but also, as a result, on patient outcomes. Anastomotic devices, proximal and distal, can facilitate the creation of rapid, reproducible, compliant anastomoses, on- or off-pump, in potentially difficult-to-access areas, often through minimal-access incisions, potentially with neuro-protective benefits, and can thus mitigate some of the hazards inherent in manually constructing anastomoses in technically challenging or suboptimal conditions. We review the three most commonly employed anastomotic devices in adult cardiac surgical practice today.

Video abstract Video, Purpose Two mega trials have raised the question as to whether the hypothesis that infection plays a role in atherosclerosis is still relevant. This controlled preliminary trial investigated an extended dose of azithromycin in the treatment of Chlamydia pneumoniae infection causing coronary artery disease (CAD). Patients and methods Forty patients with documentary evidence of CAD were screened for immunoglobulin G titers against C. pneumoniae and grouped into either the study group (patients with positive titer, n = 32) or control group (patients with negative titer, n = 8). Cases who met inclusion criteria could not have had coronary artery bypass graft surgery or percutaneous coronary intervention in the preceding 6 months. Informed consent was obtained from every patient. Baseline blood samples were analyzed for red blood cell indices, serum creatinine, and liver function tests, and repeated every 2 months. A primary event was defined as the first occurrence of death by any cause, recurrent myocardial infarction, coronary revascularization procedure, or hospitalization for angina. Patients in the study group received 500 mg of oral azithromycin once daily for 5 days, which was then repeated after a gap of 10 days (total of 24 courses in the 1-year trial period). The control group did not have azithromycin added to their standard CAD treatment. Results In the study group, 30 patients completed the trial. Two patients had to undergo percutaneous coronary intervention in the initial first quarter of the 1-year trial period. In the control group, one patient died during the trial, one had to undergo coronary artery bypass graft surgery, and one had percutaneous coronary intervention. Conclusion The patients tolerated the therapy well and there was a positive correlation between azithromycin and secondary prevention of CAD.

The aim of the study was to assess the role of myocardial perfusion scintigraphy (MPS) in the prediction of future cardiac events in elderly hypertensive patients and to investigate if its prognostic value is maintained during a 10-year follow-up period. A total of 229 consecutive patients ≥ 65 years old (range 65–88 years) with arterial hypertension, who were referred to our institution for stress/rest 99mTc-sestamibi MPS between January 2000 and November 2001, were followed up for 10–12 years. Cardiac death, myocardial infarction and a coronary revascularization procedure were considered as events. Survival curves were computed by the Kaplan-Meier method. A stepwise Cox proportional hazards analysis was used to identify predictors of events. Follow-up was completed in 221 (96.5 %) patients; 26 patients experienced cardiac death, 29 myocardial infarction and 51 coronary revascularization. Annual event rates for cardiac death, cardiac death/myocardial infarction and cardiac death/myocardial infarction/coronary revascularization were, respectively, 0, 0.2 and 0.4 % for patients with a normal scan and 1.5, 3.0 and 5.3 % after an abnormal MPS. Event-free survival was significantly different according to extent and severity of perfusion defects (all p

Currently 23.5 million working-age adults 20 years or older have had a diagnosis of both coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM), with estimates that an additional 9% of the total US population will have a diagnosis of this chronic disease combination by the year 2025. Current annual health care costs for this working-age population including medical costs, functional disability, work loss, and premature mortality currently exceed $620 billion. Prior research efforts have shown that 25% to 32% of patients requiring a coronary revascularization procedure have both CAD and T2DM. The primary intervention prescribed for these patients to regain functional ability after revascularization is enrollment in a standard outpatient cardiac rehabilitation (CR) program. These standard programs, ranging in duration from 6 to 12 weeks, have been shown to improve the physical function of CAD patients by up to 15%, but patients diagnosed with both chronic conditions of CAD and T2DM (T2DM+CAD) attending these same programs exhibit only an 8% improvement. Moreover, T2DM+CAD patients experience much lower rates of rehabilitation program appointment adherence as well as greater program attrition (T2DM+CAD: 45%-62% vs CAD: 92%). Current medical literature regarding the relationship between CAD, T2DM, and cardiac rehabilitation will be examined to identify specific factors that could influence the functional outcomes achieved by the T2DM+CAD population when enrolled in a standard CR program and help increase understanding of why the adherence and attrition differences exist.

Several reports suggest that noninvasive measurements of coronary flow reserve (CFR) by use of echocardiography may support decision making in intermediate stenosis of the left anterior descending coronary artery (LAD). The aim of the present study was therefore to analyze the clinical outcome in patients with intermediate stenosis of LAD after deferral of coronary revascularization on the basis of noninvasive CFR measurement.the study population included 280 patients with intermediate LAD stenosis (50-70% by angiography) (62.2 +/- 9.6 years). All the patients underwent transthoracic CFR assessment of LAD (after dipyridamole infusion) within 2 weeks from coronary angiography. If CFR of LAD wasor = 2, PTCA was recommended; if CFR was2, medical treatment was chosen. Primary end points were cardiac death, myocardial infarction, coronary revascularization procedure, and unstable angina.mean follow-up was 43 +/- 11 months (range 12-52 months). In 150 patients (53.6%) (CFRor = 2), coronary artery revascularization was performed (PTCA group); the remaining 130 patients (46.4%) (CFR2) were medically treated (medical group). Survival from cardiac death was 94% in the PTCA group and 92.4% in the medical group (P = 0.56). As for all cardiac events, the Kaplan-Meier percentage survival from cardiac events was 88.3% in the PTCA group and 86.4% in the medical group (P = 0.36).even if CFR as a "stand-alone" diagnostic criterion suffers from several structural limitations, a combined strategy including also other clinical and instrumental measurements before undergoing interventional procedures could improve the cost-benefit practice, in particular, for the management of patients with intermediate LAD stenosis.

purpose: The objective of this study was to examine the effect of low-dose aspirin (325 mg on alternate days) on the primary prevention of angina pectoris in the United States Physicians' Health Study. Despite a postulated role of platelets in atherogenesis and myocardial ischemia, the effect of chronic platelet inhibition on the development of clinical angina pectoris is unknown. subjects and methods: The Physicians' Health Study is a randomized, double-blind, placebo-controlled trial among 22,071 male physicians aged 40 to 84 years, free from previous myocardial infarction, stroke, and transient cerebral ischemia at entry, and followed for an average of 60.2 months. The 21,738 physicians who were also free from angina pectoris at baseline constituted the study population for the present analyses. results: During 106,652 person-years of follow-up, 331 patients with confirmed angina pectoris were diagnosed, 194 of whom underwent a coronary revascularization procedure (coronary artery bypass graft surgery or coronary angioplasty). As compared to participants assigned placebo, the relative risk of confirmed angina pectoris in the aspirin group was 1.10 (95% confidence interval [CI], 0.88 to 1.38). For coronary revascularization, the relative risk was 1.19 (95% CI, 0.88 to 1.59). After simultaneous control for other coronary risk factors in a proportional-hazards model, these relative risks remained near unity at 1.07 (95% CI, 0.84 to 1.36) and 1.11 (95% CI, 0.81 to 1.52), respectively. When the risks of angina pectoris were examined according to year of randomization in the trial, there was no pattern of increasing benefit with longer duration of treatment. conclusion: These randomized trial data indicate that chronic platelet inhibition with low-dose aspirin for an average duration of 60.2 months does not reduce the incidence of angina pectoris.

PURPOSE To determine the utility of the Stanford Brief Activity Survey (SBAS) as a quick screening tool in a clinical population, where no other measure of physical activity was available. METHODS The SBAS was administered to 500 younger cases in the Atherosclerotic Disease Vascular Function and Genetic Epidemiology (ADVANCE) study, a case-control genetic association study, between December 2001 and January 2004. Younger cases in the ADVANCE study included men (

Background Randomized clinical trials (RCTs) have shown that statins provide substantial heath benefits. Pharmaceutical companies spend enormous amounts of money on both clinical trials and marketing. The relative influence of information from clinical trials on physician prescription patterns for statins is unknown. Objective To examine the correlation between statin prescription patterns and the quality of evidence from RCTs. Methods Using the computerized administrative databases of the Quebec Health Insurance Board, the choice of statin for elderly patients (older than 65 years of age) following a coronary revascularization procedure (percutaneous coronary intervention or coronary artery bypass graft surgery) performed between January 1, 1994, and June 30, 2003, was examined. Prescriptions for each statin were compared with their evidence base obtained from a cumulative systematic literature review of RCTs that recorded mortality as an outcome and were published before December 31, 2002. Results The study cohort comprised 27,979 elderly revascularized patients who received at least one statin prescription. In 1996, the year atorvastatin was introduced, simvastatin and pravastatin had 38.3% and 37.1% of the market share, respectively. By 2003, atorvastatin had 44% of the market share, compared with 29.9% and 24.1% for simvastatin and pravastatin, respectively. In contrast, RCTs published up to the end of 2002 had culminated in 133,341 and 140,565 patient-years of follow-up for simvastatin and pravastatin, respectively, and only 1459 patient-years for atorvastatin. Conclusions Prescription patterns regarding the choice of statin do not appear to be determined uniquely from high-quality RCTs. Further research into the other possible determinants of physician prescription patterns is necessary.

UNLABELLED This case report describes damage to a pulmonary artery catheter (PAC) during transmyocardial laser revascularization. We observed persistent bleeding and a temperature reading of "too high" from the temperature connection port of PAC during cardiopulmonary bypass while the patient's nasopharyngeal temperature read 34 degrees C. This alerted us to the possibility of PAC damage during creation of laser channels in the right coronary artery territory on the inferior surface of the heart. This is a unique complication related to this coronary revascularization procedure. IMPLICATIONS We report an unusual case of pulmonary artery catheter (PAC) damage during transmyocardial laser revascularization (TMLR). This observation should alert the anesthesiologist to the fact that the PAC may be damaged when TMLR is performed on the right side of the heart. We recommend that the PAC be withdrawn during this procedure.

Background In clinical trials, cholesterol-lowering medications have been proven to decrease mortality and morbidity and are strongly recommended as secondary prevention in patients with established coronary artery disease. In routine practice, the translation of these benefits to elderly patients with recent coronary revascularization is less well known. Methods Using the provincial computerized administrative databases of the Regie de l'Assurance Maladie du Quebec, we identified all elderly patients (>65 years old) in Quebec, Canada, discharged alive after a coronary revascularization procedure (percutaneous coronary intervention or coronary artery bypass graft) between April 1, 1995, and December 31, 1997, and determined the percentage fulfilling prescriptions for cholesterol-lowering drug therapy. Time-dependent multivariable models examined the clinical end points of total mortality, acute myocardial infarctions, and repeat coronary revascularizations as a function of cholesterol-lowering drug exposure. Patients were followed up until death or December 31, 1999. Results We identified 11 958 elderly patients who had a coronary revascularization between April 1, 1995, and December 31, 1997. During an average 3-year follow-up, users of cholesterol-lowering medications had a decreased risk of death [hazard ratio (HR) 0.66, 95% CI 0.45-0.96] or myocardial infarction (HR 0.77, 95% CI 0.54-1.11) but no reduction in repeat revascularizations (HR 1.06, 95% CI 0.88-1.28). Conclusions In this population-based study of recently revascularized elderly patients, we observed health benefits associated with the use of cholesterol-lowering medications of similar size to those seen in randomized clinical trials. The translation of these benefits from clinical trials to a nonselected population of revascularized patients emphasizes the importance of this aspect of secondary prevention in clinical practice.

Left ventricular thrombus after myocardial infarction is relatively common but rarely threatening enough to warrant surgical removal at the time of coronary revascularization. The rare cases of ventricular thrombectomy described in the literature involve a pedunculated thrombus. We describe an urgent coronary revascularization procedure in a patient who had unrecognized left ventricular thrombus. The large clot was detected by transesophageal echocardiography after decannulation in a hemodynamically unstable patient. The thrombus was removed after placing the patient back on cardiopulmonary bypass emergently. He recovered and was discharged with no neurologic sequelae. Aggressive removal of clot using cardiopulmonary bypass is warranted even for the critically ill patient.

BACKGROUND This study examines the influence of gender on the healthcare provider's secondary prevention instruction and cardiac rehabilitation (CR) referral after coronary revascularization procedures such as balloon angioplasty/coronary stenting and coronary bypass surgery (CABG). Cardiac rehabilitation decreases mortality and morbidity, yet only a small percentage of women and men are referred to these programs. The patient population of our university-affiliated CR program consisted of 88% men and 12% women. METHODS In a matched case observational study, 80 patients (40 men, 40 women) who had undergone coronary revascularization procedures between 1997 and 1998 completed a questionnaire on secondary prevention instruction and written referral to CR programs. Patients were matched for age and coronary revascularization procedure. RESULTS Women were less likely to be instructed on secondary prevention strategies and CR or referred to CR as compared to men despite being matched for age and undergoing the same procedure. The data demonstrate a gender difference in hospital teaching and referral information for CR after revascularization (P < 0.001). Being a woman was associated with a decreased likelihood of receiving a physician referral to CR after revascularization (P < 0.001). CONCLUSION The instruction of patients concerning secondary prevention and CR postrevascularization procedures is poor. Within that group, women were far less likely to have CR discussed or referrals made by healthcare professionals. This study demonstrates the need for education initiatives of all healthcare providers on the comprehensive nature and benefits of CR in the secondary prevention of cardiovascular disease, with a particular emphasis on women.

Purpose: Previous studies have shown that coronary artery bypass surgery reduces the risk of cardiac complications after noncardiac surgery. Whether coronary angioplasty provides equivalent protection is not known. SUBJECTS AND METHODS: Patients were randomly assigned to undergo cardiac artery bypass surgery or angioplasty as part of the Bypass Angioplasty Revascularization Investigation trial. All subsequent noncardiac surgeries during a mean (± SD) follow-up of 7.7 years were recorded among participants in the ancillary Study of Economics and Quality of Life. Rates of mortality and nonfatal myocardial infarction, length of stay, and hospital costs were compared by the original randomized assignment. RESULTS: A total of 501 patients had noncardiac surgery at a median of 29 months after their most recent coronary revascularization procedure. Mortality and nonfatal myocardial infarction within 30 days of the first noncardiac surgery occurred in 4 of the 250 of the surgery-assigned patients and in 4 of the 251 of the angioplasty-assigned patients ( P = 1.0). There were no significant differences in the mean length of hospital stay (6.3 ± 6.7 versus 6.2 ± 6.8 days; P = 0.47) or hospital cost ($8,920 ± $11,511 versus $7,785 ± $7,643; P = 0.33) between the surgery and angioplasty groups. Similar results were obtained when subsequent noncardiac procedures were included in the analysis. CONCLUSION: Rates of myocardial infarction and death after noncardiac surgery are similarly low after contemporary bypass surgery or angioplasty in patients with multivessel coronary artery disease.

Intracoronary radiation is a promising therapy to reduce restenosis after percutaneous coronary intervention. It may be anticipated that radiation and intracoronary stents - the current standard coronary revascularization procedure - have a synergic antirestenosis effect. However, this potential benefit has not been proven in the clinical scenario. Indeed, this combined approach (stenting plus brachytherapy) may even be harmful. Delayed endothelialization and late stent malapposition are important drawbacks of implanting a metallic prosthesis in the setting of radiation therapy. Owing to the relatively high frequency of late thrombosis after stenting irradiated coronary arteries, the Food and Drug Administration required that the labeling of both gamma- and beta-radiation devices recently approved for clinical use explicitly advise avoidance of the placement of new stents. The pathophysiologic aspects as well as the clinical implications of the implantation of a new stent in association with radiation delivered by radioactive stents or catheter-based systems are discussed in this paper.

OBJECTIVES The purpose of this study was to compare early and late clinical outcomes in diabetic and nondiabetic patients after stent implantation in saphenous vein grafts (SVG). BACKGROUND Patients with diabetes mellitus have less favorable acute and long-term outcomes after stent implantation in native coronary arteries. The impact of diabetes on SVG stenting, however, is not known. METHODS We studied 908 consecutive patients (1,366 SVG lesions) treated with Palmaz-Schatz stents. In-hospital and late clinical outcomes (death, Q-wave myocardial infarction and repeat revascularization rates at one year) were compared between diabetic (n = 290) and nondiabetic (n = 618) patients. RESULTS In-hospital mortality was significantly higher in diabetic as compared with nondiabetic patients (2.2% vs. 0.3%, p = 0.003). At one-year follow-up, target lesion revascularization (TLR) was 16.6% in diabetic and 12.3% in nondiabetic patients (p = 0.03). Overall cardiac event-free survival (freedom from death, Q-wave myocardial infarction and any coronary revascularization procedure) at one year was significantly lower in the diabetic (68%) compared with the nondiabetic patients (79%, p = 0.0003). By Cox regression analysis, diabetes mellitus was an independent predictor of both TLR (relative risk: 1.23; confidence interval: 0.96 to 1.58; p = 0.004) and late cardiac events (relative risk: 1.40; confidence interval: 1.05 to 1.86; p = 0.02). CONCLUSIONS Patients with diabetes undergoing stent implantation in SVG have: 1) higher in-hospital and late mortality, 2) higher one-year TLR rates, and 3) significantly lower one-year cardiac event-free survival. Thus, diabetic patients have less favorable acute and late clinical outcomes after stent implantation in SVG lesions.

Graft coronary disease (GCD) remains the single greatest limitation to long-term survival of heart transplant recipients. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited; palliative coronary revascularization has been attempted. Because of the high mortality rate associated with advanced forms of GCD our institution offers the option of retransplantation in selected cases. The aim of this study was by analyzing retrospectively the outcomes of angioplasty, coronary bypass grafting, and retransplantation in cardiac transplant patients to attempt to identify subgroups of transplant recipients with graft coronary disease who may profit from myocardial revascularization.Of the 989 patients undergoing 1016 heart transplantations (HTx) at our institution between 10/86 and 12/97, all were screened for the development of GCD. Analyzing routinely annual angiography, intracoronary ultrasound in defined study patients, and autopsy findings, GCD was diagnosed in 124 patients (110 male, 14 female) 2 to 107 months after HTx (mean 30 months).PTCA: Fourty-six out of 124 patients underwent 76 angioplasties at a mean of 50 +/- 30 months (range 4-91 mo) following cardiac transplantation. The primary success rate was 96% (73/76). The reason for the unsuccessful angioplasty attempts (n = 3) was failure to completely penetrate a stenosis of LAD in 2 patients and severe dissection of RCA, which required emergency surgery, in one. Angiographic restenosis occurred in 42% (31 of 76 lesions) and was diagnosed 11 +/- 11 months after the first angioplasty. There was no procedure-related death. CABG: Seven patients underwent bypass surgery at a mean of 67 months (range 6-128 months) after HTx. Elective surgery was performed in 2 patients with proximal severe triple-vessel disease (Type A lesion) and in 1 patient with severe tricuspid regurgitation who received a tricuspid valve replacement and concomitant single-vessel bypass surgery for proximal GCD (Type A lesion). One patient with combined Type A and B/C lesions required emergency surgery for dissection of RCA after an angioplasty procedure. Three patients with post-infarction unstable angina developed worsening congestive heart failure which required emergency surgery. Angiographically all these patients showed diffuse, distal arteriopathy (combined Type B/C lesions). The electively operated patients and the patient with dissection of RCA were successfully treated and survived beyond hospital discharge (overall survival for CABG in GCD patients 4/7 = 57%). After a mean follow-up of 10 months (range 2-32 months) all are in good clinical condition. All 3 patients with distal arteriopathy and emergency surgery died in hospital of left-ventricular failure (43%). Retransplantation: Eight patients underwent retransplantation at a mean of 54 months (range 6-96 months) after HTx. Six of 8 patients had successful operations and survived beyond hospital discharge with a one-year-survival rate of 75%. In a mean follow-up of 31 months (5-68 months) 3 of 6 retransplant recipients developed a recurrence of GCD.The presence of angiographic distal arteriopathy should be considered a significant factor in patient selection for coronary revascularization procedure. Coronary angioplasty is to be considered as a method of treatment for severe, local stenoses (Type A lesion). PTCA may be applied in these selected cardiac transplant recipients with primary success and complication rates comparable to routine angioplasty but with an increased rate of restenosis especially in small vessels (diameter2.5 mm). The distinction between Type A lesions in large (diameteror = 2.5 mm) and small vessels may be important not only with respect to restenosis but also with respect to long-term benefit. The overall survival did not differ between GCD patients with and without PTCA, suggesting this treatment to be largely palliative. (ABSTR

In-patient telemetry units are, in many ways, the natural outgrowth of the development of coronary care units in the 1960s (1,2). These original coronary care units were created for patients with known acute myocardial infarctions in an attempt to congregate such patients in a setting in which arrhythmias could be detected promptly and the new arts of countershock and resuscitation could be instituted immediately (3,4). By the late 1960s, however, the concept of coronary care was extended to patients with suspected acute myocardial infarction (5), and the proportion of patients in such units who ruled-in for acute myocardial infarction fell to well less than 50%. More recently, we and others have emphasized that coronary care units should be reserved for patients with a high likelihood of acute myocardial infarction (6,7) and a high likelihood of developing complications that require intensive care (8). As coronary care units once again become more focused on patients with acute myocardial infarctions or evident complications requiring intensive care, in-patient telemetry units have become especially relevant for the large proportion of patients whose lower but finite possibility of life-threatening arrhythmias has suggested a potential role for telemetry monitoring without a similar need for intensive care nursing. The use of telemetry units depends primarily on local practice and custom, perhaps influenced somewhat by nearly decadeold guidelines from the American College of Cardiology (9). In this issue of the American Journal of Medicine, Durairaj and colleagues (10) report on a prospective study of 1,033 consecutive patients admitted from the emergency department to an in-patient telemetry unit at Cook County Hospital. Among these patients, a major complication occurred in 9 (0.9%), including 2 cardiac arrests that were fatal despite resuscitation efforts. This low rate of complications was very similar to the 0.9% rate of transfer from telemetry to intensive care based on arrhythmias detected by telemetry findings in a study of 2,240 patients at the Henry Ford Hospital (11). The yield of telemetry for detecting important arrhythmias was similarly low among 261 patients with normal or nonspecific electrocardiograms at University Medical Center in Stony Brook, New York (12). Furthermore, the usefulness of the American College of Cardiology guidelines (9) for determining who will benefit from telemetry has been seriously questioned (13,14). Despite the reasonably clear case for the benefit and cost effectiveness of coronary care units for the highest risk patients (6,7), the precise role for telemetry units remains uncertain. It is in this context that the study of Durairaj et al (10) is most interesting, especially its prospective evaluation of a prognostic classification scheme proposed by my colleagues and me (8). In their study, 532 (52%) of the 1,033 patients were classified as very low risk using an algorithm that we derived based on 10,682 patients with acute chest pain at seven hospitals and then validated on a separate set of 4,676 patients seen at one hospital. Very low risk patients were defined as those who did not have suspected ischemia on their electrocardiograms and who also did not have a systolic blood pressure below 110 mm Hg, rales above the bases bilaterally on physical examination, or an exacerbation of known unstable ischemic heart disease (a worsening of previously stable angina, new onset of postinfarction angina or angina after a coronary revascularization procedure, or pain that was the same as that associated with a prior myocardial infarction). Among these 532 patients, there was only 1 major complication (endotracheal intubation for management of status epilepticus). In both studies, the definition of major events included ventricular fibrillation, cardiac arrest, complete heart block, a bradyarrhythmia requiring insertion of a temporary pacemaker, emergency cardioversion, cardiogenic shock, need for an intra-aortic balloon pump, intubation, or recurrent ischemic chest pain requiring revascularization within 72 hours after admission or coronary angiography followed by revascularization before discharge. The upper bound of the 95% confidence interval for very low risk patients with chest pain was only a 1.2% risk of complications, whereas for those without chest pain it was 2.6%. Durairaj and colleagues (10) did not evaluate an alternative approach, the use of the American College of Cardiology guidelines (9), which tend to focus as much on patients who are already in the hospital as on patients who are admitted directly via an emergency department. However, prior evaluations of these guidelines (13,14) found them generally to be unhelpful for determining who would benefit most from telemetry monitoring. In the study by Durairaj and colleagues (10), 3 patients per day were denied admission to the telemetry unit for lack of beds while on average 4 of the 12 telemetry beds Am J Med. 2001;110:67– 68. From the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Requests for reprints should be addressed to Lee Goldman, MD, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, California 94143-0120.

Correct assessment of the significance of left main stem lesions is of pivotal importance to the patient with coronary artery disease. On the basis of clinical and angiographic information alone, this evaluation often cannot be done reliably. Limited data suggest that coronary pressure-derived fractional flow reserve (FFR) supports decision making in equivocal left main disease.All patients presenting to our institution between June 1999 and June 2004 with intermediate left main coronary artery disease (40%-80% diameter stenosis by angiography), or in whom left main coronary disease was suspected but could not be quantified angiographically, were included in this prospective single-center follow-up study. If FFR was0.75 along the left main stem, surgical revascularization was recommended; if FFR was0.80, medical treatment or percutaneous coronary intervention elsewhere in the coronary tree was chosen. If FFR was in the "gray zone," betweenor = 0.75 andor = 0.80 treatment recommendation was dependent on additional individual criteria. Primary end points were freedom from death, myocardial infarction, any coronary revascularization procedure, and stroke.Fifty-one patients (mean age 62.2 +/- 9.6 years, 41 male) were included. In 27 patients (53%), coronary artery bypass surgery was performed. The remaining 24 patients (47%) were treated nonsurgically. Mean follow-up was 29 +/- 16 months. Estimated survival after 4 years of follow-up was 81% among patients in the surgical group and 100% among patients in the nonsurgical group. Event-free survival was 66% in the surgical group and 69% in the nonsurgical group.Fractional flow reserve is helpful to identify patients with intermediate left main disease in whom deferral of surgical revascularization is associated with excellent survival and low event rates.

BACKGROUND: Psychiatric morbidity is common in heart patients after a myocardial infarction (MI) or coronary revascularization procedure (CRP). Common expressions of psychiatric morbidity including depression, hopelessness, distress, and post-traumatic stress disorder have increasingly drawn attention as negative prognostic indicators for heart patients. OBJECTIVE: To investigate psychological distress as a predictor of subsequent cardiac-related events in patients with a prior CRP. DESIGN: Married patients who experienced a CRP (either balloon angioplasty or coronary bypass surgery) and their spouses were surveyed within a year of the patient's CRP. MATERIAL AND METHODS: 250 CRP patients (212 men, 38 women) and their spouses completed the Michigan Family Heart Questionnaire and the COPE which assessed a wide range of psychosocial variables including patient and spouse distress, coping, spouse support, and demographic variables. Cardiovascular-related outcome data (cardiovascular events which included subsequent hospital admissions, MI, CRP, or death) were analyzed. RESULTS: A large proportion of patients (41%) were found to have high distress levels, defined by a score which met the criteria for a clinical diagnosis, and were significantly more likely (t = 2.3, p < .025) to have a subsequent cardiovascular event. High distress as compared to low distress patients had a relative risk of 1.86 for a subsequent cardiovascular event. CONCLUSIONS: This study demonstrates that elevated distress is common in CRP patients and confers an increased risk for cardiovascular events. Interventions that prevent or reduce psychological distress may be effective in reducing recurrent cardiac events.

Long-term outcome of dialysis patients in the United States with coronary revascularization procedures.BackgroundThe optimal method of coronary revascularization in dialysis patients is controversial, as previous small retrospective studies have reported increased cardiac events after percutaneous transluminal coronary angioplasty (PTCA) compared with coronary artery bypass (CAB) surgery. The purpose of this study was to compare the long-term survival of chronic dialysis patients in the United States following PTCA or CAB surgery.MethodsDialysis patients hospitalized from 1978 to 1995 for first coronary revascularization procedure after initiation of renal replacement therapy were retrospectively identified from the United States Renal Data System database. Survival for the endpoints of all-cause death, cardiac death, myocardial infarction, and cardiac death or myocardial infarction was estimated by the life-table method and was compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression model with comorbidity adjustment.ResultsThe in-hospital mortality was 5.4% for 6887 PTCA patients and 12.5% for 7419 CAB patients. The two-year event-free survival (± SE) of PTCA patients was 52.9 ± 0.7% for all-cause death, 72.5 ± 0.7% for cardiac death, and 62.0 ± 0.7% for cardiac death or myocardial infarction. In CAB patients, the comparable survivals were 56.9 ± 0.6, 75.8 ± 0.6, and 71.3 ± 0.6%, respectively (P < 0.02 for PTCA vs. CAB surgery for all endpoints). After comorbidity adjustment, the relative risk of CAB surgery (vs. PTCA) performed 1990 to 1995 for all-cause death was 0.91 (95% CI, 0.86 to 0.97); cardiac death, 0.85 (95% CI, 0.78 to 0.92); myocardial infarction, 0.37 (95% CI, 0.32 to 0.43); and cardiac death or myocardial infarction 0.69 (95% CI, 0.64 to 0.74).ConclusionsIn this retrospective study, dialysis patients in the United States had better survival after CAB surgery compared with PTCA, but our study does not exclude the possibility of more unfavorable coronary anatomy in the PTCA patients at baseline. Our data support the need for prospective trials of newer percutaneous coronary revascularization procedures in dialysis patients.