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Comparison of percutaneous interventions for unstable angina pectoris in patients with and without previous coronary artery bypass grafting

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第9期86卷 931-937页

作者： Mathew, V Berger, PB Lennon, RJ Gersh, BJ Holmes, DR Mayo Clin & Mayo Fdn Rochester MN 55905 USA

An increasing number of patients who have undergone previous coronary artery bypass grafting (CABG) are referred for percutaneous coronary revascularization. We identified patients who underwent percutaneous intervention for unstable angina from 1990 to 1998 at our institution and assigned them into 2 groups based on whether or not they had undergone previous CABG. There were 1,431 patients with and 4,629 patients without previous CABG. Previous CABG patients were older, had more atherosclerotic risk factors, more heart failure, lower ejection fraction, more multivessel disease, more multilesion treatment, more complex lesions, and less complete revascularization. Adjusting for baseline differences, previous CABG was associated with worse long-term mortality (RR 1.47, 95% confidence intervals [CI] 1.22 to 1.77, p <0.001) and death, myocardial infarction, and/or revascularization (RR 1.16, 95% CI 1.04 to 1.30, p = 0.01);treatment of native lesions in patients with previous CABG versus treatment of vein graft lesions was associated with a reduction in this composite end point (RR 0.75, 95% CI 0.65 to 0.87, p <0.001). Post-CABG patients treated between 1995 and 1998 had lower long-term mortality (RR 0.76, 95% CI 0.59 to 0.99, p = 0.04) and death, myocardial infarction, and/or revascularization (RR 0.76, 95% CI 0.66 to 0.88, p <0.001) compared with those treated between 1990 and 1994. Thus, in patients with unstable angina referred for percutaneous revascularization, previous CABG is associated with reduced event-free survival, although the outcome of post-CABG patients treated from 1995 to 1998 is superior to that observed in patients treated from 1990 to 1994. In patients who underwent previous CABG, treatment of native lesions affords better long-term outcome than vein graft intervention. (C)2000 by Excerpta Medico, Inc.

关键词：方差分析心绞痛不稳定型/死亡率心绞痛不稳定型/外科学血管成形术经腔经皮冠状动脉/方法血管成形术经腔经皮冠状动脉/死亡率卡方分布冠状动脉分流术/方法随访研究移植物闭塞血管/病因学移植物闭塞血管/放射摄影术移植物闭塞血管/治疗比值比概率前瞻性研究登记存活率治疗结果女(雌)性人类男(雄)性中年人

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Prediction of death after percutaneous coronary interventional procedures

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AMERICAN HEART JOURNAL 2000年第6期139卷 1032-1038页

作者： Rihal, CS Grill, DE Bell, MR Berger, PB Garratt, KN Holmes, DR Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mayo Clin & Mayo Fdn Biostat Sect Rochester MN 55905 USA

Background The prediction and comparison of procedural death oiler percutaneous coronary interventional procedures is inherently difficult because of variations in case mix and practice patterns. The impact of modern, expanded patient selection criteria, and newer technologic approaches is unknown. Our objective was to determine whether a risk equation bored on patient-related variables and derived from an independent data set can accurately predict procedural death after percutaneous coronary intervention in the current era. Methods and Results An analysis was made of the Mayo Clinic Coronary Interventional Database January 1, 1995, to October 31, 1997. Expected mortality rate was calculated with the use of the New York State multivariate risk score. In 3387 patients. 3830 procedures (55.1% stents) were performed, with an expected mortality rate ai 2.32% and observed mortality rate of 2.38% (P = not significant). The risk score derived from the New York multivariate model was highly predictive of death (chi-square = 213.8;P < .0001). The presence of a high-risk lesion characteristic such as calcium, thrombus, or type C lesion was modestly associated with death. Conclusions The New York State multivariate model accurately predicted procedural death in our database.

关键词：心绞痛不稳定型/死亡率心绞痛不稳定型/放射摄影术心绞痛不稳定型/治疗血管成形术经腔经皮冠状动脉/死亡率冠状血管造影术医院死亡率医院记录/统计学和数值数据心肌梗死/死亡率心肌梗死/放射摄影术心肌梗死/治疗纽约/流行病学预后前瞻性研究可重复性结果危险性评估性别分布存活率女(雌)性人类男(雄)性中年人

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Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: Final report reanalysis of the Bivalirudin Angioplasty Study

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AMERICAN HEART JOURNAL 2001年第6期142卷 952-959页

作者： Bittl, JA Chaitman, BR Feit, F Kimball, W Topol, EJ Ocala Heart Inst Munroe Reg Med Ctr Ocala FL 34474 USA St Louis Univ Dept Med St Louis MO 63103 USA NYU Sch Med New York NY USA Quintiles Inc Durham NC USA Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA

Background This study was a reanalysis of the Bivalirudin Angioplasty Study, which compared bivalirudin with high-dose heparin during coronary angioplasty for unstable angina. Methods Differences in rates of death, myocardial infarction, or repeat revascularization were compared at 7, 90, and 180 days after angioplasty with intention-to-treat analysis. Result The combined end point occurred in 135 of 2161 patients (6.2%) in the bivalirudin group and in 169 of 2151 patients (7.9%) in the heparin group at 7 days (P = .039). Differences persisted between the groups at 90 days (P = .012) and 180 days (P = .153). Bleeding occurred in 76 patients (3.5%) in the bivalirudin group versus 199 (9.3%) in the heparin group (P < .001). Conclusions This analysis supports the hypothesis that bivalirudin reduces ischemic complications and bleeding after angioplasty. Further trials are needed to evaluate bivalirudin versus heparin in conjunction with platelet-glycoprotein IIb/IIIa inhibitors and for coronary stenting.

关键词：保险统计分析心绞痛/病因学心绞痛/死亡率心绞痛/治疗心绞痛不稳定型/死亡率心绞痛不稳定型/治疗血管成形术经腔经皮冠状动脉/方法阿司匹林/投药和剂量随访研究肝素/治疗应用水蛭素疗法水蛭素类/类似物和衍生物 Logistic模型心肌梗死/并发症比值比肽碎片/治疗应用重组蛋白质类/治疗应用存活率成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Effect of institutional volume and academic status on outcomes of coronary interventions: The IMPACT-II experience

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AMERICAN HEART JOURNAL 1999年第5期138卷 976-982页

作者： Gilchrist, IC Gardner, LH Muhlestein, JB Arnold, AM Lincoff, AM Califf, RM Tcheng, JE Topol, EJ Penn State Univ Milton S Hershey Med Ctr Hershey PA 17033 USA Duke Univ Clin Res Inst Durham NC 27706 USA St Lukes Med Ctr Salt Lake City UT USA Cleveland Clin Fdn Cleveland OH 44195 USA

Background Rates of morbidity and mortality after interventional procedures are reported to be inversely associated with institutional volume. Methods This study assessed both procedural volume and academic status at the 82 US centers that participated in the IMPACT-II trial. Interventional volumes at the sites ranged from 90 to 3300 cases per year. Patients were randomly assigned to a platelet glycoprotein IIb/IIIa inhibitor (eptifibatide) or placebo during procedures done by experienced operators. The primary end point was the composite of death, myocardial infarction, nonelective repeat coronary intervention, or nonelective coronary artery bypass surgery at 80 days, or placement of an intracoronary stent for abrupt closure during the initial procedure. Results Baseline patient characteristics and median length of stay were similar between the academic and nonacademic centers. In univariable analysis, volume as a continuous variable had a nonlinear relation with the incidence of the composite end point, with better outcomes noted at the highest volume institutions. Academic status did not predict outcome. When added to a predictive model that contained the variables unstable angina,weight, prior coronary artery bypass grafting, heart rate, and platelet count, procedural volume continued to be associated with the composite outcome (P = .04). Conclusions We conclude that among hospitals participating in this trial, there is a nonlinear relation between annual interventional volume and outcomes. This relation is complex, involving variations in periprocedural infarction rates and additional, undefined institutional differences (other than academic status) that result in differences in procedural outcome.

关键词：医学科学研究中心/标准医学科学研究中心/统计学和数值数据心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率随访研究医院大学/标准医院大学/统计学和数值数据住院时间多机构系统/标准多机构系统/统计学和数值数据结果评价(卫生保健) 肽类/治疗应用血小板聚集抑制剂/治疗应用血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂回顾性研究存活率美国/流行病学老年人女(雌)性人类男(雄)性中年人

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Prodromal unstable angina in acute myocardial infarction: Prognostic value of short- and long-term outcome and predictor of infarct size

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AMERICAN HEART JOURNAL 2000年第1期140卷 126-133页

作者： Bahr, RD Leino, EV Christenson, RH Univ Maryland Med Syst Dept Pathol Baltimore MD 21201 USA St Agnes Healthcare Paul Dudley White Coronary Care Syst Baltimore MD USA Amer Coll Hlth Assoc Baltimore MD USA

Background An estimated 50% of patients with myocardial infarction have prodromal unstable angina. There is controversy over whether prodromal unstable angina identifies a group of patients at lower risk of short- and long-term death and the clinical importance of recording this event. Methods of 207 patients enrolled at a single Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) site, 196 survived the 24 hours after presentation, achieved peak creatine kinase MB concentrations, and were classified as having either abrupt symptom onset or prodromal unstable angina in the 2 weeks before myocardial infarction. Creatine kinase MB peak was used to categorize infarct size as aborted myocardial infarction, minor myocardial damage, or extensive myocardial injury. Follow-up was performed at 24 hours, 30 days, year, and 5 years. Multiple variables, including prodromal unstable angina, time to treatment, age, sex, previous infarction and infarct location, were analyzed for predicting infarct size. Also, these variables plus peak creatine kinase MB level and a combined variable of prodromal unstable angina and peak creatine kinase MB level were examined for predicting survival. Results Mortality rate was 2.5% within 24 hours, 9.0% at 30 days, 13.5% at 1 year, and 27.1% at 5 years. Patients categorized as either aborted infarction or minor myocardial damage were significantly more likely to have prodromal unstable symptoms (81.3% vs 51.2%, P < .001) and better survival at each follow-up period. Prodromal presentation was the most significant predictor of infarct size category (P = .001). Five-year survival was predicted by age (P < .0001), peak creatine kinase MB level (P = .007), infarct location (P = .009), the combined variables (P = .029), and prodromal unstable angina (P = .017). Prodromal unstable angina had the highest odds ratio for 5-year survival at 3.83 (95% confidence interval 1.27-11.47). Conclusions prodro

关键词：心绞痛不稳定型/诊断心绞痛不稳定型/病因学心绞痛不稳定型/死亡率置信区间缺血预处理 Logistic模型心肌梗死/并发症心肌梗死/死亡率比值比试验预期值预后危险因素疾病严重程度指数存活率分析治疗结果成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Clinical efficacy of three assays for cardiac troponin I for risk stratification in acute coronary syndromes: A thrombolysis in myocardial infarction (TIMI) 11B substudy

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CLINICAL CHEMISTRY 2000年第4期46卷 453-460页

作者： Morrow, DA Rifai, N Tanasijevic, MJ Wybenga, DR De Lemos, JA Antman, EM Brigham & Womens Hosp Div Cardiovasc Dept Med Boston MA 02115 USA Brigham & Womens Hosp Dept Pathol Boston MA 02115 USA Childrens Hosp Dept Lab Med Boston MA 02115 USA

Background: Significant analytic variability exists between the multiple assays for cardiac troponin I (cTnI) approved for clinical use. Until adequate cTnI standardization is possible, an evidence-based approach evaluating each assay at specific thresholds appears warranted. Methods: We examined the efficacy of three cTnI assays for predicting death, myocardial infarction (MI), or the composite of death, MI, or urgent revascularization at 43 days among patients with non-ST-elevation acute coronary syndromes enrolled in the Thrombolysis In Myocardial Infarction (TIMI) 11B study. Results: Six hundred eighty-one patients with serum samples obtained at baseline and/or 12-24 h had cTnI determined using all three assays. Baseline cTnI was greater than or equal to 0.1 mu g/L for 368, 395, and 418 patients with the Bayer Immune 1(TM), ACS:180(R), and Dimension(R) RxL assays, respectively. Correlation coefficients for the RxL with the ACS:180 and Bayer Immune 1 results were 0.89 (P = 0.0001) and 0.87 (P = 0.0001), with a coefficient of 0.92 (P = 0.0001) for the ACS:180 and Bayer Immuno 1 assays. Patients with cTnI greater than or equal to 0.1 mu g/L were at increased risk for death or MI by 43 days (relative risk, 2.2-3.0;P < 0.0006), regardless of the assay used. This prognostic capacity persisted among those with creatine kinase MB isoenzyme concentrations within the reference interval. Moreover, cTnI was the strongest multivariate predictor of death, MI, or urgent revascularization with adjusted odds ratios of 2.1-2.9 (P < 0.0006). Conclusion: This study demonstrates the prognostic efficacy of three independently developed cTnI assays at a threshold of 0.1 mu g/L for the prediction of adverse clinical outcomes among patients with non-ST-elevation acute coronary syndromes. (C) 2000 American Association for Clinical Chemistry.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/诊断心绞痛不稳定型/死亡率免疫测定心肌梗死/血液心肌梗死/诊断心肌梗死/死亡率预后回归分析危险敏感性与特异性综合征肌钙蛋白I/血液老年人女(雌)性人类男(雄)性中年人

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Elevated cardiac troponin levels predict the risk of adverse outcome in patients with acute coronary syndromes

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AMERICAN HEART JOURNAL 2000年第6期140卷 917-927页

作者： Ottani, F Galvani, M Nicolini, FA Ferrini, D Pozzati, A Di Pasquale, G Jaffe, AS Bentivoglio Hosp Div Cardiol Bentivoglio Italy GB Morgagni L Pierantoni Hosp Div Cardiol Bologna Italy Mayo Clin Div Cardiol Rochester MN USA

Background Elevations of cardiac troponin T or I ore predictive of adverse outcomes in patients with acute coronary syndromes. However, odds ratios (ORs) vary substantially between studies. This investigation refines these values by means of a meta-analysis. Methods Twenty-one studies were suitable. ORs were calculated For short-term (30 days) and long-term 15 months to 3 years) follow-up in patients with ST-segment elevation (ST up arrow), in those without ST-segment elevation (no ST up arrow), and in patients with unstable angina. The primary end point was a composite of death or nonfatal myocardial infarction. Results A total of 18,982 patients were included. At 30 days, the OR for death or myocardial infarction was 3.44 (95% confidence interval [CI], 2.94-4.03;P<.00001)for patients with positive troponin. In the ST group, troponin elevations carried a 2.86-fold (95% CI, 2.35-3.47;P <.0001) higher risk during short-term follow-up, which was maintained long term. The no-ST patients with troponin elevations manifested a 4.93-fold (95% CI, 3.77-6.45;P <.0001) increase of adverse outcomes. The OR for patients with unstable angina and positive troponin was 9.39 (95% CI, 6.46-13.67;P <.0001), For cardiac death alone, the results were similar. Conclusions Patients with acute coronary syndromes who have troponin elevations show a substantial increase in risk during short and long-term follow-up.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/死亡率心绞痛不稳定型/病理生理学生物学标记/血液猝死心脏心肌梗死/血液心肌梗死/死亡率心肌梗死/病理生理学预后复发回顾性研究疾病严重程度指数存活率肌钙蛋白I/血液肌钙蛋白T/血液人类

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Long-term outcome in patients treated by intracoronary stenting with ticlopidine and aspirin, and deleterious prognostic role of unstable angina pectoris

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第9期85卷 1065-1070页

作者： Angioi, M Danchin, N Alla, F Gangloff, C Sunthorn, H Rodriguez, RM Preiss, JP Grentzinger, A Houplon, P Juillière, Y Cherrier, F CHU Nancy Hop Brabois Serv Cardiol F-54511 Vandoeuvre Nancy France CHU Nancy Hop Marin Serv Epidemiol & Evaluat Clin Vandoeuvre Nancy France

Compared with stable clinical conditions, unstable angina carries an increased risk of immediate and delayed cardiac adverse events after balloon coronary angioplasty. The influence of stent use in reducing these differences remains unknown. We analyzed the early (30 days) and late outcome of a cohort of 459 consecutive patients who underwent stent placement with ticlopidine and aspirin as antithrombotic regimen according to the presence (group 1, n = 151) or absence (group 2, n = 308) of unstable angina at rest (Braunwald classes II and III). Group 1 patients were older and more likely to be current or former smokers. In group 2, prior myocardial infarction was more frequent. Procedural, in-hospital results, and early outcome were similar in the 2 groups. However, over the long term, the incidence of myocardial infarction (11% vs 6%, p <0.04), target lesion revascularization (19% vs 13%, p <0.04), or any revascularization (30% vs 20%, p <0.01) was significantly higher in group 1. Kaplan-Meier probabilities of survival without myocardial infarction (85% vs 91%, p <0.05), survival without revascularization of the target lesion (73% vs 83%, p <0.01), survival without any revascularization (65% vs 77%, p <0.006), and survival without any events (61% vs 73%, p <0.009) were significantly worse in group 1. In addition, Cox multivariate analysis showed that unstable angina at rest was an independent predictor of target lesion revascularization, of survival without any revascularization, and without any events. Thus, unstable angina at rest remains an adverse prognostic indicator in patients treated with intracoronary stents, particularly with regard to subsequent requirement of revascularization procedures and event-free survival. (C) 2000 by Excerpta Medica, Inc.

关键词：心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率心绞痛不稳定型/治疗阿司匹林/治疗应用血小板聚集抑制剂/治疗应用预后支架存活率分析噻氯匹定/治疗应用治疗结果老年人女(雌)性人类男(雄)性中年人

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Clinical trials of unfractionated heparin and low-molecular-weight heparin in addition to aspirin for the treatment of unstable angina pectoris: Do the results apply to all patients?

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第9期86卷 908-912页

作者： Walsh, CR Lloyd-Jones, DM Camargo, CA Giugliano, RP O'Donnell, CJ NHLBI Framingham Heart Study Framingham MA 01702 USA Massachusetts Gen Hosp Dept Med Div Cardiol Boston MA 02114 USA Massachusetts Gen Hosp Dept Emergency Med Boston MA 02114 USA Harvard Univ Sch Med Channing Lab Boston MA 02115 USA Harvard Univ Brigham & Womens Hosp Sch Med Dept MedCardiovasc Div Boston MA 02115 USA

We sought to determine how the results of available randomized controlled trials of intravenous unfractionated heparin (UH) and low-molecular weight heparin (LMWH) apply to unselected patients with unstable angina pectoris (UAP). Although UH is widely used in addition to aspirin for treatment of UAP, the evidence is weak for a net benefit over aspirin alone. LMWH preparations may confer a net benefit over UH for the treatment of UAP in clinical trials. It is not clear, however, how trial results are generalized to unselected patients with UAP, Using criteria from the Agency for Health Care Policy and Research Unstable Angina Clinical Practice Guideline, we identified 277 consecutive patients with primary UAP, Exclusion criteria were applied from 6 trials of UH in addition to aspirin and 5 trials of LMWH in addition to aspirin for the treatment of UAP. Clinical outcomes were compared among ineligible and eligible patients for trial enrollment. Patients meeting exclusion criteria were older and had more extensive coexisting medical illness than eligible patients for trial enrollment. Thirty-eight percent to 42% of our study population met greater than or equal to1 exclusion criteria for each of the 6 trials of UH, and 14% to 46% met greater than or equal to1 exclusion criteria for each of the 5 LMWH trials. The I-year all-cause death rate was higher in UH ineligible patients compared with UH eligible patients (16% vs 4%, p = 0.003) and in LMWH ineligible patients compared with LMWH eligible patients (16% vs 7%, p = 0.005). Thus, clinical trials of UH and LMWH may have limited generalizability to unselected patients with UAP, many of whom have characteristics that would exclude them from trial enrollment and put them at risk for adverse outcomes. (C)2000 by Excerpta Medica, Inc.

关键词：方差分析心绞痛不稳定型/诊断心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率阿司匹林/治疗应用卡方分布队列研究药物疗法联合肝素/治疗应用肝素低分子量/治疗应用预后比例危险度模型存活率治疗结果成年人老年人女(雌)性人类男(雄)性中年人

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Timing of and risk factors for myocardial ischemic events after percutaneous coronary intervention (IMPACT-II)

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第4期85卷 427-434页

作者： Thel, MC Califf, RM Tardiff, BE Gardner, LH Sigmon, KN Lincoff, AM Topol, EJ Kitt, MM Blankenship, JC Tcheng, JE Duke Clin Res Inst Durham NC 27715 USA Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA COR Therapeut Inc S San Francisco CA USA Weis Ctr Res Geisinger Clin Danville PA 17822 USA

We studied both the time course and risk factors for adverse clinical events after percutaneous coronary intervention (PCI). Such information is critical to clinical decision-making, but scant quantitative data exist to describe the time course of these adverse outcomes. Patients enrolled in the Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-ii (IMPACT-II) trial were analyzed. Patients undergoing elective, urgent, or emergency PCI (n = 4,010) were randomized to receive either placebo or 1 of 2 eptifibatide regimens during intervention. We evaluated the time to the primary end point of the trial, the 30-day composite of death, myocardial infarction, repeat nonelective PCI, nonelective bypass surgery, or stenting for abrupt closure. Adverse events occurred in 407 patients (10.1%). Because the risk of events declined substantially between 6 and 9 hours (66% occurred within b hours), events were classified as occurring before or after 6 hours. Independent predictors of "early" events included dissection, pre- and postprocedural coronary blood flow, side-branch occlusion, procedural thrombolytic use, previous bypass, presentation with unstable angina, absence of diabetes, and hyperlipidemia. The predictors of "late" events included lower weight, increased baseline heart rate, coronary dissection, and procedural thrombolytic use. The risk of ischemic events were greatest immediately after PCI and rapidly declined, so that by 9 hours the hazard function plot was flat;66% of events occurred within 6 hours of PCI. Knowledge of the risk factors for early and late events help risk-stratify patients before and after intervention for myocardial ischemic events. (C) 2000 by Excerpta Medico, Inc.

关键词：心绞痛不稳定型/死亡率心绞痛不稳定型/治疗冠状动脉血栓形成/死亡率冠状动脉血栓形成/治疗心电描记术输注静脉内心肌梗死/病因学心肌梗死/死亡率肽类/投药和剂量肽类/治疗应用血小板聚集抑制剂/投药和剂量血小板聚集抑制剂/治疗应用前瞻性研究复发/预防和控制危险因素存活率血栓溶解疗法时间因素治疗结果美国/流行病学老年人女(雌)性人类男(雄)性中年人

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