Role Of Myocardial Revascularization Research Articles

Patterns of revascularization in stable ischemic heart disease in the pre-ISCHEMIA era

Abstract Introduction New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints. Aim To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2). Methods and population Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or >50% for the left main. Results A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p<0.001), two vessel disease without proximal LAD stenosis (23.4% vs 10.3%; p<0.001) and three vessel disease (18.5% vs 5.9%; p<0.001). These patients had higher rates of revascularization, both CABG (25.8% vs 10.8%, p<0.001) and PCI (56.5% vs 39.5%, p<0.001). However, when comparing G1 with the subset of G2 patients with obstructive CAD, G1 patients had higher rates of CABG (26.8% vs 17.8%, p=0.034) but there were no differences on the rates of PCI (58.0% vs 56.9%, p=0.916). Conclusions Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD. Funding Acknowledgement Type of funding source: None

Hypotheses, rationale, design, and methods for prognostic evaluation of a randomized comparison between patients with coronary artery disease associated with ischemic cardiomyopathy who undergo medical or surgical treatment: MASS-VI (HF)

BackgroundIschemic cardiomyopathy and severe left ventricular dysfunction are well established to represent the main determinants of poor survival and premature death compared with preserved ventricular function. However, the role of myocardial revascularization as a therapeutic alternative is not known to improve the long-term prognosis in this group of patients. This study will investigate whether myocardial revascularization contributes to a better prognosis for patients compared with those treated with drugs alone and followed over the long term.MethodsThe study will include 600 patients with coronary artery disease associated with ischemic cardiomyopathy. The surgical or drug therapy option will be randomized, and the events considered for analysis will be all-cause mortality, nonfatal infarction, unstable angina requiring additional revascularization, and stroke. The events will be analyzed according to the intent-to-treat principle. Patients with multivessel coronary disease and left ventricular ejection fraction measurements of less than 35% will be included. In addition, myocardial ischemia will be documented by myocardial scintigraphy. Markers of myocardial necrosis will be checked at admission and after the procedure.DiscussionThe role of myocardial revascularization (CABG) in the treatment of patients with coronary artery disease and heart failure is not clearly established. The surgical option of revascularizing the myocardium is a procedure designed to reduce the load of myocardial hibernation in patients with heart failure caused by coronary artery disease. On the other hand, the assessment of myocardial viability is frequently used to identify patients with left ventricular ischemic dysfunction in which CABG may add survival benefit. However, the effectiveness of this option is uncertain. The great difficulty in establishing the efficacy of surgical intervention is based on the understanding of viability without ischemia. Thus, this study will include only patients with viable and truly ischemic myocardium to correct this anomaly.Trial registrationEvaluation of a randomized comparison between patients with coronary artery disease associated with ischemic cardiomyopathy submitted to medical or surgical treatment: MASS-VI (HF), ISRCTN77449548, Oct 10th, 2019 (retrospectively registered).

Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine

Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine

Atrial Fibrillation and Ventricular Arrhythmias in ST Segment Elevation Myocardial Infarction: Possibilities of Pharmacotherapy and Non-Pharmacological Treatment

Atrial fibrillation (AF) is the most common tachyarrhythmia complicating ST segment elevation myocardial infarction (STEMI), while ventricular arrhythmias (VA) can, not only be accompanied by a hemodynamic disorder, but in some cases, worsen its prognosis. The article presents a modern view on risk factors for development of AF (elderly age, left ventricle systolic dysfunction, heart failure, etc.), strategy and tactics of AF treatment in patients with STEMI, the indications for its pharmacological cardioversion and electro-impulse therapy. It is shown that I.V. administration of betablockers and in some cases amiodarone for reducing the frequency of ventricular contractions is advisable. Features and argumentative issues of triple antithrombotic therapy in patients with AF with STEMI, the possibilities and indications for the use of double antithrombotic therapy instead of triple one are described. Clinical significance and peculiarities of treatment of various types of VA have been determined, the role of myocardial revascularization, radiofrequency catheter ablation, normalization of electrolyte imbalance, use of beta-blockers and amiodarone in the prevention and therapy of lifethreatening ventricular arrhythmias has been emphasized. The irrationality, and sometimes the risk of carrying out prophylactic antiarrhythmic therapy for AF and VA in the acute stage of STEMI, as well as the role of the implantable cardioverter-defibrillator in primary prevention of death in certain groups of patients with low left ventricle ejection fraction after myocardial infarction was noted. The value of various antiarrhythmic drugs in their effect on the improvement of prognosis in patients after STEMI is estimated. The material is presented based on modern recommendations for the treatment of patients with STEMI, therapy of AF and VA, prevention of sudden cardiac death, as well as data from several controlled studies and own clinical experience of pharmacotherapy of arrhythmias.

O doente diabético com doença coronária crónica. Como revascularizar?

Diabetes is one of the reasons for major concerns when managing patients with acute or chronic ischemic heart disease. The presence of diabetes poses specific issues with respect to outcome and treatment options, leading to worse prognosis.The role of myocardial revascularization in the management of chronic ischemic heart disease is a matter of debate, largely due to some clinical studies that failed to demonstrate it's superiority.Following the BARI-2D trial, coronary artery bypass surgery has gained some advantage over coronary angioplasty in diabetic patients with multivessel disease. This advantage was recently consolidated in the FREEDOM trial, which showed significantly better outcomes at five year follow up.

The role of myocardial revascularization surgery and percutaneous coronary intervention in the long-term follow-up of elderly patients with myocardial infarction

Background: Little is known, especially in the elderly, about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive procedures IP) in the long-term follow-up of pts with acute myocardial infarction (AMI), aim of this study. Methods: we analyzed 481 pts with AMI included prospectively and consecutively in a databank and followed for up to 4 years (mean survival time 3.15 y). During the in-hospital phase, 309 pts were submitted to IP (64.2%). and 151 (31.4%) were older than 69 years. Pearson Chi-square, Fisher exact test and Two-sample t-test ware utilized for the m-hospital analysis; Kaplan-Mr the mortality rates for the subgroups submitted to IP @x=85) or treated conservatively were. respectively, 18.8% and 24.2% (O&0.78. ~~0.53); for pts younger than 70 y, the mortality rate was 5.5%; the mortality rates for the invasive (n=224) or conservative subgroups were 6.2% and 4.7%, respectively (ORzl.35, p=O.58). (b) Long-term follow-up analysis: the unadjusted swwal rates for mvasive and conservative groups in the whole population were, respectively, 83.1% f 2.3 and 70.6% + 3.8 (p=O.O07); in the subgroup of pts older than 69 y the survival rates were 74.8% + 4.8 and 49.7% * 7, respectively (p=O.O35); in the subgroup of pts younger than 70 y, the sutvrval rates were 863% 4 2.5 and 83.1% + 3.9 (p=O.7). Adjusted survival rates: 80 + 1.7 and 46.82 3.2 for the elderly population (p=O.O35); 87.2 -+ 1.3 and 82.5 + 2.0 for younger pts (p=O.7). SurvivalI rates excluding 83 pts treated with primary angioplasty: in the elderly group, 78.2 + 5.4 and 49.7 + 7.0 (p=O.Ol I); in the younger group 86.8 -+ 2.8 and 83.1 + 3.9 (p=O.56). Concluston: in the long-term follow-up post-AMI. the invasive strategy was more efficacious in elderly patients.

Management of the patient who has been resuscitated from sudden cardiac death.

CD is a 68-year-old man who had an anterior myocardial infarction 6 months ago. Evaluation at that time demonstrated an occluded left anterior descending artery, which was successfully stented with no other significant lesions. Left ventricular ejection fraction was 35%. He had no recurrent angina or heart failure symptoms. Early one morning he lost consciousness. Paramedics verified ventricular fibrillation (VF) and provided effective defibrillation within 5 minutes; spontaneous circulation returned before transfer to the hospital. Sudden cardiac death claims 300 000 to 450 000 lives a year in the United States and represents approximately 50% of all cardiac death.1–3⇓⇓ Despite recent declines in age-adjusted cardiac mortality and sudden death risk, the overall incidence has remained relatively stable as our population ages.3 Coronary heart disease is present in the majority (70% to 80%) of patients with sudden death, but cardiac arrest is the first manifestation of this underlying process in 50%.4 Resuscitation rates are very low, averaging from 1% to 3% in most major cities.2,5⇓ There are some data to suggest that focused attempts to reduce the time to effective defibrillation, with improved training of first responders or more widespread availability of automatic external defibrillators, provide some hope for the future. It is a widely held belief that the majority of sudden death events are due to ventricular tachycardia (VT) that degenerates into VF (Figure 1).6 This idea may well reflect our greater experience in observing patients with structural heart disease and prior myocardial infarction. Acute severe ischemia may cause primary polymorphic VT even in the absence of preexisting structural heart disease. Autopsy studies document acute changes in coronary morphology (such as plaque rupture, thrombus, etc) in >50% of sudden death events.7 Severe bradyarrhythmias or electromechanical dissociation probably represent an important …

Surgical revascularization in the treatment of ventricular tachycardia and fibrillation exposed by exercise-induced ischaemia.

The role of myocardial revascularization in the treatment of malignant ventricular arrhythmias is not well defined. Our hypothesis was that in patients with ventricular tachycardia or fibrillation exposed by exercise-induced ischaemia, the acute transient ischaemia plays a principal causal role, and that in these patients surgical myocardial revascularization alone might be an effective treatment. Among 1100 consecutive patients undergoing isolated coronary artery bypass surgery (CABG) 30 patients (2.7%) characterized by ventricular tachycardia or fibrillation at the symptom-limited exercise tests prior to revascularization were studied prospectively. All patients had exercise-induced angina pectoris or ischaemic ST-segment depression preceding at least one of the arrhythmic events. In addition, eight of these 30 patients had experienced syncope during out-of-hospital exertional activities. After surgical revascularization, the 28 patients surviving to hospital discharge were followed for 1.6 to 86 months (mean 29 +/- 29 months) as outpatients and underwent between one to eight exercise tests (mean 2.6 +/- 1.9). One of these patients died suddenly of unknown causes at 14 months, another from cancer at 53 months. Twenty-six patients experienced a total of 34 episodes of ventricular tachycardia before revascularization. Two of these patients, both having residual ischaemia, had arrhythmia recurrences during follow-up; odds ratio (OR) 84.5, 95% confidence interval (CI) 18.7-381.9; P = < 0.010. Exercise-induced ventricular fibrillation occurred in eight patients pre-operatively.(ABSTRACT TRUNCATED AT 250 WORDS)