Ссылки, новости, интересные факты и т.п.

[Maltsev]

Коллеги, друзья, предлагаю, по усмотрению Модераторов и общественности, сделать в интервенционном разделе топик по образу и подобию топика "Интересные ссылки" в терапевтической кардиологии. Если топик будет развиваться, впоследствии можно будет и прикрепить.

Для затравки - интересная статься: зависимость исходов плановых пластик от времени суток.

Time of Day and Outcomes of Nonurgent Percutaneous Coronary Intervention Performed during Working Hours

Warren J. Cantor, MD; Bradley H. Strauss, MD, PhD; Michelle M. Graham, MD; Danielle A. Southern, MSc; Ken Woo, MD; Ben Tyrrell, MD; Merril Knudtson, MD; William A. Ghali, MD, MPH

[Ссылки доступны только зарегистрированным пользователям ]

Abstract

Background During daytime working hours, outcomes may be worse when percutaneous coronary intervention (PCI) is performed later in the day because of operator fatigue and differences in process of care.
Methods Using the APPROACH database, we analyzed 2,492 consecutive nonurgent PCI procedures performed during working hours. Patients undergoing PCI for acute coronary syndromes were excluded. Patients were separated into 2 groups based on whether PCI was started in the morning (7:00 AM-12:00 PM, n = 1,446) or after noon (12:01 PM-6:00 PM, n = 1,037). Outcomes included procedural complications; target vessel revascularization (TVR); and death at 7 days, 30 days, and 1 year.
Results Patients undergoing PCI in the afternoon were more likely to have heart failure, reduced ejection fraction, and Canadian Cardiovascular Society class IV or atypical angina symptoms; more likely to be inpatients; less likely to have stable angina; and less likely to receive glycoprotein IIb/IIIa inhibitors. Patients undergoing PCI in the afternoon had significantly higher unadjusted rates of the composite of death and TVR at 7 days (0.9% vs 0.3%, P = .04) and 30 days (2.0% vs 1.0%, P = .04) and death at 1 year (2.2% vs 1.1%, P = .03) compared with PCI performed in the morning. After multivariate adjustment, the differences in the composite of death and TVR at 30 days and at 1 year were not statistically significant.
Conclusion Patients undergoing nonurgent PCI during working hours after noon had higher rates of TVR in the first 30 days and death at 1 year. Further study is required to determine whether patient characteristics, operator fatigue, differences in process of care, or a combination of these factors accounts for the difference in outcomes.

[Изображения доступны только зарегистрированным пользователям]

ЗЫ: Интересно: соотношение пластик при ОКС и при стабильных формах ИБС в исследуемых лабораториях:

[Изображения доступны только зарегистрированным пользователям]

[Maltsev]

Conclusions: DES implantation is associated with a higher rate of positive EST, compared to BMS, 1 month after PCI, likely due to a higher prevalence of endothelial dysfunction. EST seems to be helpful in predicting clinical outcome in patients with coronary stent implantation.

[Ссылки доступны только зарегистрированным пользователям ]

[Maltsev]

Key Points:

• More than 80% of stable CAD patients believe PCI will prevent a fatal MI
• Most believe they understand the treatment rationale
• Cardiologists generally aware of PCI’s limited benefit

By Kim Dalton
Wednesday, September 08, 2010

Most patients with stable coronary artery disease (CAD) who undergo catheterization believe that percutaneous coronary intervention (PCI), if necessary, will help prevent a future, possibly fatal myocardial infarction (MI). Most cardiologists, on the other hand, are aware that the benefit of PCI in this situation is limited to angina relief, according to results of a survey published in the September 7, 2010, issue of Annals of Internal Medicine.

Investigators led by Michael B. Rothberg, MD, MPH, of Baystate Medical Center (Springfield, MA), surveyed 153 patients admitted to a single center for catheterization and possible PCI between December 2007 and August 2008. The survey contained questions about symptoms, the consent procedure, and perceptions regarding the benefits of PCI.

In addition, for each of the 53 patients who underwent PCI, the researchers sent an abbreviated form of the survey along with a copy of the patient’s record to the cardiologist who performed the procedure as well as a general survey to all referring and interventional cardiologists at the center asking about the consent procedure, the anticipated benefits of elective PCI, and shared decision making without reference to a specific patient.

Ninety-six percent (95% CI 92%-99%) of patients reported that they felt they understood why they might undergo PCI, while more than half said they were actively involved in the decision-making process. Nonetheless, 88% (95% CI 81%-93%) believed that PCI would prevent an MI and 82% (95% CI 75%-89%) believed it would prevent a fatal MI. The expectations of those who actually underwent PCI were similar to those who did not.

In contrast, patients’ cardiologists believed PCI would prevent an MI in only 9 cases (17%) and a fatal MI in only 8 cases (15%). In 2 of these cases, the patient had a recent change in angina that would have excluded them from the COURAGE trial (showing no additional benefit of PCI over optimal medical therapy). However, in most cases the cardiologist believed substantial myocardium was at risk.

Divide Between Patients’ and Physicians’ Understanding

There was a disconnect between patients’ understanding and that of their cardiologists. Not only were patients more likely than their physicians to believe that PCI would prevent MI (prevalence ratio 4.25; 95% CI 2.31-7.79) and fatal MI (prevalence ratio 4.83; 95% CI 2.23-10.46), but patients also were less likely than their physicians to report pre-PCI angina (77% vs. 98%; P = 0.004) or to believe that they participated in the decision-making process (78% vs. 94%; P = 0.039).

In response to 3 patient scenarios, most of the cardiologists, including interventionalists and referring physicians, said any benefits of PCI were largely limited to symptom relief. Moreover, in evaluating 2 of the 3 scenarios, 70% of cardiologists did not identify any benefit to PCI, yet 43% said they would perform the procedure anyway.

In both univariate and multivariate analysis, 2 patient characteristics were associated with beliefs about PCI’s benefits:

• Lower income was linked with the belief that PCI reduced mortality (OR 2.24; 95% CI 1.09-4.63)
• Greater chest discomfort was linked with the belief that PCI prevented MI (OR 1.40; 95% CI 1.03-1.91)

Overestimating Benefits: Two Sides of the Coin

The authors point out that most patients tend to believe a treatment offered will be beneficial even when presented with evidence to the contrary. Moreover, they may not understand the distinction between unstable angina (for which PCI may be life-saving) and stable angina because both conditions cause chest pain. Patients know that angina increases MI risk but, without being specifically informed, they are much less likely to know that alleviating angina will not decrease the risk, the investigators say.

On the other side, physicians have little incentive to discourage patients from undergoing PCI and subconsciously may persuade themselves that a patient’s symptoms are more limiting than they really are, Dr. Rothberg and colleagues write. Another potential source of PCI overuse is ad hoc intervention, or performing PCI immediately following catheterization, they add, noting that this practice leaves little opportunity for informed decision making or consultation with the patient’s other physicians.

“Our finding that many patients with little or no angina nonetheless were undergoing catheterization and PCI highlights that even after the publication of COURAGE, the indications for PCI are still not clear,” the authors write.

Beefing Up the Benefit Side of Informed Consent

In an accompanying editorial, Alicia Fernandez, MD, of the University of California, San Francisco (San Francisco, CA), writes that what is needed to improve physician-patient communications is “careful observational research, with direct recording of informed consent discussions and open-ended interviews with patients and physicians.

“That the processes we typically use fail to accurately convey information on expected benefits is particularly distressing” for stable coronary artery disease, for which “patients’ informed preferences and values should guide the choice among several reasonable and effective treatment options,” Dr. Fernandez asserts.

A key element of informed consent is assessment of patient understanding, she adds, suggesting that supplementary educational information and decision aids be incorporated into the informed consent process.

In a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said that observations from his own practice confirm 1 study finding: To most patients, it makes intuitive sense that opening up an artery can prevent an MI.

Oversimplifying ‘Stable CAD’

In that sense the study is valuable, he commented, but the authors’ one-size-fits-all approach in portraying the benefits of PCI for stable CAD is somewhat disconcerting.

“What gets lost in this article is that many patients with stable CAD were not in the COURAGE trial or any randomized trial. Saying that PCI does not improve mortality in stable CAD is a gross oversimplification of the complexity of patients that we treat in clinical practice,” Dr. Kirtane said.

The fact that both referring physicians and interventionalists were aware of the results of the COURAGE trial is good news, he noted. The likely reason there were some apparent discrepancies between their knowledge of the data and the decision to perform PCI is that stable CAD is a complex disease. Moreover, the scenarios presented to physicians for evaluation of the benefit of PCI did not do justice to that complexity, he observed.

“You have to make sure that you appropriately risk-stratify these patients. And when you administer informed consent, the onus is on the physician to convey [the treatment implications of any added complexity],” he concluded.

Study Details

Of 153 patients:

• 68% had angina
• 42% had activity-limiting angina
• 77% had a positive stress test
• 29% had suffered a previous MI

The 53% of patients who underwent PCI were more likely than those who did not to have a positive stress test result, but angina was similar in both groups.

Most patients reported that a physician spent at least 5 minutes explaining PCI, and more than half received written information about it.

Sources:

1. Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153:307-313.
2. Fernandez A. Improving the quality of informed consent: It is not all about the risks. Ann Intern Med. 2010;153:342-343.

[Ссылки доступны только зарегистрированным пользователям ]

[oldangio]

Данные по каротидному стентированию в Западной Европе 2009-2010

[Abugov]

Прасугрел фоева?

Recent ACS Patients Can Safely Switch from Clopidogrel to Prasugrel

By L.A. McKeown
Monday, September 13, 2010

In patients already receiving clopidogrel after acute coronary syndromes (ACS), replacing the standard antiplatelet drug with prasugrel further suppresses platelet function with no evidence of treatment-related adverse events, according to a study published in the September 21, 2010, issue of the Journal of the American College of Cardiology. Moreover, the shift in strategy does not appear to lessen the existing platelet inhibition from chronic clopidogrel therapy.

Как же меня достали эти фильтры:

Inferior Vena Cava Filters Often Used Inappropriately

By Caitlin E. Cox
Tuesday, September 14, 2010

A community-based study published in the September 13, 2010, issue of Archives of Internal Medicine shows that inferior vena cava (IVC) filters are frequently used in the setting of acute venous thromboembolism (VTE). But an expert panel found that nearly half of the time, use of the filters was either inappropriate or debatable.

[oldangio]

данные регистра эндоваскулярных и хирургических вмешательств в Европе за 2009- 1 кв 2010 по аневризмам, сонным и периферическим артериям
[Ссылки доступны только зарегистрированным пользователям ] Очень интересные цифры, может кому-то интересно.

[Maltsev]

Иногда их, наверное, нужно открывать...
[Ссылки доступны только зарегистрированным пользователям ]

[Maltsev]

Исходы КШ не зависят от того, выполнялось ли пациенту ранее ЧКВ или нет.

[Ссылки доступны только зарегистрированным пользователям ]

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

Rapamycin, an antiproliferative agent used on drug-eluting stents, induces endothelial progenitor cells senescence through telomerase inactivation, and may impair the re-endothelisation of an injured arterial wall, leading to thrombosis. We examined whether silymarin, a complex of flavonolignans with hepatoprotective and antioxidative properties, can protect EPCs against rapamycin-induced senescence. Mononuclear cells were isolated from peripheral blood of healthy volunteers. EPCs were cultured in endothelial cell growth medium-2 in the presence or absence of rapamycin (0.1 ng/mL) and/or silymarin (12.5 to 50 μg/mL). EPCs senescence associated β-galactosidase activity, telomerase activity and prolifertive activity were measured. The influence on tubular-like structure formation in vitro was investigated and colony forming assay on methylcellulose plates was performed. Silymarin increased telomerase activity threefold, reduced the number of senescent cells and increased EPC proliferative activity (up to 64%) in comparison with cells cultured with rapamycin alone. Moreover, silymarin partially prevented impairment of tubular-like structure formation in Matrigel by rapamycin. These findings suggests, that silymarin counteracts the inhibitory effects of rapamycin in EPCs. Silymarin may protect EPCs against the anti-proliferative effects of rapamycin and restore their reconstructive ability.

Интересно, что же будет с гладкомышечными клетками, которые являют собой основной субстрат рестеноза, пролиферацию которых и призван "давить" сиролимус и иже с ними?

[drserg]

Очередной клондайк по книжкам.
[Ссылки доступны только зарегистрированным пользователям ]

[angio]

Сообщение от drserg

Очередной клондайк по книжкам.
[Ссылки доступны только зарегистрированным пользователям ]

Литературы и правда масса, только как ее скачать доя меня пока не дошло.

[Maltsev]

Сообщение от angio

Литературы и правда масса, только как ее скачать доя меня пока не дошло.

1. Регистрируетесь на форуме
2. Выбираете интересующий раздел и книгу
3. Постите ответ в ветку (что нить типа thanks!)
4. После отправки поста Вам становятся видны ссылки на файлообменники, на которых лежит искомая книга. Качаете.

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

J Interv Cardiol. 2009 Jun;22(3):291-8. Epub 2009 May 13.
Drug delivery at the aortic valve tissues of healthy domestic pigs with a Paclitaxel-eluting valvuloplasty balloon.

Spargias K, Milewski K, Debinski M, Buszman PP, Cokkinos DV, Pogge R, Buszman P.

Onassis Cardiac Surgery Centre, Athens, Greece. [Ссылки доступны только зарегистрированным пользователям ]
Abstract

BACKGROUND: Restenosis occurs invariably within 1 year following balloon valvulopasty in aortic valve stenosis. The mechanism of restenosis seems to involve a dynamic cellular component that could be a target for drug inhibition. We investigated the feasibility of local drug delivery at the aortic valve tissues of healthy pigs with a paclitaxel-eluting balloon.

METHODS: Aortic valvuloplasty was performed in eight anesthetized domestic pigs using paclitaxel-eluting balloons (3 micro2) balloon surface area). They were assigned to two or four times 15-second balloon inflations and were sacrificed 30 minutes after final balloon inflation.

RESULTS: The aortic annulus to balloon diameter ratio was 1.15 +/- 0.07. The mean paclitaxel concentration in the aortic valve leaflets was 0.91 +/- 1.36 micro (0.34 +/- 0.05 micro in the two-inflation group, 1.48 +/- 1.86 micro in the four-inflation group, P = 0.23). The percentage of the total paclitaxel dose recovered in the aortic valve leaflets was 18 +/- 11(-6)% (13 +/- 6(-6)% and 25 +/- 14(-6)% in the two- and four-inflation group, P = 0.16).

CONCLUSION: Local drug delivery at the aortic valve leaflets of healthy pigs with a paclitaxel-eluting balloon is feasible and concentrations within the therapeutic window are detected 30 minutes after the procedure. The antirestenotic potential of this treatment should be studied.

Новое применение DEB?

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

JACC Cardiovasc Interv. 2009 May;2(5):393-401.

Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting: the SHARP study.

Versaci F, Reimers B, Del Giudice C, Schofer J, Giacomin A, Saccà S, Gandini R, Albiero R, Pellegrino A, Bertoldo F, Simonetti G, Chiariello L.

Divisione di Cardiologia, Università Tor Vergata, Rome, Italy.

Comment in:
JACC Cardiovasc Interv. 2009 May;2(5):402-3.

Abstract

OBJECTIVES: In an attempt to reduce post-operative events we investigated a new therapeutic strategy consisting of a simultaneous hybrid revascularization by carotid artery stenting (CAS), immediately followed by an on-pump coronary artery bypass graft (CABG).

BACKGROUND: Preventing stroke and cardiovascular events after coronary artery revascularization in patients with elevated surgical risk is a complex and multifaceted problem.

METHODS: One hundred-one consecutive patients with severe carotid and coronary artery disease and a standard EuroSCORE >or=5 were included in this multicenter study. Immediately after CAS, patients underwent CABG. The primary end point was the incidence of stroke, acute myocardial infarction (AMI), or death at 30 days. Secondary outcomes were transient ischemic attacks; major local complications; bleeding and systemic complications within 30 days after treatment; and any stroke, AMI, or death occurring from the 31st day to the end of the 12-month follow-up. All clinical outcomes were assessed by an independent monitoring board.

RESULTS: The rate of procedural success was 98%. The 30-day cumulative incidence of disabling stroke, AMI, or death was 4%: 2 patients died (2%) in the post-operative period, and 2 patients (2%) had a stroke immediately after CAS and before CABG. Three patients died from the 31st day to the 12th month after the procedure.

CONCLUSIONS: Our findings indicate that in high-risk patients with coronary artery disease suitable for CABG and carotid artery disease, the hybrid revascularization by CAS immediately followed by CABG is a promising and feasible therapeutic strategy.

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

J Interv Cardiol. 2009 Aug;22(4):390-7. Epub 2009 May 6.

Periprocedural management and in-hospital outcome of patients with indication for oral anticoagulation undergoing coronary artery stenting.

Rubboli A, Colletta M, Valencia J, Capecchi A, Franco N, Zanolla L, La Vecchia L, Piovaccari G, Di Pasquale G; WARfarin and Coronary STENTing (WAR-STENT) Study Group.

Cardiac Catheterization Laboratory, Division of Cardiology, Ospedale Maggiore, Bologna, Italy. [Ссылки доступны только зарегистрированным пользователям ]


Abstract

PURPOSE: In patients on oral anticoagulation (OAC) undergoing coronary stenting (PCI-S), procedural management and in-hospital outcome have never been specifically and prospectively investigated. Also, the contribution of early bleeding to the relevant hemorrhagic rate reported at follow-up with triple therapy of OAC, aspirin, and clopidogrel is largely unknown.

METHODS: Consecutive patients with indication for OAC undergoing PCI-S at 5 centers were enrolled and prospectively evaluated.

RESULTS: Out of 3410 patients undergoing PCI-S in the study period, indication for OAC was present in 4.8%. Femoral approach and bare metal stents were the most frequently used. During PCI-S, OAC was continued in about 30% of patients, whereas in about 20% heparin bridging was carried out. Glycoprotein IIb/IIIa inhibitors were rarely used (11%), whereas a standard bolus of unfractionated heparin was given in 93% of cases. Major adverse cardiovascular events (MACE) occurred in 4.8% of patients and major bleeding in 4.3%. No predictors of MACE or bleeding were identified, although the femoral approach was of borderline significance for major bleeding (OR 4.6, 95% CI 1.0-20.8; P = 0.05). A history of previous hemorrhage (OR 5.3, 95% CI 1.6-18.1; P = 0.007) predicted Carbofilm-coated stent implantation.

CONCLUSIONS: A limited, albeit clinically relevant, proportion of patients undergoing PCI-S has indication for OAC. Procedural management appears not substantially different from that of common patients. In-hospital major bleeding is relevant and should be taken into account when evaluating the overall hemorrhagic rate at a medium- to long-term follow-up.