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Role of target vessel size and body surface area on outcomes after percutaneous coronary interventions in women

AMERICAN HEART JOURNAL 2002年第2期144卷 297-302页

作者： Cantor, WJ Miller, JM Hellkamp, AS Kramer, JM Peterson, ED Hasselblad, V Zidar, JP Newby, LK St Michaels Hosp Div Cardiol Toronto ON M5B 1W8 Canada Johns Hopkins Univ Hosp Baltimore MD 21287 USA Duke Clin Res Inst Durham NC USA

Background Women have higher mortality rates than men after coronary angioplasty. Differences in target vessel size may partially account for these differences. We set out to explore the effects of sex, body surface area (BSA), and target coronary vessel size on clinical outcomes after angioplasty. Methods Data from 5 interventional trials and 1 registry were pooled for analysis (n = 3982). Results Compared with men, women undergoing angioplasty were older, had lower weights and BSA, more coronary risk factors, and slightly smaller target coronary vessel size (as assessed by reference vessel diameter). The correlation between target vessel size and BSA was poor (r = 0.13). At 6 months, women had higher mortality rates (1.7% vs 0.8%, P = .03) but similar rates of myocardial infarction and repeat revascularization. On univariate analysis, advanced age, smaller BSA, and female sex were associated with increased mortality, but target vessel size was not. Advanced age was the only significant,multivariate predictor of mortality. Target vessel size and diabetes were independent predictors of repeat revascularization. Conclusions Women have higher unadjusted 6-month mortality rates after angioplasty, owing largely to their more advanced age at the time of intervention. Smaller target vessel size is associated with increased risk of restenosis and repeat revascularization;however, it does not appear to be a predictor for downstream mortality. As such, the fact that women have smaller vessels does not account for their higher 6-month mortality after coronary angioplasty.

关键词：血管成形术经腔经皮冠状动脉/死亡率体表面积冠状血管造影术冠心病/病理生理学冠心病/治疗随访研究多元分析试验预期值前瞻性研究危险因素性别因素存活率治疗结果老年人女(雌)性人类男(雄)性中年人

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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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Is there a benefit to early angiography in patients with ST-segment depression myocardial infarction? An observational study

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AMERICAN HEART JOURNAL 2002年第3期143卷 488-496页

作者： Shavelle, DM Parsons, L Sada, MJ French, WJ Every, NR Univ Washington Div Cardiol Seattle WA 98195 USA Harbor UCLA Med Ctr Puget Sound Vet Affairs Med Ctr Torrance CA 90509 USA Harbor UCLA Med Ctr St Johns Cardiovasc Res Ctr Div Cardiol Torrance CA 90509 USA

Background and Objective Patients with ST-segment depression myocardial infarction (MI) have a similar long-term outcome compared with those who have ST-segment elevation. It remains unclear whether an aggressive treatment approach with very early (<6 hours) angiography and revascularization improves outcome over an early conservative approach. We compared the short-term outcome of patients who received very early (<6 hours) angiography with patients who received early conservative therapy for ST-segment depression MI. Methods Patients seen within 12 hours with ST-segment depression on the initial electrocardiogram (ECG) were identified from the National Registry of Myocardial Infarction 2 (NRMI) database, which collected information from 1994 to 1998. Those who received very early (<6 hours) angiography were compared with those who received early conservative therapy. The short-term outcomes, including major bleeding episodes, cerebral vascular events, recurrent ischemia and angina, MI, and death, were compared on the basis of the initial therapy received. Results Patients treated with very early angiography (2402) were younger, more likely to be males, smokers, and have less of a cardiac history (angina, MI, congestive heart failure, aortocoronary bypass surgery) and less likely to have diabetes mellitus than those who received early conservative therapy (17,735). Hospital outcome in the very early angiography group was similar to the early conservative therapy group in terms of cerebral vascular events (0.8% vs 1.0%, P =.27), major bleeding events (2.8% vs 2.4%, P =.25), and recurrent MI (2.1% vs 2.3%, P = .57) but was associated with lower recurrent ischemia or angina (11.4% vs 16.7%, P < .001) and improved survival (death, 4.9% vs 7.3%, P < .001). Multivariate analysis suggested that patients receiving very early angiography had lower mortality compared with those receiving early conservative therapy (odds ratio [OR] = 0.76;95% Cl 0.60-0.95). However, comparing

关键词：年龄因素血管成形术经腔经皮冠状动脉/死亡率冠状血管造影术冠状动脉分流术/死亡率数据库事实型心电描记术医院死亡率多元分析心肌梗死/死亡率心肌梗死/放射摄影术心肌梗死/治疗登记/统计学和数值数据性别因素治疗结果老年人女(雌)性人类男(雄)性中年人

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Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts

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AMERICAN HEART JOURNAL 2002年第1期143卷 111-117页

作者： Shah, BR Velazquez, E Shaw, LK Bart, B O'Connor, C Wagner, GS Duke Univ Med Ctr Div Cardiol Dept Med Durham NC USA Hennepin Cty Med Ctr Div Cardiol Minneapolis MN 55415 USA

Background The purpose of the current study was to determine whether survival after revascularization (coronary artery bypass grafting or percutaneous transluminal coronary angioplasty) is influenced by the extent of electrocardiographic (ECG) evidence of previous myocardial infarction (MI) in patients with ischemic cardiomyopathy by use of the 50-criteria, 31-point Selvester QRS scoring system. Methods Patients with ischemic cardiomyopathy documented by a left ventricular ejection fraction (LVEF) less than or equal to30% undergoing coronary angiography between January 1984 and July 1996, with no acute MI within the last 30 days, follow-up through 1996, and greater than or equal to75% occlusion in at least 1 major coronary artery at catheterization were included. These patients were subdivided on the basis of subsequent treatment: revascularization or no revascularization. The complete Selvester QRS system was applied to each patient's ECG and the subgroups were further subdivided by QRS score. Results The 141 patients receiving revascularization had better survival at 5 years compared with the 298 patients receiving no revascularization (adjusted 5-year survival rate 73% vs 47%, P = .0001). No significant treatment differences were observed for low (less than or equal to3 points) versus high (>3 points) QRS levels in either of the 2 treatment groups (revascularized patients: P = .215, patients without revascularization: P = .126) between the 2 treatment groups. Although all patients had LVEF less than or equal to30%, only 8% of patients had QRS scores >10 points, the level that would be expected if the decrease in LVEF could be attributed entirely to infarcted myocardium. Conclusions Hibernating myocardium may contribute significantly to the decreased function in patients with ischemic cardiomyopothy, and the QRS score cannot be used as an independent predictor of survival in those patients with a marked decrease in LVEF but small to moderate infarct sizes.

关键词：血管成形术经腔经皮冠状动脉/死亡率冠状动脉分流术/死亡率心电描记术随访研究心肌梗死/死亡率心肌梗死/病理学心肌梗死/治疗心肌缺血/死亡率心肌缺血/病理生理学心肌缺血/治疗心肌顿抑/病理生理学每搏输出量存活率女(雌)性人类男(雄)性中年人

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Short-term outcomes after percutaneous coronary intervention: Effects of stenting and institutional volume shifts

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AMERICAN HEART JOURNAL 2002年第2期144卷 309-314页

作者： Watanabe, CT Maynard, C Ritchie, JL Univ Washington Dept Med Seattle WA 98195 USA Univ Washington Dept Hlth Sci Seattle WA 98195 USA Hlth Serv Res & Dev Seattle WA USA Dept Vet Affairs Dept Med Seattle WA USA

Background This study examines how the dissemination of stenting and procedural shifts to high-volume facilities have affected short-term outcomes after percutaneous coronary intervention (PCI). Methods Discharge information from the 1994 and 1997 US Nationwide Inpatient Sample was used. Data from 1994 involved 84,036 angioplasties, 27.3% of which were performed for acute myocardial infarction (AMI), at a time when stents were generally unavailable. Data from 1997 included 118,548 angioplasties, 30.2% of which were performed for AMI and 59% of which involved stenting. Outcomes included same-admission mortality and same-admission bypass grafting surgery (CABG). Results Compared with 1994, in 1997 stents were in widespread use, and there was a significant shift in PCI procedures to high-volume facilities. There was no significant difference in overall mortality rates between 1994 and 1997. However, same-admission CABG rates were lower in 1997 than in 1994 for the AMI group (2.9% vs,4.7%, P < .0001) and for the no-AMI group (1.8% vs 3.0%, P < .0001), which was attributable almost entirely to stenting. For 1997 only, patients receiving stents had a lower mortality rate than patients undergoing PCI without stenting (AMI 2.7% vs 4.7%, P < .0001, no AMI 0.7% vs 0.9%, P = .004). Conclusions Despite the dissemination of stenting and shifts to high-volume facilities, overall mortality rates after PCI have not significantly changed. However, patients undergoing stenting in 1997 had a significantly lower mortality rate than patients who did not undergo stenting, suggesting that stents may prevent inhospital deaths. Furthermore, same-admission CABG rates have decreased dramatically, an association seen with the introduction of stenting, but not with volume shifts.

关键词：血管成形术经腔经皮冠状动脉/死亡率冠状动脉分流术/统计学和数值数据医院死亡率/发展趋势住院病人/统计学和数值数据多元分析心肌梗死/流行病学心肌梗死/治疗比值比支架/统计学和数值数据存活率/发展趋势治疗结果美国/流行病学女(雌)性人类男(雄)性中年人

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Low-risk percutaneous coronary interventions without on-site cardiac surgery: Two years' observational experience and follow-up

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AMERICAN HEART JOURNAL 2003年第2期145卷 278-284页

作者： Ting, HH Garratt, KN Singh, M Kjelsberg, MA Timimi, FK Cragun, KT Houlihan, RJ Boutchee, KL Crocker, CH Cusma, JT Wood, DL Holmes, DR Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA

Background We studied the safety and efficacy of performing low-risk elective and acute infarct percutaneous coronary interventions at a community hospital without cardiac surgical capability. Methods Immanuel St Joseph's Hospital is located 85 miles from St Mary's Hospital, which is the nearest center with on-site cardiac surgery. All components of the Mayo Clinic percutaneous coronary intervention program were replicated at Immanuel St Joseph's Hospital, including a telemedicine system to enable real-time consultation with interventional and cardiac surgical colleagues during procedures. Results From March 1999. to June 2001, 196 patients underwent elective percutaneous coronary intervention at Immanuel St Joseph's Hospital. Procedural success was achieved in 195 (99.5%) patients, with 1 (0.5%) inhospital death. At mean follow-up of 8.2 months, 2 (1.0%) additional patients died of noncardiac causes and 15 (7.7%) patients required target vessel revascularization. From March 2000 to June 2001, 89 patients underwent primary percutaneous coronary intervention for acute myocardial infarction. Procedural success was achieved in 83 (93.3%) patients, with 3 (3.4%) inhospital deaths. At 30-day follow up, no additional patients died, had recurrent myocardial infarction, or required target vessel revascularization. No patients required transfer to another facility for emergent cardiac surgery for a procedure-related complication. Conclusions Low-risk elective and acute infarct percutaneous coronary interventions can be performed with safety and efficacy at a community hospital without cardiac surgical capability by following rigorous standards.

关键词：血管成形术经腔经皮冠状动脉/死亡率血管成形术经腔经皮冠状动脉/标准心脏病学科医院/组织和管理心脏病学科医院/标准死亡原因冠状血管造影术卫生服务易得程度医院死亡率明尼苏达心肌梗死/治疗病人遴选危险安全远程医学治疗结果老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty: A report from the NHLBI Dynamic Registry

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AMERICAN HEART JOURNAL 2003年第3期146卷 513-519页

作者： Cohen, HA Williams, DO Holmes, DR Selzer, F Kip, KE Johnston, JM Holubkov, R Kelsey, SF Detre, KM Univ Pittsburgh Dept Epidemiol Pittsburgh PA 15261 USA Rhode Isl Hosp Providence RI USA Mayo Clin Rochester MN USA Univ Pittsburgh Med Ctr Pittsburgh PA 15261 USA Univ Utah Dept Family & Prevent Med Salt Lake City UT 84112 USA

Background older age has been associated with adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). As PCI technology evolves and the US population becomes proportionally older, assessment of PCI in older age groups is essential. Methods From the National Heart, Lung, and Blood Institute Dynamic Registry, 4620 PCI-treated patients (1997 to 1999) were studied. Differences in clinical presentation, treatment strategy, and inhospital and 1-year outcomes were compared between patient age groups: younger (<65 years, n = 2537);older (65 to 79 years, n = 1776);and elderly (≥80 years, n = 307). Results Older and elderly patients had more cardiac and comorbid noncardiac conditions and more extensive and complex arteriosclerosis, including stenoses in bypass grafts. Stent use was similar as age increased (72% vs 73% vs 73%), as was the use of IIb/IIIa receptor antagonists (29% vs 26% vs 28%). Rates of successful treatment of all attempted lesions were 93%, 92%, and 89%, respectively. Adjusted relative risks of inhospital death (1.0 vs 2.91 vs 3.64) and myocardial infarction (1.0 vs 1.35 vs 2.57) increased by age group, as did 1-year mortality rates (1.0 vs 1.87 vs 3.02). However, the relative magnitude of excess mortality rates at 1 year was comparable to that observed by age in the US general population. Age was not associated with 1-year risk of myocardial infarction or coronary artery bypass grafting. Conclusions Although new technologies may allow for treatment of complex disease in older and elderly patients with comorbid disease, the increased procedural risk remains substantial in these patients. After PCI, the long-term relative risk of death is similar to that expected among persons of similar ages in the general population.

关键词：年龄因素血管成形术经腔经皮冠状动脉/死亡率死亡原因冠心病/死亡率冠心病/病理学冠心病/治疗医院死亡率心肌梗死/死亡率心肌梗死/治疗登记统计数据血栓溶解疗法治疗结果老年人老年人 80以上女(雌)性人类男(雄)性

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Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction

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AMERICAN HEART JOURNAL 2003年第5期145卷 862-867页

作者： Goldenberg, I Matetzky, S Halkin, A Roth, A Di Segni, E Freimark, D Elian, D Agranat, O Zahav, YH Guetta, V Hod, H Chaim Sheba Med Ctr Inst Heart Cardiac Intens Care Unit IL-52621 Tel Hashomer Israel Soraski Med Ctr Inst Heart Tel Aviv Israel Tel Aviv Univ Sackler Fac Med IL-69978 Tel Aviv Israel

Background Prior studies have yielded conflicting data on the advantage of primary angioplasty compared with thrombolysis in elderly patients with acute myocardial infarction (AMI). These studies, however, were performed before the contemporary widespread use of intracoronary stents and glycoprotien IIb/IIIa antagonists. Methods we prospectively compared the outcome of 130 consecutive elderly patients (aged greater than or equal to70 years) with ST-elevation AMI who were admitted to 2 similar neighboring medical centers. Patients were assigned to receive either thrombolytic therapy with accelerated tissue-type plasminogen activator (center 1) or primary angioplasty with routine stenting (center II). Results Of the patients assigned to receive primary angioplasty, 91% underwent stenting. At 6 months, patients treated with primary angioplasty, compared with those treated with thrombolytic therapy, had a lower incidence of reinfarction (2% vs 14%, P = .053) and revascularization for recurrent ischemia (9% vs 61%, P < .001) and a significant reduction in the prespecified combined end point of death, reinfarction, or revascularization for recurrent ischemia (29% vs 93%, P < .01). Primary angioplasiy remained an independent predictor of the triple combined end point after controlling for potential covariables (relative risk 0.63, 95% Cl 0.38-0.84.). Major bleeding complications were also significantly reduced in the primary angioplasty group (0% vs 17%, P = .03). Conclusions Compared with thrombolysis, primary angioplasty with routine stenting in elderly patients with AM is associated with better clinical outcomes and a lower risk of bleeding complications.

关键词：血管成形术经腔经皮冠状动脉/死亡率用药计划表纤维蛋白溶解药/治疗应用出血/化学诱导医院死亡率以色列/流行病学 Logistic模型心肌梗死/药物疗法心肌梗死/死亡率心肌梗死/治疗心肌缺血/病因学前瞻性研究复发支架组织型纤溶酶原激活物/治疗应用治疗结果老年人女(雌)性人类男(雄)性

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Adjusting for patient differences in predicting hospital mortality for percutaneous coronary interventions in the Clinical Outcomes Assessment Program

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AMERICAN HEART JOURNAL 2003年第4期145卷 658-664页

作者： Maynard, C Goss, JR Malenka, DJ Reisman, M Dartmouth Hitchcock Med Ctr Hanover NH USA Dept Vet Affairs Puget Sound Healthcare Syst Swedish Hlth Serv Seattle WA USA Univ Washington Dept Med Seattle WA USA Univ Washington Dept Hlth Serv Seattle WA 98195 USA

Background The Clinical. Outcomes Assessment Program (COAP) is a coordinated quality improvement program for percutaneous coronary interventions (PCIs) performed in Washington State hospitals. This study describes the development and testing of models for predicting hospital mortality in patients undergoing PCI. Methods The COAP PCI database contains extensive demographic, medical history, and procedural information. This study included 19,358 consecutive PCIs performed in 27 Washington hospitals in 1999 and 2000. The study population was randomly assigned to development (n = 11,591) and test (n = 7614) sets. Logistic regression mortality models were run in the development set and evaluated in the test set. Result S The test and development sets were similar in demographic, medical history, and procedural characteristics. The overall hospital mortality rate was 1.6% and was similar in the test and development sets. By means of stepwise logistic regression analysis, cardiogenic shock, age, nonelective priority, elevated creatinine level, ejection fraction, number of diseased vessels, myocardial infarction <24 hours from admission, history of chronic obstructive pulmonary disease, male sex, history of peripheral vascular disease, history of PCI, and history of congestive heart failure were identified as predictors of hospital mortality. When applied to the test set, this model had excellent discrimination (c statistic = 0.87, 95% Cl 0.84-0.90). The model was also evaluated in the Northern New England PCI Registry, with very good results (c statistic 0.85). Conclusion Developing. risk-adjusted models of mortality and other outcomes is an essential part of the quality improvement process for cardiac revascularization procedures. Because of the rapidly changing nature of PCI, modification of these models in the years to come will be required.

关键词：血管成形术经腔经皮冠状动脉/死亡率血管成形术经腔经皮冠状动脉/标准冠心病/死亡率冠心病/治疗医院死亡率 Logistic模型结果评价(卫生保健)/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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Effect of fasting glucose levels on mortality rate in patients with and without diabetes mellitus and coronary artery disease undergoing percutaneous coronary intervention

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AMERICAN HEART JOURNAL 2003年第2期146卷 351-358页

作者： Muhlestein, JB Anderson, JL Horne, BD Lavasani, F Maycock, CAA Bair, TL Pearson, RR Carlquist, JF Latter Day St Hosp 8th Ave & C St Salt Lake City UT 84143 USA Univ Utah Salt Lake City UT USA

Background Diabetes mellitus (DM) is predictive of increased mortality for patients with coronary artery disease (CAD). To what extent this risk extends below the diabetic threshold (fasting glucose level [FG] < 126 mg/dL) is uncertain. Methods The study objective was to determine the risk associated with FG in a prospectively assembled cohort of 1612 patients with CAD who were undergoing percutaneous coronary intervention (PCI) and had a FG measured or a clinical diagnosis of DM (CDM). Patients were grouped as: CDM;no CDM, but FG >= 126 mg/dL (ADA-DM);impaired FG, 110-125 mg/dL (IFG);or normal FG, <110 mg/dL (NFG). Survival was assessed for 2.8 +/- 1.2 years. Results The average patient age was 62 +/- 12 years;74% of the patients were men. Diagnostic frequencies were: CDM, 24%;ADA-DM, 18%;IFG, 19%;and NFG, 39%. Mortality rates were greater for patients in the CDM (44/394 [11.2%], P <.0001), ADA-DM (27/283 [9.5%], P <.001), and IFG (20/305 [6.6%], P =.04) groups than patients in the NFG group(12/630 [1.9%]). Independent receiver operating characteristic analysis chose FG ! 109 mg/dL as the best cutoff for increased risk (sensitivity, 81%;specificity, 51%). After adjustment with Cox regression analysis, CDM (hazard ratio [HR] = 5.0;95% CI, 2.6-9.6;P <.001), ADA-DM (HR, 4.1;95% Cl, 2.1-8.2;P <.001), and IFG status (HR, 3.2;95% Cl, 1.5-6.5;P =.002) remained independent predictors of mortality. Conclusions Prognostically significant abnormalities of FG are much more prevalent (61%) than expected in patients with CAD who are undergoing PCI;Despite revascularization, the associated mortality risk of even mild elevations in FG is substantial, emphasizing the importance of early detection and treatment of glycemia-related risk.

关键词：血管成形术经腔经皮冠状动脉/死亡率血糖/代谢混杂因素(流行病学) 糖尿病并发症糖尿病/流行病学禁食随访研究多元分析试验预期值患病率比例危险度模型 ROC曲线危险因素敏感性与特异性存活率分析老年人女(雌)性人类男(雄)性中年人

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