The American journal of cardiology
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Multicenter Study Comparative Study
Coronary artery bypass grafting versus drug-eluting stent implantation for left main coronary artery disease (from a two-center registry).
Recent studies have suggested that percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (LMCA) disease renders outcomes comparable to those from coronary artery bypass grafting (CABG). It is necessary to stratify individual patient risk and select the optimal revascularization strategy. We compared the clinical outcomes of patients with unprotected LMCA disease who had undergone PCI with drug-eluting stents or CABG. ⋯ The analyses after propensity score adjustment and matching corroborated the crude group results. In conclusion, PCI with drug-eluting stents showed a safety profile comparable to that of CABG in patients with unprotected LMCA disease. However, the risk of repeat revascularization was significantly greater in the PCI group.
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Although the benefit of antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is well recognized, its potential effect on stroke severity and outcome is less well established. Our objective was to examine the effect of preadmission antithrombotic therapy on stroke severity and outcome in patients with AF within a large comprehensive nationwide stroke survey. The data from consecutive patients with AF admitted with acute ischemic stroke or transient ischemic attack during a 2-month period were collected. ⋯ Compared to warfarin therapy with an admission INR of > or = 2, the adjusted odds ratio for more severe strokes was 4.0 (95% confidence interval [CI] 1.7 to 10.0) for no antithrombotic therapy, 2.2 (95% CI 1.0 to 9.4) for antiplatelet therapy, and 2.7 (95% CI 1.1 to 6.7) for warfarin therapy with an INR of <2. Similarly, graded associations of antithrombotic medication were observed with severe disability (modified Rankin Scale score >3) or death at discharge, with corresponding adjusted odds ratios of 4.1 (95% CI 1.8 to 9.9), 2.1 (95% CI 1.0 to 4.6), and 1.5 (95% CI 0.6 to 3.5), and 1-year mortality, with corresponding adjusted ORs of 2.4 (95% CI 0.9 to 6.7), 1.9 (95% CI 0.8 to 5.0), and 2.2 (95% CI 0.8 to 6.2). In conclusion, in addition to its established benefit for stroke prevention, effective anticoagulation therapy is associated with decreased stroke severity and better functional outcome and survival in patients with AF presenting with acute brain ischemia.
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Current guidelines recommend pretreatment with a loading dose of clopidogrel before percutaneous coronary intervention (PCI) to reduce the incidence of periprocedural myocardial infarctions in patients undergoing PCI. However, because of concerns about postoperative bleeding, clopidogrel loading is frequently administered either immediately before or after PCI. Using the 2004/2005 Cornell Angioplasty Registry, we analyzed 1,041 consecutive patients undergoing urgent PCI for non-ST-elevation acute coronary syndrome. ⋯ The Kaplan-Meier long-term survival rates were similar in the 2 groups (93.4% vs 95.8%, p log-rank = 0.152). After multivariate Cox regression analysis, administration of a 600-mg clopidogrel loading dose <2 hours before PCI did not have a significant effect on long-term mortality (hazard ratio 0.97, 95% confidence interval 0.54 to 1.75, p = 0.927). In conclusion, treatment with a 600-mg loading dose <2 hours before PCI is associated with similar short-term ischemic outcomes and long-term mortality compared to the currently recommended clopidogrel pretreatment regimen.
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Comparative Study
Relation between red cell distribution width and clinical outcomes after acute myocardial infarction.
Increased red blood cell distribution width (RDW) has been associated with adverse outcomes in heart failure and stable coronary disease. We studied the association between baseline RDW and changes in RDW during hospital course with clinical outcomes in patients with acute myocardial infarction (AMI). Baseline RDW and RDW change during hospital course were determined in 1,709 patients with AMI who were followed for a median of 27 months (range 6 to 48). ⋯ The association between increased RDW and worse outcome was evident in patients with and without anemia. In conclusion, there is a graded, independent association between increased RDW and mortality after AMI. An increase in RDW during hospitalization also portends adverse clinical outcome.
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Data on the diagnostic accuracy of multislice computed tomographic coronary angiography (CTA) have been mostly derived from patients with a high pretest likelihood of coronary artery disease. Systematic comparisons with invasive angiography in patients with an intermediate pretest likelihood are scarce. The purpose of the present study was to determine the diagnostic accuracy of CTA in patients without known coronary artery disease with an intermediate pretest likelihood. ⋯ In conclusion, the results from the present study have confirmed that CTA has excellent diagnostic accuracy in the target population of patients with an intermediate pretest likelihood. The high negative predictive value allowed us to rule out significant stenosis in a large proportion of patients. CTA can, therefore, be used as a highly effective gatekeeper for invasive coronary angiography.