Restenosis begets restenosis: implications for stent selection

Background. Identifying the risk for restenosis is of critical importance in the stent selection process of patients undergoing percutaneous coronary intervention (PCI). Therefore, we sought to determine if a history of clinical recurrence (CR) after PCI increases the risk of CR after treatment of a de novo lesion in another coronary artery. Methods. We retrospectively analysed all 12,763 patients who underwent PCI between 1993 and 2004 and selected patients with two or more interventions in two different native vessels. These patients were divided into two groups: patients without CR, and patients with CR after the first PCI. Clinical recurrence was defined as revascular-isation of the target vessel by either PCI or CABG within one year. Results. A total of 1010 patients with two or more interventions in two different native vessels were identified: 727 patients without and 283 patients with CR after the first PCI. Baseline patient characteristics and conventional risk factors were comparable between the two groups. Patients with a history of CR had a higher risk of CR after a second intervention in a second vessel (OR=3.4, 95% CI=2.3 to 4.9). A total of 112 patients also had a third intervention in a third native vessel: 12 patients with two CR, 30 patients with one CR and 70 patients with no CR after the first two interventions. CR rates in these patients were 50, 17 and 3%, respectively (p<;0.001). Conclusion. Patients with a history of CR have a markedly increased risk of developing CR after a second or third PCI in a different coronary artery. Therefore, in the decision-making process on whether to use a bare metal stent or drug-eluting stent, the history of CR is a simple and powerful aid. (Neth Heart J 2008;16:376-81.)     

Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention

Background/Objectives. A rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is mandatory for optimal treatment. However, a small proportion of patients with suspected STEMI suffer from other conditions. Although case reports have described these conditions, a contemporary systematic analysis is lacking. We report the incidence, clinical characteristics and outcome of patients with suspected STEMI referred for primary percutaneous coronary intervention (PCI) with a final diagnosis other than STEMI. Methods. From January 2004 to July 2005, 820 consecutive patients were included with suspected STEMI who were referred for primary PCI to a university medical centre, based on a predefined protocol. Clinical characteristics, final diagnosis and outcome were obtained from patient charts and databases. Results. In 19 patients (2.3%), a final diagnosis other than myocardial infarction was established: coronary aneurysm (n=1), (myo)pericarditis (n=5), cardiomyopathy (n=2), Brugada syndrome (n=1), aortic stenosis (n=1), aortic dissection (n=3), subarachnoidal haemorrhage (n=2), pneumonia (n=1), chronic obstructive pulmonary disease (n=1), mediastinal tumour (n=1), and peritonitis after recent abdominal surgery (n=1). These patients less often reported previous symptoms of angina (p<0.001), smoking (p<0.05) and a positive family history of cardiovascular diseases (p<0.05) than STEMI patients. Mortality at 30 days was 16%. Conclusion. A 2.3% incidence of conditions mimicking STEMI was found in patients referred for primary PCI. A high clinical suspicion of conditions mimicking STEMI remains necessary. (Neth Heart J 2008;16:325-31.)     

冠状动脉支架植入术后行冠脉旁路移植术

目的:总结15例冠状动脉支架植入术后行冠状动脉旁路移植术的临床经验。方法:回顾分析行冠状动脉支架植入术后行冠状动脉旁路移植术15例患者的资料,男10例,女5例,平均年龄(61±5)岁。行冠状动脉支架植入术后再行冠状动脉旁路移植术时间间隔(24±4)月,冠状动脉内置入支架3-6枚,左室射血分数为43%-64%,其中50%为3例。全组行体外循环下冠状动脉旁路移植术3例,行非体外循环心脏跳动下冠状动脉旁路移植术12例。结果:全组共行动脉桥吻合13支,静脉桥33支;围术期并发低心排综合征3例,肺部感染4例,胸腔内出血行胸腔闭式引流术2例,本组患者无死亡病例。术后平均住院日(13±4)天。结论:对冠状动脉内支架植入术后再狭窄或(和)冠状动脉再血管化不足的病例进行冠状动脉旁路移植治疗,可使冠状动脉达到充分再血管化,提高冠心病患者生活质量及预后。     

Temporal Trends of In-Hospital Mortality in Patients Treated with Intra-Aortic Balloon Pumping: A Nationwide Population Study in Taiwan, 1998-2008

Intra-aortic balloon pumping (IABP) is widely used for hemodynamic support in critical patients with cardiogenic shock (CS). We examined whether the in-hospital mortality of patients in Taiwan treated with IABP has recently declined. We used Taiwan’s National Health Insurance Research Database to retrospectively review the in-hospital all-cause mortality of 9952 (7146 men [71.8%]) 18-year-old and older patients treated with IABP between 1998 and 2008. The mortality rate was 13.84% (n = 1377). The urbanization levels of the hospitals, and the number of days in the intensive care unit, of hospitalization, and of IABP treatment, and prior percutaneous coronary intervention (PCI) were associated with mortality. Seven thousand six hundred thirty-five patients (76.72%) underwent coronary artery bypass grafting (CABG) surgery, and 576 (5.79%) underwent high-risk PCI with IABP treatment. The number of patients treated with IABP significantly increased during this decade (p_trend < 0.0001), the in-hospital all-cause mortality for patients treated with IABP significantly decreased (p_trend = 0.0243), but the in-hospital all-cause mortality of patients who underwent CABG and PCI plus IABP did not decrease. In conclusion, the in-hospital mortality rate of IABP treatment decreased annually in Taiwan during the study period. However, high-risk patients who underwent coronary revascularization with IABP had a higher and unstable in-hospital mortality rate.     

冠状动脉支架植入术后行冠脉旁路移植术

目的：总结15例冠状动脉支架植入术后行冠状动脉旁路移植术的临床经验。方法：回顾分析行冠状动脉支架植入术后行冠状动脉旁路移植术15例患者的资料,男10例,女5例,平均年龄（61±5）岁。行冠状动脉支架植入术后再行冠状动脉旁路移植术时间间隔（24±4）月,冠状动脉内置入支架3-6枚,左室射血分数为43％-64％,其中〈50％为3例。全组行体外循环下冠状动脉旁路移植术3例,行非体外循环心脏跳动下冠状动脉旁路移植术12例。结果：全组共行动脉桥吻合13支,静脉桥33支;围术期并发低心排综合征3例,肺部感染4例,胸腔内出血行胸腔闭式引流术2例,本组患者无死亡病例。术后平均住院日（13±4）天。结论：对冠状动脉内支架植入术后再狭窄或（和）冠状动脉再血管化不足的病例进行冠状动脉旁路移植治疗,可使冠状动脉达到充分再血管化,提高冠心病患者生活质量及预后。     

Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure

Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001.Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively.Results. All 133 patients were successfully revascularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by percutaneous coronary intervention. (Neth Heart J 2010;18:7-11.)     

Patients with coronary stenosis and a fractional flow reserve of ≥0.75 measured in daily practice at the VU University Medical Center

Objectives. The aim of this study was to analyse the rate of major adverse clinical events in patients with coronary artery disease and a fractional flow reserve (FFR) of ≥0.75 and deferred for coronary intervention in daily practice. Methods. From 1 January to 31 December 2006, FFR measurement was initiated in 122 patients (5%) out of 2444 patients referred for coronary angiography. In two patients FFR measurement failed and in one patient the FFR value could no longer be traced in the documents. Thus, 119 patients (84 men, 64 years, range 41-85) were included in the evaluation (145 lesions). Major adverse clinical events (death, myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)) and the presence of angina were evaluated at follow-up. Furthermore a cost-effectiveness analysis was performed. Results. In 93 patients (76%) the FFR value was ≥0.75. Seventy of these 93 patients (76%) were treated with medication alone or underwent PCI for a different lesion (medical treatment group). Average duration of follow-up of all 119 patients was 22 months (range 4 days to 30 months). In the medical treatment group seven patients (10%) experienced a major adverse clinical event related to the FFR-evaluated lesion during follow-up. In this study population, the use of FFR measurement is cost-reducing provided that at least 65% of the patients in the medical treatment group has had a PCI with stent implantation when the use of FFR measurement is impossible. In this case, the decision to use PCI with stent implantation is purely based on the angiogram. Conclusions. In patients with a coronary stenosis based on visual assessment and an FFR of ≥0.75 deferral of PCI or CABG is safe in daily clinical practice and saves money. (Neth Heart J 2010;18:402-7.)     

Prediction of mortality using a multi-bed vascular calcification score in the Diabetes Heart Study

Background

Diabetes is associated with a high risk of death due to coronary artery disease (CAD). People with diabetes suffering from CAD are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of coronary revascularization procedures in diabetic and non-diabetic patients in Spain between 2001 and 2011.

Methods

We identified all patients who had undergone coronary revascularization procedures, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. The incidence of discharges attributed to coronary revascularization procedures were calculated stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We apply joinpoint log-linear regression to identify the years in which changes in tendency occurred in the use of PCI and CABG in diabetic and non-diabetic patients. Multivariate analysis was adjusted by age, sex, year and comorbidity (Charlson comorbidity index).

Results

From 2001 to 2011, 434,108 PCIs and 79,986 CABGs were performed. According to the results of the joinpoint analysis, we found that sex and age-adjusted use of PCI increased by 31.4% per year from 2001 to 2003, by 15.9% per year from 2003 to 2006 and by 3.8% per year from 2006 to 2011 in patients with diabetes. IHM among patients with diabetes who underwent a PCI did not change significantly over the entire study period (OR 0.99; 95% CI 0.97-1.00). Among patients with diabetes who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 10.4% per year from 2001 to 2003, and then decreased by 1.1% through 2011. Diabetic patients who underwent a CABG had a 0.67 (95% CI 0.63-0.71) times lower probability of dying during hospitalization than those without diabetes.

Conclusions

The annual percent change in PCI procedures increased in diabetic and non-diabetic patients. Higher comorbidity and the female gender are associated with a higher IHM in PCI procedures. In diabetic and non-diabetic patients, we found a decrease in the use of CABG procedures. IHM was higher in patients without diabetes than in those with diabetes.     

Thrombus Aspiration during Percutaneous coronary intervention in Acute non-ST-elevation myocardial infarction Study (TAPAS II)-Study design

Background and Objective. The Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) has shown that thrombus aspiration improves myocardial perfusion and clinical outcome compared with conventional primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction. Impaired myocardial perfusion due to spontaneous or angioplasty-induced embolisation of atherothrombotic material also occurs in patients with non-ST-elevation myocardial infarction (NSTEMI). The aim of this study is to determine whether thrombus aspiration before stent implantation will result in improved myocardial perfusion in patients with NSTEMI compared with conventional PCI. Study design. The study is a single-centre, prospective, randomised trial with blinded evaluation of endpoints. The planned inclusion is 540 patients with acute NSTEMI who are candidates for urgent PCI. Patients are randomised to treatment with manual thrombus aspiration or to conventional PCI. The primary endpoint is the incidence of myocardial blush grade 3 after PCI. Secondary endpoints are coronary angiographic, histopathological, enzymatic, electrocardiographic and clinical outcomes including major adverse events at 30 days and one year. Implications. If thrombus aspiration leads to significant improvement of myocardial perfusion in patients with acute NSTEMI it may become part of the standard interventional approach. (Neth Heart J 2009;17:409–13.)     

PCI及CABG治疗严重病变程度冠心病患者的临床效果比较

目的:比较经皮冠状动脉介入术(Percutaneous Coronary Intervention,PCI)和冠状动脉旁路移植术(Coronary Artery Bypass Grafting,CABG)治疗术前SYNTAX积分32分的重度病变冠状动脉粥样硬化心脏病(Coronary Heart Disease,CHD)患者的临床效果及安全性。方法:纳入2017年3月6日至2017年5月20日在西京医院心血管内外科成功行CABG且术前SYNTAX积分32分的重度病变CHD患者50名和成功行PCI且术前SYNTAX积分32分的重度病变CHD患者50名,分为PCI组与CABG组。比较两组患者的一般基线资料和院内死亡发生情况,术后一年电话随访患者存活情况、病死原因、再次入院、心绞痛、心肌梗死、脑卒中等发生情况,通过SF-12量表和西雅图量表评估患者的生活质量的改善情况。结果:与CABG组相比,PCI组患者心率更低、住院时间更短、住院花费更少、有PCI史的患者比例更高,差异具有统计学意义(P0.05)。术后一年,两组患者心功能改善情况和主要不良心脑血管事件(major adverse cardiac and cerebrovascular events,MACCE)发生率、SF-12量表与西雅图心绞痛量表(Seattle Angina Questionnaire, SAQ)的各个维度评分比较差异均无统计学意义(P0.05)。结论:PCI与CABG治疗不同病变严重程度的冠心病患者的临床效果及安全性相当。     

Long-term follow-up after bypass surgery or coronary stenting in elderly with multivessel disease

Background

We sought to compare long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in elderly patients with left main or multivessel disease, hypothesising that completeness of revascularisation and severity of coronary artery disease are predictors of adverse outcomes.

Methods

Patients aged ≥75 years with multivessel disease or left main disease who underwent PCI or CABG between 2012–2016 were included in this retrospective cohort study. Baseline characteristics from the index procedure were collected. Severity of coronary artery disease and completeness of revascularisation were assessed. Primary outcome was all-cause mortality, in addition we captured major adverse cardiac and cerebral events, bleedings, recurrent angina and new onset atrial fibrillation.

Results

A total of 597 patients were included. Median follow-up was 4 years (interquartile range 2.8–5.3 years). At baseline, patients in the PCI group more often had a previous medical history of CABG and more frequently underwent an urgent procedure compared with patients in the CABG group. Mortality at 5‑year follow-up was significantly higher in patients who underwent PCI compared with CABG (39.9% vs 25.4%, p < 0.001). Furthermore, acute coronary syndrome (ACS), repeat revascularisation and recurrent angina occurred more frequently after PCI, while occurrence of bleedings and new onset atrial fibrillation were more frequent after CABG. Neither completeness of revascularisation nor severity of coronary artery disease was a predictor for any of the outcomes.

Conclusion

Long-term mortality was higher in elderly patients with multivessel disease undergoing PCI compared with CABG. In addition, patients undergoing PCI had a higher risk of ACS, repeat revascularisation and recurrent angina.

     

The value of the ECG for decision-making at first medical contact in the patient with acute chest pain

Background/Objectives. Rapid risk stratification of the patient with acute chest pain is essential to select the best management. We investigated the value of the ECG at first medical contact to determine size of the ischaemic myocardial area and thereby severity of risk. Methods. In 386 patients with acute chest pain, ECG findings were correlated with the coronary angiogram. Using ST-segment deviation patterns the location of the coronary culprit lesion was predicted and thereby size of the area at risk. Four groups of patients were present. Those with a narrow QRS and a total 12-lead ST-segment deviation score of ≥5 mm (group 1) or ≤4 mm (group 2); a QRS width of ≥120 ms (group 3), and patients with previous coronary bypass grafting (CABG) or percutaneous coronary intervention (PCI) (group 4). Results. Correct coronary culprit lesion localisation was possible in 84% of the 185 patients in group 1, 40% of the total cohort. Accurate prediction was not possible in most patients in groups 2, 3 and 4, in spite of extensive coronary artery disease in group 3 and 4. Conclusions. Using the 12-lead ECG the size of the myocardial area at risk can be accurately predicted when the total ST-segment deviation score is ≥5 mm, allowing identification of those in need of a PCI. In most patients with bundle branch block, previous CABG or PCI, the ECG can not localise the culprit lesion. This approach simplifies and accelerates decision-making at first medical contact. (Neth Heart J 2010;18:301-6.)     

Timing of intervention in high-risk non-ST-elevation acute coronary syndromes in PCI versus non-PCI centres

Aims

To compare the effect of timing of intervention in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in percutaneous coronary intervention (PCI) versus non-PCI centres.

Methods and results

A post-hoc sub-analysis was performed of the ELISA III trial, a randomised multicentre trial investigating outcome of early (< 12 h) versus late (> 48 h) angiography and revascularisation in 542 patients with high-risk NSTE-ACS. 90 patients were randomised in non-PCI centres and tended to benefit more from an early invasive strategy than patients included in the PCI centre (relative risk 0.23 vs. 0.85 [p for interaction = 0.089] for incidence of the combined primary endpoint of death, reinfarction and recurrent ischaemia after 30 days of follow-up). This was largely driven by reduction in recurrent ischaemia. In non-PCI centres, patients randomised to the late group had a 4 and 7 day longer period until PCI or coronary artery bypass grafting, respectively. This difference was less pronounced in the PCI centre.

Conclusions

This post-hoc analysis from the ELISA-3 trial suggests that NSTE-ACS patients initially hospitalised in non-PCI centres show the largest benefit from early angiography and revascularisation, associated with a shorter waiting time to revascularisation. Improved patient logistics and transfer between non-PCI and PCI centres might therefore result in better clinical outcome.     

ST 段抬高心肌梗死靶血管长病变急诊介入治疗的安全性及疗效分析

目的:探讨ST段抬高急性心肌梗死(ST-elevation myocardial infarction,STEMI)患者靶血管长病变(病变>25 mm)急诊经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗的临床疗效及安全性。方法:回顾性收集2009年1月-2010年6月因STEMI就诊于沈阳军区总医院并急诊行PCI处理的患者442例,以靶病变长度分为两组,即≤25 mm为短病变组(n=235)和>25mm为长病变组(n=207),均急诊行PCI治疗,分析和比较两组患者术前的基线资料、术中资料及并发症的发生情况、辅助措施(临时起搏、IABP、血栓抽吸装置)应用情况,术后30天、2年电话或临床随访,记录主要不良心血管事件(major adverse cardiac events,MACE)的发生情况。结果:与短病变组比较,长病变组吸烟者更多(81.6%vs 62.6%,P=0.000);以三支病变偏多(34.8%vs 24.7%,P=0.037);多枚支架使用率更高(1.47±0.63 vs 1.04±0.28,P=0.000),平均支架总长度显著增加(29.80±7.02 mm vs 22.95±5.58mm,P=0.000),手术成功率、术中并发症及辅助措施应用情况比较差异无统计学意义(P>0.05),30天及2年随访MACE的发生率比较差异无统计学意义(P>0.05)。结论:与急诊PCI治疗的STEMI短病变患者对比,长病变患者虽然病变复杂,多枚支架使用率高,平均支架总长度增加,但术中并发症、30天、2年内MACE与短病变患者相当,提示在以药物洗脱支架为主的介入治疗时代,急诊PCI处理STEMI靶血管长病变具有良好的疗效及安全性。     

Predictors of postoperative atrial fibrillation after coronary artery bypass graft surgery

Objectives

The present study was aimed to identify the preoperative, intraoperative, and postoperative predictors of AF in a pure cohort of the patients with coronary artery disease who underwent CABG surgery.

Methods

Between November 2005 and May 2006, 302 consecutive patients were included in this prospective study. All the relevant clinical, electrocardiographic, echocardiographic, and laboratory data were gathered in the included patients and they were also monitored for development of post-CABG AF.

Results

Postoperative AF occurred in 46 (15%) of patients. By univariate analysis, older age, P-wave abnormality in ECG, presence of mitral regurgitation, larger left atrium (LA), left main coronary artery involvement, failure to graft right coronary artery (RCA), and adrenergic use in ICU were significantly associated with occurrence of post-CABG AF (all P< 0.05). However, in the logistic regression model, age (OR: 1.067, 95%CI: 1.02-1.116, P=0.005), LA dimension (OR: 1.102, 95%CI: 1.017-1.1936, P=0.017), P-wave morphology (OR: 12.07, 95%CI: 3.35-48.22, P=0.0001), failure to graft RCA (OR: 3.57, 95%CI: 1.20-10.64, P=0.022), and postoperative adrenergic use (OR: 0.35, 95%CI: 0.13-0.93, P=0.036) remained independently predictive of postoperative AF.

Conclusion

The present study suggested that age, P-wave morphology, LA dimension, failure to graft right coronary artery, and postoperative adrenergic use were independent predictors of post-CABG AF. Therefore, clinical data, ECG and echocardiography may be useful in preoperative risk stratification of the surgical patients for the occurrence of post-CABG AF.     

Monocyte-to-albumin ratio as a novel predictor of long-term adverse outcomes in patients after percutaneous coronary intervention

Background: Monocyte count and serum albumin (Alb) have been proven to be involved in the process of systemic inflammation. Therefore, we investigated the prognostic value of monocyte-to-albumin ratio (MAR) in patients who underwent percutaneous coronary intervention (PCI).Methods: We enrolled a total of 3561 patients in the present study from January 2013 to December 2017. They were divided into two groups according to MAR cut-off value (MAR < 0.014, n=2220; MAR ≥ 0.014, n=1119) as evaluated by receiver operating characteristic (ROC) curve. The average follow-up time was 37.59 ± 22.24 months.Results: The two groups differed significantly in the incidences of all-cause mortality (ACM; P<0.001), cardiac mortality (CM; P<0.001), major adverse cardiovascular events (MACEs; P=0.038), and major adverse cardiovascular and cerebrovascular events (MACCEs; P=0.037). Multivariate Cox regression analyses revealed MAR as an independent prognostic factor for ACM and CM. The incidence of ACM increased by 56.5% (hazard ratio [HR] = 1.565; 95% confidence interval [CI], 1.086–2.256; P=0.016) and that of CM increased by 76.3% (HR = 1.763; 95% CI, 1.106–2.810; P=0.017) in patients in the higher-MAR group. Kaplan–Meier survival analysis suggested that patients with higher MAR tended to have an increased accumulated risk of ACM (Log-rank P<0.001) and CM (Log-rank P<0.001).Conclusion: The findings of the present study suggested that MAR was a novel independent predictor of long-term mortality in patients who underwent PCI.     

Utility of nuclear stress imaging for detecting coronary artery bypass graft disease

ABSTRACT: BACKGROUND: The value of Single Photon Emission Computed Tomography stress myocardial perfusion imaging (SPECT-MPI) for detecting graft disease after coronary artery bypass surgery (CABG) has not been studied prospectively in an unselected cohort. METHODS: Radial Artery Versus Saphenous Vein Graft Study is a Veterans Affairs Cooperative Study to determine graft patency rates after CABG surgery. Seventy-nine participants agreed to SPECT-MPI within 24 hours of their coronary angiogram, one-year after CABG. The choice of the stress protocol was made at the discretion of the nuclear radiologist and was either a symptom-limited exercise test (n=68) or an adenosine infusion (n=11). The SPECT-MPI results were interpreted independent of the angiographic results and estimates of sensitivity, specificity and accuracy were based on the prediction of a graft stenosis of [greater than or equal to]70% on coronary angiogram. RESULTS: A significant stenosis was present in 38 (48%) of 79 patients and 56 (22%) of 251 grafts. In those stress tests with an optimal exercise heart rate response (>80% maximum predicted heart rate) (n=26) sensitivity, specificity and accuracy of SPECT-MPI for predicting the graft stenosis was 77%, 69% and 73% respectively. With adenosine (n=11) it was 75%, 57% and 64%, respectively. Among participants with a suboptimal exercise heart rate response, the sensitivity of SPECT-MPI for predicting a graft stenosis was <50%. The accuracy of SPECTMPI for detecting graft disease did not vary significantly with ischemic territory. CONCLUSIONS: Under optimal stress conditions, SPECT-MPI has a good sensitivity and accuracy for detecting graft disease in an unselected patient population 1 year post-CABG.     

坐式八段锦联合运动康复治疗对急性冠脉综合征PCI术后患者运动耐力、血清心肌损伤标志物和生活质量的影响

摘要 目的：探讨坐式八段锦联合运动康复治疗对急性冠脉综合征（ACS）经皮冠状动脉介入治疗术（PCI）后患者运动耐力、血清心肌损伤标志物和生活质量的影响。方法：根据随机数字表法,将我院2020年4月~2021年5月期间收治的ACS行PCI术的患者（n=120）分为对照组（运动康复治疗,n=60）和研究组（坐式八段锦联合运动康复治疗,n=60）。对比两组心功能指标[左心室舒张末期内径（LVEDD）、左心室射血分数（LVEF）、氨基末端B型脑利钠肽前体（NT-proBNP）、左心室舒张末期容积（LVEDV）]、心肌损伤标志物[肌酸激酶同工酶（CK-MB）、心肌肌钙蛋白I（cTnI）]、运动耐力指标[无氧阈（AT）、最大摄氧量（VO_2max ）、运动持续时间（ED）]和生活质量[西雅图心绞痛量表（SAQ）评分：躯体活动受限程度（PL）、心绞痛稳定情况（AS）、疾病认知程度（DS）、心绞痛发作状况（AF）和治疗满意程度（TS）],并纪录两组不良心血管事件发生情况。结果：研究组的心血管不良事件发生率低于对照组（P<0.05）。研究组治疗3个月后LVEF高于对照组,LVEDD、LVEDV、NT-proBNP低于对照组（P<0.05）。研究组治疗3个月后CK-MB、cTnI低于对照组（P<0.05）。研究组治疗3个月后AT、VO_2max 、ED高于对照组（P<0.05）。研究组治疗3个月后PL、AS、DS、AF、TS评分高于对照组（P<0.05）。结论：坐式八段锦联合运动康复治疗可促进ACS患者PCI术后心功能改善,减轻心肌损伤,进而提高运动耐力和生活质量。     

Determinants of variations in coronary revascularization practices

Background:

The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario.

Methods:

In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low–medium [2.0–2.7], medium–high [2.8–3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization.

Results:

The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%–99.0%) and those with left main artery disease usually underwent CABG (80.8%–94.2%), regardless of the hospital’s procedure ratio. Variation in the management of patients with non-emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization “culture” at the treating hospital.

Interpretation:

The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non-emergent multivessel disease.Large inter-regional and inter-hospital variations exist in the ratio of percutaneous coronary intervention (PCI) procedures to coronary artery bypass graft (CABG) surgeries performed in many countries, but the reasons for these variations are uncertain.^1–3 Bypass surgery was the first method of coronary revascularization to be developed.⁴ The less-invasive alternative of PCI was developed initially to treat single-vessel disease. However, advances in PCI technology (e.g., bare-metal stents and, later, drug-eluting stents) combined with increased operator experience have led to its use for a broader list of indications, including multivessel disease and acute coronary syndromes.^5–7In Ontario, Canada’s most populous province, the overall PCI:CABG ratio has steadily increased, from 1.6 in 2001 to 2.7 in 2006 (unpublished data available from the authors upon request); similar increases have been observed in other jurisdictions.^1,2,8 Although the change in ratio has been driven in part by expanded use of urgent PCI for acute myocardial infarction (MI), increased use of PCI in patients with multivessel disease has likely also been a contributing factor. This application of PCI is more controversial, because several studies, including the recent randomized SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) trial, have shown that long-term outcomes of certain patients with multivessel disease were better with CABG surgery than with PCI.^9–13In addition to an overall increase in the PCI:CABG ratio, the amount of variation in the ratio across cardiac centres in Ontario has also steadily increased over time, with more than a threefold regional variation observed in 2006 (unpublished data available from the authors upon request). This degree of variation has raised concerns among some policy-makers and clinicians as to why such striking variations exist in Ontario’s universal health care system. To address this issue, we conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the PCI:CABG ratio across the province’s 17 cardiac centres.     

高龄（80-89 岁）非ST 段抬高心肌梗死早期 介入治疗的疗效观察

目的:研究调查高龄(80-89岁)非ST段抬高心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)患者行早期经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的有效性。方法:回顾分析2008年8月-2009年10月期间我院住院的66例80-89岁NSTEMI患者,冠状动脉造影检查后45例行PCI术,5例因为左主干病变或者严重的三支病变行冠脉搭桥(CABG)术,其余16例做保守治疗。发病到行介入治疗时间<72h。结果:45例行PCI术中42例成功,再血管化的成功率为63.6%,失败的3例PCI术病人中2例因导丝或球囊未能通过病变,1例为顽固性室速。共植入支架80枚,术后梗死相关动脉血流均达到TIMI2-3级。术后死亡2例(心源性休克、颅内出血各1例),死亡率为4.8%。住院期间出血并发症较高,有4(9.5%)例(穿刺部位血肿2例,消化道、颅内出血各1例)。住院期间无再发心肌梗死,偶发心绞痛2例。结论:穿刺尽管高龄(80-89岁)非ST段抬高心肌梗死冠脉早期介入主要出血事件较多,但可改善住院期间的预后。