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Circulation Jan 2022The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery... (Review)
Review
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
AIM
The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.
METHODS
A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
Topics: American Heart Association; Cardiology; Coronary Artery Bypass; Coronary Artery Disease; Coronary Vessels; Humans; Myocardial Revascularization; Percutaneous Coronary Intervention; United States; Vascular Surgical Procedures
PubMed: 34882436
DOI: 10.1161/CIR.0000000000001039 -
Journal of the American Heart... Mar 2023Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for... (Review)
Review
Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for revascularization in patients with ICM and the role of ischemia and viability detection in guiding treatment. Methods and Results We searched for randomized controlled trials evaluating the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. Out of 1397 publications, 4 randomized controlled trials were included, enrolling 2480 patients. Three trials (HEART [Heart Failure Revascularisation Trial], STICH [Surgical Treatment for Ischemic Heart Failure], and REVIVED [REVascularization for Ischemic VEntricular Dysfunction]-BCIS2) randomized patients to revascularization or optimal medical therapy. HEART was stopped prematurely without showing any significant difference between treatment strategies. STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow-up of 9.8 years. However, neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes. REVIVED-BCIS2 showed no difference in the primary end point between percutaneous revascularization or optimal medical therapy. PARR-2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging-guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623). No difference in survival was revealed according to adherence or no adherence to viability imaging. Conclusions In ICM, the largest randomized controlled trial, STICH, suggests that revascularization improves patients' prognosis at long-term follow-up, whereas evidence supports no benefit of percutaneous coronary intervention. Data from randomized controlled trials do not support myocardial ischemia or viability testing for treatment guidance. We propose an algorithm for the workup of patients with ICM considering clinical presentation, imaging results, and surgical risk.
Topics: Humans; Tomography, X-Ray Computed; Myocardial Ischemia; Myocardial Revascularization; Heart Failure; Cardiomyopathies; Ischemia; Ventricular Dysfunction, Left
PubMed: 36892041
DOI: 10.1161/JAHA.122.026943 -
Circulation May 2021Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes... (Review)
Review
Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association.
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
Topics: American Heart Association; Female; Humans; Male; Nervous System Diseases; Perioperative Period; Postoperative Complications; Risk Factors; Stroke; United States
PubMed: 33827230
DOI: 10.1161/CIR.0000000000000968 -
RoFo : Fortschritte Auf Dem Gebiete Der... Apr 2020Acute limb ischemia represents a clinical emergency with eventual limb loss and life-threatening consequences. It is characterized by a sudden decrease in limb... (Review)
Review
BACKGROUND
Acute limb ischemia represents a clinical emergency with eventual limb loss and life-threatening consequences. It is characterized by a sudden decrease in limb perfusion. Acute ischemia is defined as a duration of symptoms for less than 14 days. Aging of the population increases the prevalence of acute limb ischemia. The two principal etiologies are arterial embolism and in situ thrombosis of an atherosclerotic artery. Immediate diagnosis, accurate assessment and urgent intervention when needed are crucial to save the limb and to prevent a major amputation. Delay in diagnosis and therapy may lead to irreversible ischemic damage.
METHOD
To assess the current treatment options in acute limb ischemia, this review is based on a selective literature search in PubMed representing the current state of research.
RESULTS AND CONCLUSION
Patients with acute limb ischemia should receive immediate anticoagulation. Treatment depends on the classification based on the degree of ischemia and limb viability. Especially acute (< 14 days symptom duration) Rutherford Categories IIa and IIb with marginally and immediately threatened limbs require definitive therapeutic intervention and are salvageable, if promptly revascularized. The current literature suggests that open surgical revascularization is more time effective then catheter-directed thrombolysis. However, with the advent of thrombolytic delivery systems and mechanical thrombectomy devices, treatment time can be minimized and successful utilization in patients with Category IIb (Rutherford Classification for Acute Limb Ischemia) has been reported with promising limb-salvage and survival rates. Large randomized studies are still missing, and guidelines suggest choosing the method of revascularization depending on anatomic location, etiology, and local practice patterns, with the time to restore the blood flow being an important factor to consider.
KEY POINTS
· Acute limb ischemia is an interdisciplinary emergency. It can lead to limb loss with life-threatening consequences.. · Immediate diagnosis and treatment are crucial to prevent irreversible damage.. · An endovascular approach should be considered in acute limb ischemia Category IIa and IIb of the Rutherford Classification for Acute Limb Ischemia (< 14 days), on a case-based decision and local capabilities. Especially elderly, multimorbid patients with high perioperative risk (may probably) benefit from these minimally invasive procedures..
CITATION FORMAT
· Fluck F, Augustin A, Bley T et al. Current Treatment Options in Acute Limb Ischemia. Fortschr Röntgenstr 2020; 192: 319 - 326.
Topics: Acute Disease; Amputation, Surgical; Anticoagulants; Extremities; Humans; Ischemia; Limb Salvage; Regional Blood Flow; Thrombolytic Therapy
PubMed: 31461761
DOI: 10.1055/a-0998-4204 -
Neurology India 2022
Topics: Carotid Stenosis; Cerebral Revascularization; Endarterectomy, Carotid; Humans; Stents; Stroke; Treatment Outcome; Vascular Surgical Procedures
PubMed: 35263845
DOI: 10.4103/0028-3886.338738 -
The Journals of Gerontology. Series A,... Jul 2021Little is known on the incidence and postoperative outcomes of revascularizations according to electivity in persons with Alzheimer's disease (AD).
BACKGROUND
Little is known on the incidence and postoperative outcomes of revascularizations according to electivity in persons with Alzheimer's disease (AD).
METHODS
The Medication Use and Alzheimer's disease (MEDALZ) cohort includes 70 718 community dwellers diagnosed with incident AD during 2005-2011 in Finland. For each person with AD, 1-4 age-, sex-, and hospital district-matched comparison persons without AD were identified. Altogether 448 persons with AD and 5909 without AD underwent revascularization during the follow-up. The outcomes were 30-day and 90-day re-admission rate after discharge, and all-cause 1-year and 3-year mortality. Risk of outcomes in persons with AD were compared to those without AD using Cox proportional hazard models adjusted with age, sex, comorbidities, statin use, revascularization type, length of stay, and support at discharge.
RESULT
People with AD had less revascularizations (adjusted hazard ratio 0.24, 95% confidence interval 0.22-0.27). Emergency procedures were more common (42.6% vs 33.1%) than elective procedures (34.2% vs 48.6%) among people with AD. There was no difference in 30-day readmissions (0.97, 0.80-1.17) or 1-year mortality (1.04, 0.75-1.42) and 90 days readmission risk was lower in persons with AD (0.85, 0.74-0.98). People with AD had higher 3-year mortality (1.42, 1.15-1.74), but the risk increase was observed only for emergency (1.71, 1.27-2.31), not for elective procedures (0.96, 0.63-1.46).
CONCLUSION
People with AD did not have worse readmission and mortality outcomes following elective revascularization. These findings in conjunction with lower revascularization rate especially for elective procedures raise questions on the threshold for elective procedures in people with AD.
Topics: Aged; Alzheimer Disease; Comorbidity; Coronary Disease; Elective Surgical Procedures; Emergency Treatment; Female; Finland; Humans; Independent Living; Male; Myocardial Revascularization; Outcome Assessment, Health Care; Patient Readmission; Risk Assessment; Survival Analysis
PubMed: 33420783
DOI: 10.1093/gerona/glab006 -
VASA. Zeitschrift Fur Gefasskrankheiten May 2022Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid... (Review)
Review
Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid revascularization, but the impact of carotid angioplasty stenting (CAS) or carotid endarterectomy (CEA) on cognitive functions remains unclear. The aim of this systematic review was to realize a report on the actual state of results about asymptomatic carotid stenosis revascularization and cognitive function. We performed a systematic literature review to analyze all studies assessing the impact of asymptomatic carotid stenosis revascularizations on cognitive functions. We reviewed all publications published in Medline database and Cochrane between January 2010 and January 2020 including subjects with a cognitive evaluation and receiving carotid revascularization for asymptomatic stenosis. We identified 567 records for review, and finally we included in the systematic review 20 studies about ACS revascularization and cognitive functions. Only observational studies analyzed the impact of CEA and CAS on cognitive functions. Thus, too heterogeneous data associated to the lack of randomized controlled trials with an evaluation of optimal medical treatment did not enable to affirm the interest of the revascularization management of ACS in cognitive domain. There was a lack of standardization and finally studies were too heterogeneous to conclude on the impact of carotid revascularization on cognitive functions. There is an urgent need to harmonize research in this domain in order to prevent and treat cognitive dysfunction related to ACS, especially in our society with an aging population.
Topics: Aged; Angioplasty; Asymptomatic Diseases; Carotid Stenosis; Cognition; Constriction, Pathologic; Endarterectomy, Carotid; Humans; Stents; Stroke; Treatment Outcome
PubMed: 35306881
DOI: 10.1024/0301-1526/a000996 -
Journal of the American College of... Nov 2022In the multicenter, randomized, sham-controlled FAVOR (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients with... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
In the multicenter, randomized, sham-controlled FAVOR (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients with Coronary Artery Disease) III China trial, quantitative flow ratio (QFR)-based lesion selection improved 1-year clinical outcomes compared with conventional angiographic guidance for percutaneous coronary intervention (PCI).
OBJECTIVES
The purpose of this study was to determine whether the benefits of QFR guidance persist at 2 years, particularly for patients in whom QFR changed the revascularization strategy.
METHODS
Eligible patients were randomized to a QFR-guided strategy (PCI performed only if QFR ≤0.80) or a standard angiography-guided strategy. Major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), or ischemia-driven revascularization occurring within 2 years were analyzed in the intention-to-treat population.
RESULTS
Among 3,825 randomized participants, 2-year MACE occurred in 161 of 1,913 (8.5%) patients in the QFR-guided group and in 237 of 1,912 (12.5%) patients in the angiography-guided group (HR: 0.66; 95% CI: 0.54-0.81; P < 0.0001), driven by fewer MIs (4.0% vs 6.8%; HR: 0.58; 95% CI: 0.44-0.77; P = 0.0002) and ischemia-driven revascularizations (4.2% vs 5.8%; HR: 0.71; 95% CI: 0.53-0.95; P = 0.02) in the QFR-guided group. Landmark analysis showed consistent results within the first year and between 1-2 years (P = 0.99). Although the 2-year MACE rate was lower in the QFR-guided group in both patients with and without revascularization strategy changes, the extent of outcome improvement was greater (P = 0.009) among those patients in whom the preplanned PCI strategy was modified by QFR.
CONCLUSIONS
QFR-guided lesion selection improved 2-year clinical outcomes compared with standard angiography guidance. The benefits were most pronounced among patients in whom QFR assessment altered the planned revascularization strategy. (FAVOR III China Study [The Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients with Coronary Artery Disease] NCT03656848).
Topics: Humans; Coronary Artery Disease; Percutaneous Coronary Intervention; Heart; Angiography; Myocardial Infarction
PubMed: 36424680
DOI: 10.1016/j.jacc.2022.09.007 -
Current Cardiology Reviews 2022The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent... (Review)
Review
The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent technology coupled with the increasing utility of physiology and imaging guidance for procedures have led to an evolving role of percutaneous coronary intervention in left main disease of low and intermediate anatomical complexity. This revascularization modality carries the clear advantage of being less invasive and significantly reduced recovery times. This practice is currently supported by international guidelines, however, it remains a controversial topic in the field of interventional cardiology, and the long-term outcomes of a percutaneous strategy have been questioned. This review describes the current evidence base for the assessment and choice of intervention in left main coronary artery disease. The percutaneous revascularization techniques and use of imaging to optimize procedures and improve clinical outcomes have been discussed.
Topics: Coronary Artery Bypass; Coronary Artery Disease; Drug-Eluting Stents; Humans; Percutaneous Coronary Intervention; Treatment Outcome
PubMed: 34139985
DOI: 10.2174/1573403X17666210617094735 -
Journal of the American College of... Dec 2019Repeat revascularization is a commonly used outcome measure in trials comparing percutaneous coronary intervention and coronary artery bypass graft surgery, and... (Review)
Review
Repeat revascularization is a commonly used outcome measure in trials comparing percutaneous coronary intervention and coronary artery bypass graft surgery, and differences in this outcome often drive the relative risk for the primary endpoint. However, repeat revascularization as an outcome measure has important limitations that complicates its meaningful interpretation, including confounding by indication (driven by varying use of stress testing and thresholds for invasive angiography), differential likelihood of revascularization after graft versus stent failure, uncertainty of the prognostic impact of repeat revascularization, and patient preferences and appraisal of the import of repeat revascularization. Knowledge of these issues will result in better appreciation of the utility of repeat revascularization as a clinically meaningful outcome measure. The authors describe these issues and provide recommendations for the use and assessment of repeat revascularization as an endpoint when comparing different revascularization modalities.
Topics: Confounding Factors, Epidemiologic; Coronary Artery Bypass; Humans; Outcome Assessment, Health Care; Percutaneous Coronary Intervention; Reoperation
PubMed: 31856974
DOI: 10.1016/j.jacc.2019.10.041