1,722,250 research outputs found
Comparative Effectiveness and Safety of New-Generation Versus Early-Generation Drug-Eluting Stents According to Complexity of Coronary Artery Disease: A Patient-Level Pooled Analysis of 6,081 Patients.
No full textOBJECTIVES
The purpose of this study was to compare the 2-year safety and effectiveness of new- versus early-generation drug-eluting stents (DES) according to the severity of coronary artery disease (CAD) as assessed by the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score.
BACKGROUND
New-generation DES are considered the standard-of-care in patients with CAD undergoing percutaneous coronary intervention. However, there are few data investigating the effects of new- over early-generation DES according to the anatomic complexity of CAD.
METHODS
Patient-level data from 4 contemporary, all-comers trials were pooled. The primary device-oriented clinical endpoint was the composite of cardiac death, myocardial infarction, or ischemia-driven target-lesion revascularization (TLR). The principal effectiveness and safety endpoints were TLR and definite stent thrombosis (ST), respectively. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated at 2 years for overall comparisons, as well as stratified for patients with lower (SYNTAX score ≤11) and higher complexity (SYNTAX score >11).
RESULTS
A total of 6,081 patients were included in the study. New-generation DES (n = 4,554) compared with early-generation DES (n = 1,527) reduced the primary endpoint (HR: 0.75 [95% CI: 0.63 to 0.89]; p = 0.001) without interaction (p = 0.219) between patients with lower (HR: 0.86 [95% CI: 0.64 to 1.16]; p = 0.322) versus higher CAD complexity (HR: 0.68 [95% CI: 0.54 to 0.85]; p = 0.001). In patients with SYNTAX score >11, new-generation DES significantly reduced TLR (HR: 0.36 [95% CI: 0.26 to 0.51]; p 11 (HR: 0.45 [95% CI: 0.27 to 0.76]; p = 0.003) but not in patients with SYNTAX score ≤11 (pint = 0.042).
CONCLUSIONS
New-generation DES improve clinical outcomes compared with early-generation DES, with a greater safety and effectiveness in patients with SYNTAX score >11
Intracranial haemorrhage in patients with atrial fibrillation on anticoagulants
No full textAnticoagulants increase the risk of bleeding. Rarely, they become devastating instead of preventing thrombosis and embolism. Intracranial haemorrhagic complications in particular can be disabling or fatal. Careful monitoring of anticoagulation and treatment of risk factors are important to reduce the bleeding risk and, if haemorrhage occurs nonetheless, early recognition and management can be life-saving and reduce long-term sequelae. Controlling the intensity of anticoagulation, treatment of hypertension, avoiding concomitant use of other antithrombotic drugs, and observing drug–drug interactions minimize the bleeding risk of anticoagulants. In case of anticoagulation-related intracranial haemorrhage, immediate normalization of coagulation is the cornerstone of treatment in addition to general measures. Prothrombin complex concentrate serves as the best antidote against vitamin K antagonists, idarucizumab to reverse the effect of dabigatran, and andexanet alfa to antagonize the inhibition of factor Xa.</p
Comprehensive geriatric assessment in cardiovascular disease
No full textComprehensive geriatric assessment (CGA) is an efficient and effective way for evaluating complex elderly patients and for planning improved care based on CGA findings. Based on these findings, a plan for geriatric management is developed, usually involving a multidisciplinary team. CGA has been shown to improve functional status as well as survival, while reducing healthcare utilization and costs. Therefore, CGA should be systematically performed in the growing population of older patients with cardiovascular diseases.</p
Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention.
No full textFew data are available on the timing of adverse events in relation to the status of diabetes mellitus and the type of acute coronary syndrome (ACS). We investigated this issue in diabetic and nondiabetic patients admitted with a diagnosis of non-ST-segment elevation ACS (NSTE-ACS) or ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. Patient-level data from 6 studies (n = 16,601) were pooled and only patients with ACS are included (n = 9,492). Early (0 to 30 days), late (31 to 365 days), and overall (0 to 365 days) events were analyzed. Diabetes mellitus was present in 1,927 patients (20.3%). At 1 year, all-cause mortality was highest for diabetic patients with STEMI (13.4%), followed by diabetic patients with NSTE-ACS (10.3%), nondiabetic patients with STEMI (6.4%) and nondiabetic patients with NSTE-ACS (4.4%; p 10% in both STEMI and NSTE-ACS. Notwithstanding the high absolute rates, the temporal distribution of adverse events related to the type of ACS is similar between diabetic and nondiabetic patients
Treatment of acute stroke
No full textStroke is caused by a clot blocking a cerebral artery and leading to ischaemic damage or by haemorrhage destroying cerebral tissue. The goal of stroke treatment is recanalization of the blocked cerebral artery and reperfusion in order to salvage the tissue jeopardized by ischaemia. Clots blocking the internal carotid T or the main stem of the middle cerebral artery are large and usually cause moderate to severe neurological deficits. They can be removed quickly and safely with mechanical thrombectomy, with or without prior thrombolytics. Clots blocking peripheral branches are smaller, usually associated with minor or moderate neurological deficits, and can be dissolved with recombinant tissue plasminogen activator. Clots blocking the basilar artery can be treated with recombinant tissue plasminogen activator or removed mechanically, but there is equipoise regarding what approach results in better clinical outcomes. Treatment of acute cerebral haemorrhage is limited to blood pressure lowering when elevated, normalization of coagulation when abnormal, and surgery in selected patients. Stroke treatment is time critical. Time is brain, and therefore stroke is an emergency. Stroke treatment requires teamwork in stroke units or centres and should best be organized in regional stroke networks.</p
Percutaneous placement and removal of large diameter femoral artery sheaths with the prostar XL device
No full textINTRODUCTION For successful transcatheter aortic valve implantation (TAVI) as well as endovascular abdominal aneurysm repair (EVAR), and thoracic endovascular aneurysm repair (TEVAR), the insertion of large diameter arterial sheaths is necessary. Because of the necessary caliber of the sheaths, usually between 18 and 24 F (6-8 mm), the access is almost exclusively chosen via the femoraliliac arteries. In the past years we gradually changed our technique from a surgical cut-down to a percutaneous technique in all patients. The advantages of this less invasive technique are increased patient comfort immediately after the procedure and a diminished requirement for anesthetic drugs during and after the procedure. In most patients, the percutaneous technique of placement and removal of large diameter femoral arterial sheaths can be performed under local anesthesia only. In other words, the need for the presence of an anesthesiological team is dictated by the condition of the patient only and, to some extent, to the length of the procedure and not by the necessity to perform an open-surgical cut-down in the groin
Efficacy and Safety of Ticagrelor Monotherapy by Clinical Presentation: Pre-Specified Analysis of the GLOBAL LEADERS Trial.
Full text linkBackground The optimal duration of dual antiplatelet therapy after coronary drug-eluting stent placement in adults with stable coronary artery disease (SCAD) versus acute coronary syndromes (ACS) remains uncertain. Methods and Results This was a prespecified subgroup analysis of the GLOBAL LEADERS trial. Participants were randomly assigned 1:1 to the experimental or reference strategy, stratified by ACS (experimental, n=3750; reference, n=3737) versus SCAD (experimental, n=4230; reference, n=4251). The experimental strategy was 75 to 100 mg aspirin daily plus 90 mg ticagrelor twice daily for 1 month, followed by 23 months of ticagrelor monotherapy. The reference strategy was 75 to 100 mg aspirin daily plus either 75 mg clopidogrel daily (for SCAD) or 90 mg ticagrelor twice daily (for ACS) for 12 months, followed by aspirin monotherapy for 12 months. The primary end point at 2 years was a composite of all-cause mortality or non-fatal centrally adjudicated new Q-wave myocardial infarction. The key secondary safety end point was site-reported Bleeding Academic Research Consortium grade 3 or 5 bleeding. The primary end point occurred in 147 (3.92%) versus 169 (4.52%) patients with ACS (rate ratio [RR], 0.86; 95% CI, 0.69-1.08; P=0.189), and in 157 (3.71%) versus 180 (4.23%) patients with SCAD (RR, 0.87; 95% CI, 0.71-1.08; P=0.221) with experimental and reference strategy, respectively (P-interaction=0.926). Bleeding Academic Research Consortium grade 3 or 5 bleeding occurred in 73 (1.95%) versus 100 (2.68%) patients with ACS (RR, 0.73; 95% CI, 0.54-0.98; P=0.037), and in 90 (2.13%) versus 69 (1.62%) patients with SCAD (RR, 1.32; 95% CI, 0.97-1.81; P=0.081; P-interaction=0.007). Conclusions While there was no evidence for differences in efficacy between treatment strategies by subgroup, the experimental strategy appeared to reduce bleeding risk in patients with ACS but not in patients with SCAD. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435
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