scholarly journals MEDIATION ANALYSIS TO INFORM POLICY ON CORONARY REVASCULARIZATION BY EXPECTED TIME TO TREATMENT: ANALYTICAL FRAMEWORK

2022 ◽  
Author(s):  
Boris Sobolev ◽  
Lisa Kuramoto
Keyword(s):  
Mediation Analysis ◽  
Thought Experiment ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Analytical Framework ◽  
Total Effect ◽  
Treatment Recommendation ◽  
Stable Complex ◽  
Time To Treatment

Objectives Clinical guidelines favor coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for patients with stable complex coronary disease. Yet the benefit of CABG as established in trials may not be generalizable to populations in which treatment method determines time to treatment, typically being longer for CABG. For cases in which the cardiac anatomy is suitable for either treatment, it is unclear whether it is appropriate to recommend CABG, which is likely to be delayed, if PCI can be performed sooner. This paper outlines an analytical framework for a policy analysis of the timing of coronary revascularization. Methods We constructed a thought experiment to examine whether time to treatment will influence the advantage of CABG. We substantiated the use of mediation analysis to estimate the extent to which differences in outcomes between CABG and PCI would change if times to CABG were the same as times to PCI. Results We designed a study that uses data from a population-based patient registry to obtain effect measures of mediation analysis: the total effect, the natural indirect effect, and the natural direct effect. The partitioning of the total effect will allow us to estimate the proportional reduction in the risk of an outcome if the time to CABG was similar to that of PCI. Interpretation Treatment recommendation, resource allocation and scheduling benchmarks will be guided by understanding the extent to which the time to treatment mediates the relation between revascularization method and outcome.

scholarly journals Progenitor Cells for Arterial Repair: Incremental Advancements towards Therapeutic Reality

2017 ◽  
Vol 2017 ◽  
pp. 1-14 ◽  
Author(s):  
Trevor Simard ◽  
Richard G. Jung ◽  
Pouya Motazedian ◽  
Pietro Di Santo ◽  
F. Daniel Ramirez ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Progenitor Cells ◽  
Clinical Outcomes ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Obstructive Coronary Artery Disease ◽  
Bypass Graft ◽  
Coronary Intervention ◽  
Therapeutic Modality ◽  
Vascular Repair

Coronary revascularization remains the standard treatment for obstructive coronary artery disease and can be accomplished by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Considerable advances have rendered PCI the most common form of revascularization and improved clinical outcomes. However, numerous challenges to modern PCI remain, namely, in-stent restenosis and stent thrombosis, underscoring the importance of understanding the vessel wall response to injury to identify targets for intervention. Among recent promising discoveries, endothelial progenitor cells (EPCs) have garnered considerable interest given an increasing appreciation of their role in vascular homeostasis and their ability to promote vascular repair after stent placement. Circulating EPC numbers have been inversely correlated with cardiovascular risk, while administration of EPCs in humans has demonstrated improved clinical outcomes. Despite these encouraging results, however, advancing EPCs as a therapeutic modality has been hampered by a fundamental roadblock: what constitutes an EPC? We review current definitions and sources of EPCs as well as the proposed mechanisms of EPC-mediated vascular repair. Additionally, we discuss the current state of EPCs as therapeutic agents, focusing on endogenous augmentation and transplantation.

Clinical Outcomes after Hybrid Coronary Revascularization versus Off-Pump Coronary Artery Bypass

2009 ◽  
Vol 4 (6) ◽  
pp. 299-306 ◽  
Author(s):  
Thomas A. Vassiliades ◽  
Patrick D. Kilgo ◽  
John S. Douglas ◽  
Vasilis C. Babaliaros ◽  
Peter C. Block ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Left Internal Mammary Artery ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Off Pump ◽  
Internal Mammary ◽  
Hybrid Coronary Revascularization ◽  
Pump Coronary Artery Bypass ◽  
Hybrid Group

Objective Hybrid coronary revascularization is offered as an alternative strategy for patients with multivessel coronary artery disease (CAD). We present our experience and provide a comparative analysis to off-pump coronary artery bypass grafting (OPCAB). Methods Ninety-one patients with multivessel CAD underwent minimally invasive left internal mammary artery to left anterior descending grafting in combination with percutaneous coronary intervention of nonleft anterior descending targets (HYBRID). The primary end point of this study was major adverse cardiac and cerebrovascular events (MACCE), defined as death, stroke, and nonfatal myocardial infarction. MACCE in the HYBRID group were compared with 4175 contemporaneously performed OPCAB operations by logistic (30-day outcomes) and Cox proportional hazards (long-term survival) regression methods. Propensity scoring was used to adjust for potential selection bias. Results The 30-day MACCE (death/stroke/nonfatal myocardial infarction) rate was 1.1% for the HYBRID group (0%/0%/1.1%) and 3.0% for the OPCAB group (1.8%/1.1%/0.5%) (odds ratio = 0.47, P = 0.48). Angiographic left internal mammary artery evaluation was obtained in 95.6% of patients (87 of 91) revealing FitzGibbon A patency in 98.0% (96 of 98). The reintervention rate at 1 year for the HYBRID group was 5.5% (5 of 91) and was limited to repeat percutaneous coronary intervention. Three-year survival was statistically similar for the two groups (hazard ratio = 0.44, P = 0.18, see Kaplan-Meier figure). Conclusions Hybrid coronary revascularization may be noninferior to OPCAB with respect to early MACCE and 3-year survival in the treatment of multivessel CAD.

scholarly journals Mortality and Revascularization among Myocardial Infarction Patients with Schizophrenia: A Population-Based Cohort Study

2020 ◽  
Vol 65 (7) ◽  
pp. 454-462 ◽  
Author(s):  
Tanya S. Hauck ◽  
Ning Liu ◽  
Harindra C. Wijeysundera ◽  
Paul Kurdyak
Keyword(s):  
Myocardial Infarction ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Coronary Intervention ◽  
Population Based ◽  
Geographic Region ◽  
Time Varying ◽  
The Impact ◽  
The Relationship

Background: Cardiovascular disease is a major source of mortality in schizophrenia, and access to care after acute myocardial infarction (AMI) is poor for these patients. Aims: To understand the relationship between schizophrenia and access to coronary revascularization and the impact of revascularization on mortality among individuals with schizophrenia and AMI. Method: This study used a retrospective cohort of AMI in Ontario between 2008 and 2015. The exposure was a diagnosis of schizophrenia, and patients were followed 1 year after AMI discharge. The primary outcome was all-cause mortality within 1 year. Secondary outcomes were cardiac catheterization and revascularization (percutaneous coronary intervention or coronary artery bypass graft). Cox proportional hazard regression models were used to study the relationship between schizophrenia and mortality, and the time-varying effect of revascularization. Results: A total of 108,610 cases of incident AMI were identified, among whom 1,145 (1.1%) had schizophrenia. Schizophrenia patients had increased mortality, with a hazard ratio (HR) of 1.55 (95% CI, 1.37 to 1.77) when adjusted for age, sex, income, rurality, geographic region, and comorbidity. After adjusting for time-varying revascularization, the HR reduced to 1.38 (95% CI, 1.20 to 1.58). The impact of revascularization on mortality was similar among those with and without schizophrenia (HR: 0.42; 95% CI, 0.41 to 0.44 vs. HR: 0.40; 95% CI, 0.26 to 0.61). Conclusions: In this sample of AMI, mortality in schizophrenia is increased, and treatment with revascularization reduces the HR of schizophrenia. The higher mortality rate yet similar survival benefit of revascularization among individuals with schizophrenia relative to those without suggests that increasing access to revascularization may reduce the elevated mortality observed in individuals with schizophrenia.

scholarly journals Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization

JAMA ◽  
2021 ◽  
Vol 325 (19) ◽  
pp. 1955
Author(s):  
Elizabeth L. Whitlock ◽  
L. Grisell Diaz-Ramirez ◽  
Alexander K. Smith ◽  
W. John Boscardin ◽  
Kenneth E. Covinsky ◽  
...  
Keyword(s):  
Older Adults ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Bypass Grafting ◽  
Memory Decline ◽  
Percutaneous Coronary ◽  
With Memory

Abstract 130: Revascularization Rates Have Decreased for Commercially-Insured Adults in Michigan, 2006-2010

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Ji Y Song ◽  
Erin Schlemmer ◽  
Elizabeth A Wasilevich
Keyword(s):  
Primary Care Physicians ◽  
Claims Data ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Rank Correlation ◽  
Coronary Intervention ◽  
Administrative Claims ◽  
Medicare Population ◽  
Spearman’S Rank Correlation

Introduction: Recently published trend studies of Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in the U.S. have used primarily Medicare data, and most focus on inpatient claims. These studies have observed a decrease in CABG, with steady or declining PCI from 2001-2009. Little is known about trends in revascularization among a non-Medicare population. This study aims to understand recent trends in rates of coronary revascularization among a commercially-insured non-Medicare population, using both inpatient and outpatient claims data. The study will describe potential areas of focus for an incentive program to engage primary care physicians (PCPs) and cardiologists. Methods: The study population (median 1,920,169 persons/month) included members of Blue Cross Blue Shield of Michigan aged 18-64 and residing in Michigan. Using inpatient and outpatient administrative claims data, monthly crude and sex- and age-adjusted PCI and CABG utilization rates (per 1,000 member-months) were calculated from January 1, 2006 to December 31, 2010. Trend was assessed using Spearman's Rank Correlation test. The Wilcoxon Rank Sum test was used to compare the median age for those receiving PCI and CABG services. The Pearson Chi-Square test was used to assess differences in the distribution of demographic factors by procedure type and by year (2006 vs. 2010). Results: The overall annual crude rate of PCI decreased by 23.5% over the study period, from 0.319 in 2006 to 0.244 in 2010; there was a greater decrease for women than men (25.2% vs 21.4%). Annual CABG rates decreased by 30.7%, from 0.077 in 2006 to 0.053 in 2010 (women: 31.1%; men: 29.1%). Compared to men, PCI accounted for a higher proportion of revascularization procedures among women (82.1% vs 79.0%, p <0.01). The median age for those having a PCI was lower than for those having a CABG (57 vs. 59 years; p <0.01). There was a significant association between type of revascularization and age group ( p <0.01). The majority of procedures were performed in older adults aged 55-64 (CABG: 72.3%, PCI: 62.9%). Conclusions: Both PCI and CABG rates have decreased from 2006 to 2010 for a commercially-insured population in Michigan. Persons receiving CABG were generally older than those receiving PCI. Future studies will examine time trends by type of PCI and explore potential factors contributing to the observed decrease in revascularization rates. The current findings may be used to encourage increased discussions between PCPs and cardiologists about the care of shared patients.

Hybrid coronary revascularization

2021 ◽  
pp. 359-362
Author(s):  
Michael O. Kayatta ◽  
Henry A. Liberman ◽  
Michael E. Halkos
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Coronary Artery Bypass Grafting ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Bypass Grafting ◽  
Artery Bypass Grafting ◽  
Percutaneous Coronary ◽  
Hybrid Coronary Revascularization

Traditionally, the treatment of coronary artery disease has been divided among medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting. However, with hybrid coronary revascularization (HCR), both percutaneous coronary intervention and coronary artery bypass grafting are utilized to treat different lesions in the same patient; the goal being to take advantage of the benefits of each procedure while minimizing their limitations. This chapter will discuss the advantages and disadvantages of hybrid coronary revascularization, patient selection, and the various techniques and strategies used in successful hybrid coronary revascularization programmes.

Abstract P111: Revascularization in Perioperative Myocardial Infarction After High Risk Surgery is Associated With Reduced Mortality

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
Joshua Cohen ◽  
John Kao ◽  
Mladen I Vidovich
Keyword(s):  
Myocardial Infarction ◽  
High Risk ◽  
Hospital Mortality ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Perioperative Myocardial Infarction ◽  
Chi Square ◽  
Abdominal Aortic ◽  
Chi Square Test

Background: The incidence of perioperative myocardial infarction (PMI) is 5-35% after high-risk vascular surgeries, and increases mortality. We sought to determine the incidence of PMI after abdominal aortic aneurysm (AAA) and lower extremity revascularization (LE) procedures in current practice and describe the potential benefit of coronary revascularization. Methods: We analyzed the Nationwide Inpatient Sample from 1998 - 2006. Adult records were selected for indicating AAA and LE procedures. This group was queried for acute myocardial infarction and either percutaneous coronary intervention or coronary artery bypass grafting. In-hospital mortality was determined. We compared categorical data using the Chi-square test. Results: The incidence of PMI was 2.4% (6755/269100) overall, in-hospital mortality increased with PMI. Revascularization was associated with decreased mortality. Conclusion: In contemporary US practice, PMI appears to be under-diagnosed in this sample compared to previous prospective studies, and continues to be associated with increased in-hospital mortality. The utilization of coronary revascularization was associated with decreased mortality. Due to the retrospective nature of this study, causation cannot be determined.

Phẫu thuật cầu nối chủ vành ở bệnh nhân có tiền sử can thiệp mạch vành qua da tại Bệnh viện Trung ương Huế

2021 ◽  
Author(s):  
An Vinh Bui Duc
Keyword(s):  
Risk Factors ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Coronary Artery Bypass ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Bypass Grafting ◽  
Cabg Surgery ◽  
Percutaneous Coronary

TÓM TẮT Đặt vấn đề: Can thiệp mạch vành qua da là lựa chọn điều trị đối với bệnh lý động mạch vành trong những trường hợp hẹp một hoặc hai nhánh động mạch vành, hội chứng vành cấp. Số lượng các trường hợp can thiệp mạch gia tăng dẫn đến ngày càng có nhiều bệnh nhân nhập viện phẫu thuật bắc cầu chủ vành đã có tiền sử can thiệp mạch vành. Nghiên cứu này nhằm mục tiêu 1) nhận diện các yếu tố nguy cơ phẫu thuật của các bệnh nhân có chỉ định tái tưới máu vào viện với tiền sử can thiệp mạch vành trước đó và 2) đánh giá kết quả phẫu thuật bắc cầu chủ vành ở nhóm bệnh nhân này. Đối tượng, phương pháp: Bệnh nhân có tiền sử can thiệp mạch vành qua da được phẫu thuật chương trình bắc cầu chủ vành tại Bệnh viện Trung Ương Huế. Nghiên cứu hồi cứu, mô tả. Kết quả: Trong giai đoạn từ 1/2012 - 1/2017, có 16 bệnh nhân được phẫu thuật. Tuổi trung bình là 64,6 ± 8,2, trung bình BMI - 24,7 ± 1,8, thời gian phẫu thuật sau can thiệp qua da trung bình 2 năm. Các yếu tố nguy cơ bao gồm: tăng huyết áp 87,5%, đái tháo đường 81,3%, rối loạn lipid máu 68,8%, hút thuốc lá 62,5%. Tất cả các bệnh nhân đều có triệu chứng của đau thắt ngực ổn định với 62,5% xếp loại CCS IV. Thời gian tuần hoàn ngoài cơ thể trung bình 125,3 ± 19,5 phút trong đó 37,5% không sử dụng tuần hoàn ngoài cơ thể. Phẫu thuật bắc cầu chủ vành ở nhiều vị trí chiếm đa số 87,5%. Quá trình hậu phẫu ghi nhận các biến chứng: chảy máu (43,8%), rung nhĩ (12,5%), tai biến mạch máu não (6,25%). 1 trường hợp đặt bóng đối xung trong thời gian hậu phẫu. Thời gian nằm viện trung bình 27,4 ± 8,5 ngày. Không ghi nhận tử vong trong quá trình nằm viện và sau 6 tháng theo dõi. Kết luận: Các yếu tố nguy cơ ảnh hưởng đến kết quả phẫu thuật đối với bệnh nhân có chỉ định tái tưới máu vào viện có tiền sử can thiệp mạch vành gồm hút thuốc lá, tăng huyết áp, đái tháo đường, thời gian phẫu thuật sau can thiệp mạch vành, số lượng mạch vành đã can thiệp, số mạch vành cần tái tưới máu và phân suất tống máu thất trái. Phẫu thuật bắc cầu chủ vành là phương pháp điều trị đem lại kết quả tốt ở các bệnh nhân này trong ngắn hạn. Từ khóa: Can thiệp mạch vành qua da, bắc cầu chủ vành, tái tưới máu ABSTRACT CORONARY ARTERY BYPASS GRAFTING AMONG PATIENTS WITH PRIOR PERCUTANEOUS CORONARY INTERVENTION AT HUE CENTRAL HOSPITAL Background: Percutaneous coronary intervention (PCI) is the preferred treatment modality for single and double vessel coronary artery disease and in the setting of acute coronary syndrome. The rising volume of PCI is directly proportional to the representation of patients hospitalized for coronary artery bypass graft (CABG) surgery who have a history of previous PCI procedures. This study aims to 1) identify the risk factors in patients requiring revascularization with prior PCI and 2) evaluate the surgical outcomes. Materials and method: This is a retrospective case series of patients with prior PCI undergoing elective CABG surgery at Hue Central Hospital. Results: From January 2012 and January 2017, 16 patients operated. The mean age was 64.6 ± 8.2. Mean Body Mass Index was 24.7 ± 1.8. The PCI and CABG gap was 2 years. Coronary risk factors including hypertension (87.5%), diabetes mellitus (81.3%), dyslipidemia (68.8%) and smoke (62.5%). All patients presented stable angina with 62.5% CCS class IV. Mean cardiopulmonary bypass time was 125.3 ± 19.5 minutes, 37.5% off - pump coronary surgery. Multi - bypass bypass grafting was performed in 87.5%. Surgical complications were recognized, including 43.8% bleeding, 12.5% atrial fibrillation, and 6.25% stroke. A case required an intra - aortic balloon pump during the postoperative period. Mean hospital stay was 27.4 ± 8.5 days. There was no mortality during hospitalization and 6 - month follow - up. Conclusion: Risk factors for surgical outcome in patients requiring coronary revascularization with prior PCI include diabetes mellitus, smoking, hypertension, time of CABG surgery after PCI, previously intervened vessels, coronary revascularization strategies, and left ventricular ejection fraction. CABG is an appropriate modality for reperfusion in these patients with positive early outcomes. Keywords: Percutaneous coronary intervention, coronary artery bypass grafting, revascularization.

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