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The effect of clinical coronary disease severity on outcomes of carotid endarterectomy with and without combined coronary bypass.

临床冠状动脉疾病严重程度对颈动脉内膜剥脱术伴或不伴冠状动脉旁路移植术结局的影响。

  • 影响因子:2.50
  • DOI:10.1016/j.jvs.2019.03.074
  • 作者列表:"Wang LJ","Mohebali J","Goodney PP","Patel VI","Conrad MF","Eagleton MJ","Clouse WD
  • 发表时间:2020-02-01
Abstract

OBJECTIVE:The management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB). METHODS:Using the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort. RESULTS:There were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P < .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not. CONCLUSIONS:In patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.

摘要

目的: 颈动脉狭窄伴症状性冠状动脉疾病 (CAD) 患者的治疗具有挑战性。本研究评估了临床冠状动脉疾病严重程度对颈动脉内膜切除术 (CEA) 伴或不伴冠状动脉旁路移植术 (CCAB) 的影响。 方法: 使用血管质量倡议,对 2003年至 2017年接受 CCAB 或孤立性 CEA (ICEA) 的症状性 CAD 患者进行鉴定。根据 CAD 严重程度对患者进行分层: 稳定型心绞痛 (SA) 和近期心肌梗死/不稳定型心绞痛 (UA)。主要结局,包括围手术期卒中、心肌梗死 (MI) 和卒中/死亡/MI (SDM),在每个 CAD 队列内的手术之间进行评估。 结果: 确定了 9098 例患者: 887 例 CCAB 患者 (215 [24%] SA,672 [76%] UA) 和 8211 例 ICEA 患者 (6385 [78%] SA, 1826 [22%] UA)。总体而言,CCAB 患者卒中发生率较高 (2.6% vs 1.3%; P =. 002) 和 SDM (7.3% vs 3.5%,P

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发表时间:2020-01-01
DOI:10.1055/s-0039-1700546
作者列表:["Tavenier AH","Hermanides RS","Fabris E","Lapostolle F","Silvain J","Ten Berg JM","Lassen JF","Bolognese L","Cantor WJ","Cequier Á","Chettibi M","Goodman SG","Hammett CJ","Huber K","Janzon M","Merkely B","Storey RF","Zeymer U","Ecollan P","Collet JP","Willems FF","Diallo A","Vicaut E","Hamm CW","Montalescot G","van 't Hof AWJ","ATLANTIC investigators."]

METHODS:BACKGROUND: Glycoprotein IIb/IIIa inhibitors (GPIs) in combination with clopidogrel improve clinical outcome in ST-elevation myocardial infarction (STEMI); however, finding a balance that minimizes both thrombotic and bleeding risk remains fundamental. The efficacy and safety of GPI in addition to ticagrelor, a more potent P2Y12-inhibitor, have not been fully investigated. METHODS: 1,630 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were analyzed in this subanalysis of the ATLANTIC trial. Patients were divided in three groups: no GPI, GPI administration routinely before primary PCI, and GPI administration in bailout situations. The primary efficacy outcome was a composite of death, myocardial infarction, urgent target revascularization, and definite stent thrombosis at 30 days. The safety outcome was non-coronary artery bypass graft (CABG)-related PLATO major bleeding at 30 days. RESULTS: Compared with no GPI (n = 930), routine GPI (n = 525) or bailout GPI (n = 175) was not associated with an improved primary efficacy outcome (4.2% no GPI vs. 4.0% routine GPI vs. 6.9% bailout GPI; p = 0.58). After multivariate analysis, the use of GPI in bailout situations was associated with a higher incidence of non-CABG-related bleeding compared with no GPI (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.32-6.64; p = 0.03). However, routine GPI use compared with no GPI was not associated with a significant increase in bleeding (OR 1.78, 95% CI 0.88-3.61; p = 0.92). CONCLUSION: Use of GPIs in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome. A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation.

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影响因子:1.21
发表时间:2020-01-01
DOI:10.1097/MCA.0000000000000737
作者列表:["Huang X","Chen S","Redfors B","Zhang Y","Souza CF","Mehran R","Bansilal S","Kirtane AJ","Brener SJ","Feite F","Dangas GD","Ben-Yehuda O","Stone GW"]

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影响因子:2.86
发表时间:2020-01-01
DOI:10.1016/j.amjcard.2019.09.045
作者列表:["Ravi V","Pulipati P","Vij A","Kodumuri V"]

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