The American journal of cardiology
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Randomized Controlled Trial Comparative Study
Relation of systemic venous return, pulmonary vascular resistance, and diastolic dysfunction to exercise capacity in patients with single ventricle receiving fontan palliation.
Fontan patients have a reduced exercise capacity, primarily owing to limitations in the ability to augment pulmonary blood flow and stroke volume. To date, the mechanism of peak exercise pulmonary blood flow restriction has not been elucidated. We performed a single-center, prospective, crossover trial of supine and upright exercise in Fontan patients and healthy controls to determine the mechanisms of exercise limitation in the Fontan-palliated patient. ⋯ Six Fontan patients who underwent supine exercise with indwelling catheters failed to demonstrate the expected decrease in pulmonary vascular resistance characteristically seen with peak exercise (at rest, 2.8 + or - 0.7 mm Hg/L/min/m(2) vs at peak, 2.8 + or - 0.9 mm Hg/L/min/m(2); p = 0.9). In conclusion, supine exercise in Fontan patients does not result in an increased VO(2) or oxygen pulse, suggesting that inadequate venous return might not be the primary limitation of exercise capacity in this population. Diastolic dysfunction and relatively excessive peak exercise pulmonary vascular resistance might be more important factors in Fontan exercise limitation.
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The aim of this study was to compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. The current American College of Cardiology and American Heart Association guidelines recommend CABG for the treatment of patients with ULMCA disease on the basis of clinical trials demonstrating a survival benefit with CABG compared to medical therapy. DES reduce the rate of target vessel revascularization compared with bare-metal stents in ULMCA PCI and may be a safe alternative to CABG. ⋯ At 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.80 to 1.56) or the composite end point of death, myocardial infarction, or stroke (OR 1.25, 95% CI 0.86 to 1.82). The risk for target vessel revascularization was significantly lower in the CABG group compared to the PCI group (OR 0.44, 95% CI 0.32 to 0.59). In conclusion, PCI with DES is safe and could represent a good alternative to CABG for selected cases in patients with ULMCA disease.
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Randomized Controlled Trial Comparative Study
Comparison of bivalirudin and unfractionated heparin plus protamine in patients with coronary heart disease undergoing percutaneous coronary intervention (from the Antithrombotic Regimens aNd Outcome [ARNO] trial).
Previous studies have compared bivalirudin and unfractionated heparin (UFH) plus the routine use of glycoprotein IIb/IIIa inhibitors. They have demonstrated that bivalirudin can decrease bleeding complications without a significant increase in ischemic complications, resulting in a better net clinical outcome, as defined by the efficacy (ischemic complications) or safety (bleeding complications) end point. The aim of the present study was to compare bivalirudin and UFH plus protamine in patients undergoing elective percutaneous coronary intervention and pretreated with clopidogrel and aspirin. ⋯ At 30 days, the rate of major bleeding was 0.9% in the bivalirudin arm and 2.8% in the UFH arm (p = 0.043). The composite of death, myocardial infarction, and target vessel revascularization rate and the net clinical outcome rate was 2.8% and 6.4% (p = 0.014) and 3.3% and 7.8% (p = 0.004), respectively, in the bivalirudin and UFH arms. In conclusion, in percutaneous coronary intervention patients pretreated with clopidogrel and aspirin, bivalirudin was associated with less major bleeding and fewer ischemic complications and a better net clinical outcome than UFH.
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Comparative Study
Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension.
Obstructive sleep apnea (OSA) is a secondary cause of hypertension and independently associated with target-organ damage in hypertensive patients. However, OSA remains largely underdiagnosed and undertreated. The aim of the present study was to evaluate the characteristics and clinical predictors of OSA in a consecutive series of patients followed up in a hypertension unit. ⋯ Metabolic syndrome was associated with high sensitivity and specificity for OSA (0.86 and 0.85, respectively). Multiple regression analysis showed that age of 40 to 70 years (odds ratio 1.09, 95% confidence interval 1.03 to 1.16), a high risk of OSA on the Berlin Questionnaire (odds ratio 8.36, 95% confidence interval 1.67 to 41.85), and metabolic syndrome (odds ratio 19.04, 95% confidence interval 5.25 to 69.03) were independent variables associated with OSA. In conclusion, more important than the typical clinical features that characterize OSA, including snoring and excessive daytime sleepiness, the presence of the metabolic syndrome is as an important marker of OSA among patients with hypertension.
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Data on the ability of serum biomarkers to predict microvascular obstruction by ST-segment recovery after primary percutaneous coronary intervention (PCI) is largely absent. Therefore, we determined the association between 5 serum biomarkers, obtained before emergency coronary angiography, and immediate ST-segment recovery in patients who had undergone primary PCI for ST-segment elevation myocardial infarction. We measured N-terminal pro-brain natriuretic peptide (NT-pro-BNP), cardiac troponin T, creatinine kinase-MB fraction, high-sensitivity C-reactive protein, and serum creatinine from blood samples obtained through the arterial sheath at the start of primary PCI. ⋯ An elevated NT-pro-BNP level was more strongly predictive in patients without a history of coronary artery disease or hypertension (adjusted odds ratio 4.7, 95% confidence interval 2.4 to 9.2; p <0.001). NT-pro-BNP was the best contributor to both net reclassification (0.43; p <0.001) and integrated discrimination improvement (0.04; p <0.001) when added to a multivariate model with clinical predictors of incomplete ST-segment recovery. In conclusion, NT-pro-BNP was the strongest independent predictor of ST-segment recovery at the end of primary PCI for ST-segment elevation myocardial infarction compared to the other serum biomarkers reflecting myocardial cell damage, renal function, and inflammation.