Angioplasty Bypass Research Articles

99-OR: HbA1c Variability Predicts Both Coronary Atherosclerosis and CVD Events in Type 1 Diabetes

Introduction: Interventions that decrease mean glucose have reduced rates of type 1 diabetes (T1D) vascular complications, but the difference in cardiovascular disease (CVD) risk between people with T1D and the general population endures. This suggests that factors beyond hemoglobin A1c (HbA1c) normalization may drive T1D CVD outcomes. HbA1c variability is an established predictor of T1D microvascular disease, but thus far only the FinnDiane Study has implicated it as a risk factor for T1D CVD events. No studies have examined the relationship of HbA1c variability to both CVD risk factors and events in a prospective T1D cohort. Methods: We used multivariable logistic regression to analyze the Coronary Artery Calcification in Type 1 Diabetes (CACTI) T1D cohort (N=597) . Primary outcomes were square root-transformed coronary artery calcium (CAC) volume and CVD events. CVD events were defined as myocardial infarction, coronary artery bypass grafting, angioplasty, or cardiovascular death. HbA1c variability was defined as a 1-standard deviation increment in HbA1c and calculated as standard deviation of all HbA1c values for each subject. Results: After adjustment for age, sex, and T1D duration, HbA1c variability predicted both CVD events (HR: 1.562, 95% CI: 1.052-2.318, P=0.0269) and CAC volume (rpartial= 0.3346, P<0.001) , while mean HbA1c predicted CVD events (HR: 1.399, 95% CI: 1.079-1.816, P=0.0114) but not CAC volume (rpartial= 0.0934, P=0.2886) . Further investigation revealed that the relationship between HbA1c variability and CVD events was strongest in those with good glycemic control (HR: 6.330 at mean HbA1c of 6.0%, HR: 3.920 at mean HbA1c of 7.0%, HR: 2.428 at mean HbA1c of 8.0%, HR: 1.5at mean HbA1c of 9.0%, and HR: 0.931 at mean HbA1c of 10.0%) . Conclusion: HbA1c variability may be a risk factor for both coronary atherosclerosis and CVD events in T1D, and the appropriate care strategy for this population may include maintaining an HbA1c value over time that is both at-target and stable. Disclosure W.B.Horton: None. J.K.Snell-bergeon: Stock/Shareholder; GlaxoSmithKline plc. Funding National Institutes of Health (R01DK116731) National Institutes of Health (R01HL113029)

Is cardiac rehabilitation effective in improving quality of life post cardiac event?

Cardiac rehabilitation following a cardiac event is a key aspect of patient management and ongoing quality of life. Coronary heart disease (CHD) is one of the leading causes of death in the UK, killing over 110 000 people ( Department of Health (DH), 2005 ). In addition to this, nearly 275 000 people experienced a myocardial infarction with a further 1.4 million people suffering from angina ( DH, 2005 ). The National Service Framework for Coronary Heart Disease outlines the government's intention to improve the care of patients with CHD over a 10-year period ( DH, 2000 ). Standards and NICE guidelines have been developed for the improved prevention, diagnosis, treatment and rehabilitation of people with coronary heart disease. One element is cardiac rehabilitation. The purpose of this article is to appraise current evidence (undertaken within the last 10 years) with regards to the effectiveness of cardiac rehabilitation on improving quality of life post-cardiac event such as myocardial infarction or cardiac surgery/intervention. To achieve this, relevant databases such as CINAHL plus, MedLine and PsycINFO were used to identify appropriate recent research studies: this identified eight studies. The findings within these studies suggests that programmes of shorter duration have a positive impact on quality of life but over time, this impact is not maintained. This could suggest that adherence to cardiac rehabilitation reduces over time. The findings also suggest that cardiac rehabilitation, in people who have undergone bypass grafts or angioplasty, has more of a positive impact on quality of life than in patients who have had a myocardial infarction. There continues to be a key role for cardiac rehabilitation in contemporary health care, and the health-promotion strategies within cardiac rehabilitation may need to focus more on enabling those who have had a cardiac event to take ownership of the interventions embedded within cardiac rehabilitation.

Abstract P382: Fried Food Consumption is Associated with a Higher Risk of Heart Failure among US Male Physicians

Background: While previous studies have reported a positive relation of fried food consumption with type 2 diabetes, hypertension, and obesity, no previous study has examined the relation of total fried food intake with risk of heart failure (HF) in a prospective cohort. Objective: To test the hypothesis that fried food consumption is positively associated with risk of HF in male physicians. Methods: A prospective cohort of 19,968 participants from the Physicians’ Health Study. Frequency of fried food consumption was assessed between 1999 and 2002 using a food frequency questionnaire and HF was ascertained through annual follow-up questionnaires with validation in a subsample. We used Cox regression to estimate multivariable adjusted hazard ratios of HF. Results: During a median follow-up of 10.6 years, 862 cases of HF occurred. The mean age at baseline was 66.4 ± 9.2 years. Median frequency of fried food consumption was <1 time per week. Multivariable adjusted hazard ratios (95% CI) were: 1.0 (ref), 1.18 (1.01-1.37), 1.25 (1.02-1.54), and 1.68 (1.19-2.36) for fried food consumption of <1/week, 1-3/week, 4-6/week, and 7+/week, respectively (p for linear trend: 0.0004), after adjustment for age, alcohol use, smoking, exercise, and history of myocardial infarction, coronary artery bypass graph or angioplasty (Fig). Additional adjustment of total trans fats did not alter the findings. In a secondary analysis, body mass index did not modify the relation of fried foods with HF risk. Conclusions: Our data show a positive association between fried food intake and risk of HF in US male physicians.

Do evidence practice gaps exist for medication prescription at hospital discharge in patients undergoing coronary artery bypass and coronary angioplasty

Do evidence practice gaps exist for medication prescription at hospital discharge in patients undergoing coronary artery bypass and coronary angioplasty

Using comparative analysis to address health system caricatures.

To learn from health care systems abroad, we must move beyond simplistic characterizations and compare different systems with respect to salient performance measures. Despite findings from recent cross-national studies suggesting that many health care systems outperform the United States, claims by U.S. public officials often fail to acknowledge the actual accomplishments of health care systems abroad. We document significant variation among the United States and France, Germany, and England, which provide universal coverage, albeit in different ways. As previously documented, the United States has the highest rate of mortality amenable to health care. We extend this work by adding two indicators: (a) access to timely and effective primary care as measured by hospital discharges for avoidable hospital conditions; and (b) use of specialty services as indicated by coronary revascularization (bypass surgery and angioplasty), adjusted for the burden of coronary artery disease. Our findings indicate that: (a) the United States suffers the gravest consequences of financial barriers to primary care; (b) in all four countries, older people (65+) receive fewer revascularizations than their younger counterparts once we account for disease burden; and (c) in France, patients receive the most revascularizations, after adjusting for the burden of disease.

Readmission Rate After Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Narrowing

Many studies have reported comparable risk of hard end points between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) stenosis. However, there are limited data regarding the morbidity associated with ULMCA revascularization. This study sought to compare the cause and risk of readmissions after PCI and CABG for ULMCA stenosis. We evaluated the unadjusted and adjusted risk of readmissions in 1,352 patients (783 PCI treated and 569 CABG treated) who were consecutively enrolled in a multicenter registry of patients with ULMCA stenosis, named the Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease trial. Overall, 206 PCI-treated patients (26.3%) experienced at least 1 readmission after the index procedure during 48.7 ± 16.0 months of follow-up compared with 84 CABG-treated patients (14.8%, p <0.001). The most frequent causes of readmission were repeat revascularization after PCI (41%) and noncardiac readmissions after CABG (48%). Through repeated events analysis, PCI was associated with more frequent readmissions than CABG (hazard ratio 2.037, 95% confidence interval 1.542 to 2.692, p <0.001), being an independent predictor of readmission (hazard ratio 1.820, 95% confidence interval 1.420 to 2.331, p <0.001). Except for the acute period, defined as the first 3 months, when there was no significant difference in readmission rate, a higher readmission rate after PCI was consistently observed over the remainder of the follow-up period. In conclusion, PCI was shown to be associated with a higher risk of readmission than CABG in treating ULMCA disease. This higher risk was attributable to more frequent revascularization in the PCI group.

Comparison of survival rate between coronary artery bypass surgery and angioplasty based on number of diseased coronary vessels

This study has been conducted to compare one-year survival rate of patients who underwent coronary artery bypass sur- gery (CABG) vs. percutaneous coronary intervention (PCI) in general as well as considering the number of diseased coro- nary vessels. In this retrospective study, we reviewed the medical records of patients who underwent CABG (484 cases) or PCI (292 cases) at out university heart center from 2009 to 2012. The mortality and survival was compared between the two studied groups based on left ventricular function and number of diseased coronary vessels. Twenty-seven patients (5.57%) died in CABG group which was significantly higher than in PCI group (8 cases, 2.73%); P= 0.04. However, no significant dif- ference was observed regarding mortality between CABG and PCI groups in one- diseased vessel (5.15% vs. 2.22%, P= 0.28), two- diseased vessel (6.12% vs. 3.57%, P= 0.41), and three-vessel disease (5.41% vs.0, P= 0.4). Although PCI was associated with a better one-year survival rate compared to CABG, but number of the diseased coronary vessels did not af- fect survival rate significantly.

Multivisceral fibromuscular dysplasia: an unusual case of renal and superior mesenteric involvement.

Fibromuscular dysplasia (FMD), a disease process which leads to arterial stenosis and aneurysm formation, has been reported to occur in almost every arterial bed in the body. However, multivisceral FMD is rare, and we report a 43-year-old woman with hypertension who had incidental finding of FMD of both renal arteries and the superior mesenteric artery (SMA). The left renal aneurysms and right renal stenosis were successfully treated by aneurysm resection and aortorenal bypass and percutaneous transluminal angioplasty, respectively. The asymptomatic FMD of the SMA was treated conservatively. The indications for intervention in patients with asymptomatic FMD have not been clarified till date, and we therefore advise a close surveillance program.

Printing a Tissue

Severe ischemic diseases are often caused by atherosclerotic occlusion of arteries supplying blood to the myocardium or limbs. In such cases, transluminal angioplasty or bypass surgery is the most effective strategy for restoring blood supply in the affected arteries. However, in patients with severe ischemic heart disease or peripheral artery disease who cannot undergo bypass surgery or angioplasty, therapeutic angiogenesis is an effective means of preserving the integrity of tissues.1 Therapeutic angiogenesis is mediated by either injection of angiogenic cytokines, such as vascular endothelial growth factor, basic fibroblast growth factor, and hepatocyte growth factor; or implantation of angiogenic cells, including bone marrow mononuclear cells, peripheral blood mononuclear cells, and endothelial progenitor cells.1 See accompanying article on page 1300 Several studies have demonstrated successful therapeutic angiogenesis using autologous bone marrow mononuclear cells in patients with critical limb ischemia, such as the Therapeutic Angiogenesis with Cell Transplantation (TACT) trial.2 Although the safety and efficiency …

Intracoronary thrombus in patients with unstable angina pectoris

Intracoronary thrombi were found in 20 of 52 patients (38%) who had coronary angiography because of treatment-resistant unstable angina. Unrelated to the angiographic finding, eight patients (15%) sustained a myocardial infarction, and two died during their hospital stay. Only one patient (5%) with and six patients (19%) without intracoronary thrombi were stabilized and discharged from hospital. The remaining patients either had an aortocoronary bypass (n = 31) or transluminal balloon angioplasty (n = 13). These findings underline the importance of intracoronary thrombus formation in the pathogenesis of treatment-resistant unstable angina.

Ambulatory blood pressure: associations with coronary heart disease in the aged Finnish population

Ambulatory blood pressure (ABP) has been shown to be a better predictor of cardiovascular events than clinical blood pressure (BP) in middle-aged and older populations. This study studied the association of various components of ABP (daytime, night-time, 24-hour ABP) in the presence of coronary heart disease (CHD) in an older Finnish population. This cross-sectional, observational, population-based study was carried out in The Lieto Health Centre, Finland, in 1998-99. The study population consisted of 502 subjects (237 men, 265 women) aged 64-87 years. ABP measurements for 24 hours, daytime (awake) and night-time (asleep), were made. Resting electrocardiograms (ECG) were recorded. A person was considered to have CHD if at least one of the following criteria was met: (I) history of coronary by-pass surgery or coronary angioplasty, (II) diagnosis of CHD in previous medical records, (III) ischemia-related changes on ECG. CHD increased by 30% with a 10 mmHg increase in night-time systolic blood pressure (SBP) (OR 1.30, 95% Cl 1.15-1.47). When ambulatory 24-hour and daytime SBP values were each entered separately into the multivariate model, 24-hour SBP, but not daytime SBP, was associated with CHD. The most important information gained from 24-h BP monitoring in subjects with CHD is night-time BP. Night-time BP may provide new information about the CHD risk which is not identified in common clinical diagnoses of hypertension. ABP measurements should be made to confirm sufficient control of night-time BP, especially SBP, in older people with CHD.

Five-Year Follow-Up of the Medicine, Angioplasty, or Surgery Study (MASS-II)

Clinical trials are organized for many different reasons. Most drug and device trials are designed to demonstrate the safety and efficacy of a drug or device, not to prove that they are the optimal treatments for patients. On the other hand, treatment strategy trials are designed to study the value of one therapeutic regimen compared with another when equipoise or confusion exists regarding which course to pursue. Assumptions are based on prior knowledge and opinion; in the case of coronary artery disease, most trials have been divided into those studying patients who “need” revascularization (ie, EAST [Emory Angioplasty versus Surgery Trial], BARI [Bypass Angioplasty Revascularization Investigation], CABRI [Coronary Artery Bypass Revascularization Investigation], RITA [Second Randomized Intervention Treatment of Angina], GABI [German Angioplasty Bypass Intervention], ARTS [Arterial Revascularization Therapies Study], SOS [Stent or Surgery], ERACI II [Estudio Randomizado Argentino de Angioplastia vs Cirugia II], and meta-analyses of these trails1,2⇓) and those in whom medical therapy is judged to be a reasonable choice. The latter list is short—RITA-2 [Second Randomized Intervention Treatment of Angina]3 and the awaited COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation]4 and BARI 2D [Bypass Angioplasty Revascularization Investigation 2 Diabetes]5 trials. Article p 1082 An assumption is made that patient groups can be identified that will be suitable candidates either for equipoise between 2 revascularization choices or for medical therapy versus revascularization. The study by Hueb et al6 in this issue of Circulation enrolled patients, most of whom would have been eligible for percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) trials, to 3 arms including medical therapy only. Eligible patients had multivessel coronary artery disease (3 vessels, 58%; 2 vessels, 42%), and the left anterior descending artery was involved in 92% of the patients. Therefore, these patients seem …

13-year follow-up of the German Angioplasty Bypass Surgery Investigation (GABI)

Aims: The German Angioplasty Bypass Surgery Investigation (GABI) was designed to compare symptomatic efficacy and safety of percutaneous coronary angioplasty (PCI) and coronary artery bypass surgery (CABG) in patients with symptomatic multivessel disease. This follow-up was performed to determine the long-term outcome of patients undergoing these interventions.

Clinical Benefits of a Metabolic Approach with Trimetazidine in Revascularized Patients with Angina

As patients with coronary artery disease live longer and more often reach the stage where further myocardial revascularization procedures can no longer be performed, efficacious and well-tolerated antianginal medications are needed. Metabolic agents offer the advantage of controlling symptoms without untoward hemodynamic effects. This article reviews the epidemiology of stable angina and the use of antianginal medications in patients who have undergone myocardial revascularization. It also describes the clinical data on the anti-ischemic effects of metabolic agents in patients undergoing coronary artery bypass surgery or angioplasty, the latter in the setting of acute myocardial infarction and elective procedures. Lastly, the effects of trimetazidine on exercise tests in previously revascularized patients treated with beta-blockers, such as documented in the subgroup analysis of the Second Trimetazidine in Poland (TRIMPOL II) trial, are reported. In all, metabolic agents are likely to be beneficial in revascularized patients, with a documented anti-ischemic effect during myocardial revascularization procedures and the ability to improve exercise tolerance and symptoms in patients with chronic stable angina, despite myocardial revascularization.

Five-year vascular audit from a district hospital

Vascular patients under the care of one surgeon over a 5-year period have been reviewed, from computer-based discharge records, with regard to in-hospital measures of outcome to determine whether or not surgery was being performed to an acceptable standard. Out of 466 procedures, 30 per cent of patients had at least one complication, 14 per cent had further surgery and 9 per cent died. Outcome was examined within the following treatment groups: aorto/iliac aneurysm, aortofemoral bypass, femoroproximal popliteal bypass, femorodistal popliteal bypass, femorocrural bypass, embolectomy and percutaneous transluminal angioplasty. Patients having below-knee bypass surgery were found to have an unacceptably high rate of complications, reoperations and amputations. An overall rate of reoperation for postoperative bleeding of 5 per cent was also considered to be high. With these exceptions, it was concluded that the surgery was being performed to an acceptable standard, but that comparative audit of this type remained difficult while there was a deficiency of national statistics against which the work of individual surgeons could be judged.

New Prospects in Myocardial Surgical Revascularization

Myocardial revascularization with coronary bypass graft surgery or angioplasty is the conventional treatment for ischaemic heart disease. The progressive refinement of both techniques (eg, use of arterial grafts and drug eluting stents) has improved clinical outcomes but the elucidation of which of the two treatments is more effective would require well designed randomised studies. While the utility of off-pump as compared to on-pump coronary bypass graft surgery is still debated, the evidence for the exclusive use of arterial conduits for surgical revascularization is compelling. Patients with diffuse coronary artery disease that cannot be treated by conventional revascularization treatments remain a challenge for the control of angina and a variety of alternative treatments, including transmyocardial laser revascularization and cardiac denervation, have been applied. However, these treatments do not eliminate angina and the benefit obtained is transient. The angiogenic therapy using stem cells and modification of gene expression is a new treatment which potential, in spite of the promising animal studies and the initial clinical trials, is still unclear. The introduction of less invasive surgical techniques and robotics could play an important role for the delivery of these treatments in the future.

Therapeutic approaches to organ preservation injury

The long-term preservation of organ explants and protection from cold ischaemia and subsequent rewarming reperfusion injury is essential to successful allografting and instrumental in enlarging the international donor pool. Current hypothermic preservation solutions may have reached the limit of what is possible in terms of explant longevity and viability, and research attention has been turned to novel organoprotective pharmacotherapeutics that could provide the next generation of explant/transplant nurture. Organoprotection is equally paramount during surgical procedures requiring a period of ischaemia as in coronary artery bypass grafting, angioplasty or stenting. Similarly, the phenomenon of non-freezing cold injury (NFCI), associated with microcirculatory and neuronal damage in exposed and often immersed extremities, also involves ischaemia–reperfusion injury. Whilst additions to cold storage solutions of antioxidants and modulators of cellular metabolism may extend their preservative efficacy, pharmacological triggers of ischaemic preconditioning and the hibernation phenotype may offer breakthroughs in the prevention of ischaemia–reperfusion injury.

13-year follow-up of the German angioplasty bypass surgery investigation

The German Angioplasty Bypass Surgery Investigation was designed to compare symptomatic efficacy and safety of percutaneous coronary balloon angioplasty (PTCA) with coronary artery bypass surgery (CABG) in patients with symptomatic multi-vessel disease. This follow-up study was performed to determine the long-term outcome of patients following these interventions. From 1986 to 1991, 359 patients with angina CCS class II-IV, age below 75 years, and coronary multi-vessel disease requiring revascularization of at least two major coronary vessels were recruited at eight German centres and randomized to PTCA or CABG. From 337 patients undergoing the planned procedure, 324 patients could be followed-up (96%). Baseline parameters were identical in both groups, 2.2+/-0.6 vessels were treated in CABG patients, whereas 1.9+/-0.5 vessels were treated in PTCA patients. Thirty-seven per cent of surgical patients received internal mammary artery grafts, while no stents were used in patients undergoing PTCA. At the end of the 13-year follow-up period, the degree of angina, the degree of dyspnea, and the utilization of nitrates were comparable in both groups. With a total number of 76 deaths, Kaplan-Meier analysis revealed a comparable distribution in both groups. Although time to first re-intervention was significantly shorter in the PTCA group, P<0.001, frequencies of re-intervention (CABG, n=94; PTCA, n=136) and crossover rates (CABG to PTCA, n=49; PTCA to CABG, n=51) were comparable in both groups. The results of our 13-year follow-up suggest that in patients with symptomatic multi-vessel disease, both PTCA and CABG are associated with a comparable long-term survival and symptomatic efficacy. How far these results may be altered by developments such as drug-eluting stents or off-pump surgery remains to be determined.

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377. Developing siRNAs to the E2Fs to Control Vascular Growth and Remodeling

Ischemia represents a major causative condition in cardiovascular and cerebrovascular syndromes, which triggers proliferative and degenerative alterations of the vascular wall leading to the stenosis of arteries supplying blood to vital organs. Surgery is often the final treatment modality to restore blood supply to the ischemic organ via by-passing the site of major stenosis using arterial or venous grafts. Alternatively, percutaneous transluminal catheters can be used to restore blood flow to an organ by reopening the stenosis from the inside of the arterial lumen using the methods of balloon angioplasty alone or in combination with stent implantation. However, the major limitation of these procedures is that they themselves trigger accumulation and proliferation of vascular smooth muscle (VSM) cells from the tunica media to tunica intima of the vascular wall leading to restenosis or vein-graft failure in a significant percentage of all cases. This pathological process is known as intimal hyperplasia. Limiting intimal hyperplasia in grafted vessels or vessels following angioplasty is a critically important therapeutic target. A number of studies have shown that growth suppression action of the retinoblastoma tumor suppressor protein (Rb) and other Rb family members is dependent on their ability to regulate the E2F family of transcription factors (E2F1-7). Recently it has been demonstrated that inhibition of the entire family of E2F proteins can reduce intimal hyperplasia. Here we show that inhibition of individual (or subsets of the) E2Fs can enhance or reduce intimal hyperplasia following vessel damage or grafting. Specifically, we show that siRNAs to E2F1 and E2F3 act as specific inhibitors of vascular smooth muscle cell proliferation in vitro and in vivo. Importantly, these studies have lead to a better understanding of how distinct E2F activities promote or repress vascular smooth muscle cell proliferation during intimal hyperplasia and have yielded lead siRNAs that establish a therapeutic proof of principal in animals undergoing by-pass surgery or angioplasty. In conclusion, this work has facilitated the development of more potent and more specific inhibitors of this pathological process.