Evaluation in vivo of the endothelial function of the native gastroepiploic artery (original) (raw)
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The Annals of thoracic surgery, 2016
Recent large randomized trials and metaanalyses have shown that, for patients with diabetes mellitus and advanced coronary artery disease, coronary artery bypass graft surgery (CABG) was superior to percutaneous intervention. We investigated whether total arterial revascularization (TAR) conferred an additional survival advantage for diabetic patients having CABG. We reviewed 63,592 cases from an audited, collaborative Australian cardiac surgical database. A total of 34,181 patients undergoing first time isolated CABG from 2001 to 2012 were identified. Of the 34,181, 11,642 (34.1%) were diabetic patients, and TAR was performed in 12,271 of 34,181 (35.9%). Of the 11,642 diabetic patients, TAR was performed in 3,795 (32.6%) and non-TAR in 7,847 (67.4%). Propensity matching resulted in 6,232 matched pairs of patients who did and patients who did not have TAR. Data were linked to the National Death Index. In the propensity matched sample, of 6,232 diabetic patients, 2,017 (32.4%) underw...
Background-The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial in 2368 patients with stable ischemic heart disease assigned before randomization to percutaneous coronary intervention or coronary artery bypass grafting strata reported similar 5-year all-cause mortality rates with insulin sensitization versus insulin provision therapy and with a strategy of prompt initial coronary revascularization and intensive medical therapy or intensive medical therapy alone with revascularization reserved for clinical indication(s). In this report, we examine the predefined secondary end points of cardiac death and myocardial infarction (MI). Methods and Results-Outcome data were analyzed by intention to treat; the Kaplan-Meier method was used to assess 5-year event rates. Nominal P values are presented. During an average 5.3-year follow-up, there were 316 deaths (43% were attributed to cardiac causes) and 279 first MI events. Five-year cardiac mortality did not differ between revascularization plus intensive medical therapy (5.9%) and intensive medical therapy alone groups (5.7%; Pϭ0.38) or between insulin sensitization (5.7%) and insulin provision therapy (6%; Pϭ0.76). In the coronary artery bypass grafting stratum (nϭ763), MI events were significantly less frequent in revascularization plus intensive medical therapy versus intensive medical therapy alone groups (10.0% versus 17.6%; Pϭ0.003), and the composite end points of all-cause death or MI (21.1% versus 29.2%; Pϭ0.010) and cardiac death or MI (Pϭ0.03) were also less frequent. Reduction in MI (Pϭ0.001) and cardiac death/MI (Pϭ0.002) was significant only in the insulin sensitization group. Conclusions-In many patients with type 2 diabetes mellitus and stable ischemic coronary disease in whom angina symptoms are controlled, similar to those enrolled in the percutaneous coronary intervention stratum, intensive medical therapy alone should be the first-line strategy. In patients with more extensive coronary disease, similar to those enrolled in the coronary artery bypass grafting stratum, prompt coronary artery bypass grafting, in the absence of contraindications, intensive medical therapy, and an insulin sensitization strategy appears to be a preferred therapeutic strategy to reduce the incidence of MI. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.
2024
Background Coronary artery disease (CAD) significantly contributes to morbidity and mortality globally, particularly in individuals with diabetes mellitus, who are at a heightened risk for cardiovascular complications. The complexity of coronary lesions and diffuse atherosclerosis in diabetic patients presents challenges in their treatment and prognosis. Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are primary revascularization strategies for managing multi-vessel CAD in diabetic patients. Despite advancements in both techniques, their relative efficacy and safety remain debated, especially in the diabetic population. Objective This multicenter study aims to compare the long-term outcomes of CABG and PCI in diabetic patients with multi-vessel CAD. The primary endpoints include overall survival and the incidence of major adverse cardiac events (MACE). Secondary endpoints encompass revascularization success and procedural complication rates.
The American Journal of Cardiology, 2012
Clinical outcomes in patients with diabetes mellitus and multivessel disease (MVD) undergoing coronary revascularization have not been extensively evaluated, we sought to examine outcomes in a diabetic cohort of 195 consecutive patients with MVD characterized by SYNTAX scores (SSs) undergoing nonrandomized revascularization, 102 (52%) by percutaneous intervention (PCI) and 93 (48%) by coronary artery bypass grafting (CABG) at Liverpool Hospital (Sydney, Australia) from June 2006 to March 2010. Clinical outcomes were assessed at a median term of 14 months. The overall median SS was 44, with significantly higher SSs in CABG-than PCI-treated patients (48 vs 39, p <0.0001). There was a similar incidence of all-cause death, nonfatal myocardial infarction and stroke in PCI-and CABG-treated patients (6.1% vs 8.3%, p ؍ 0.383; 12% vs 4.9%, p ؍ 0.152; 3.1% vs 3.5%, p ؍ 0.680 respectively). However, the rates of target vessel revascularization and major adverse coronary and cerebral event were significantly higher in PCI-treated patients than in those undergoing CABG (20% vs 1.2%, p <0.0001; 29% vs 15%, p ؍ 0.034). Despite a much higher SS, patients who underwent PCI achieved comparable outcomes at 1 year to those with diabetes mellitus and a SS >33 as reported in the SYNTAX trial. In conclusion, in this single-center nonrandomized observational study, coronary revascularization by PCI is associated with increased major adverse coronary and cerebral events at 1-year follow-up, predominantly driven by a high rate of target vessel revascularization. Thus, CABG should remain the revascularization procedure of choice for diabetic patients with MVD and high SSs.
Coronary revascularization in the diabetic patient
Circulation, 2014
Investigation (BARI) who were randomized to initial revascularization with PTCA had significantly worse 5-year survival than patients assigned to CABG. This treatment difference was not seen among diabetic patients eligible for BARI who opted to select their mode of revascularization. We hypothesized that differences in patient characteristics, assessed and unmeasured, together with the treatment selection in the registry, at least partially account for this discrepancy. Methods and Results-Among diabetics taking insulin or oral hypoglycemic drugs at entry, angiographic and clinical presentations were comparable between randomized and registry patients. However, more registry patients were white, and registry diabetics tended to be more educated and more physically active and to report better quality of life. Procedural characteristics and in-hospital complications were comparable. The 5-year all-cause mortality rate was 34.5% in randomized diabetic patients assigned to PTCA versus 19.4% in CABG patients (Pϭ0.0024; relative risk [RR]ϭ1.87); corresponding cardiac mortality rates were 23.4% and 8.2%, respectively (Pϭ0.0002; RRϭ3.10). The CABG benefit was more apparent among patients requiring insulin. In the registry, all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (Pϭ0.86, RRϭ1.10), with corresponding cardiac mortality rates of 7.5% and 6.0%, respectively (Pϭ0.73; RRϭ1.07). These RRs in the registry increased to 1.29 and 1.41, respectively, after adjustment for all known differences between treatment groups. Conclusions-BARI registry results are not inconsistent with the finding in the randomized trial that initial CABG is associated with better long-term survival than PTCA in treated diabetic patients with multivessel coronary disease suitable for either surgical or catheter-based revascularization. (Circulation. 1999;99:633-640.)
Journal of the American College of Cardiology, 2017
Randomized trial data support the superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (MV-CAD). However, whether this benefit is seen in a real-world population among subjects with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS) is unknown. The main objective of this study was to assess the generalizability of the FREEDOM (Future REvascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease) trial in real-world practice among patients with diabetes mellitus and MV-CAD in residents of British Columbia, Canada. Additionally, the study evaluated the impact of mode of revascularization (CABG vs. PCI with drug-eluting stents) in diabetic patients with ACS and MV-CAD. In a large population-based database from British Columbia, this study evaluated major cardiovascular outcomes in all diabetic patients wh...
Coronary Revascularization in Diabetic Patients
2000
Investigation (BARI) who were randomized to initial revascularization with PTCA had significantly worse 5-year survival than patients assigned to CABG. This treatment difference was not seen among diabetic patients eligible for BARI who opted to select their mode of revascularization. We hypothesized that differences in patient characteristics, assessed and unmeasured, together with the treatment selection in the registry, at least partially account for this discrepancy. Methods and Results-Among diabetics taking insulin or oral hypoglycemic drugs at entry, angiographic and clinical presentations were comparable between randomized and registry patients. However, more registry patients were white, and registry diabetics tended to be more educated and more physically active and to report better quality of life. Procedural characteristics and in-hospital complications were comparable. The 5-year all-cause mortality rate was 34.5% in randomized diabetic patients assigned to PTCA versus 19.4% in CABG patients (Pϭ0.0024; relative risk [RR]ϭ1.87); corresponding cardiac mortality rates were 23.4% and 8.2%, respectively (Pϭ0.0002; RRϭ3.10). The CABG benefit was more apparent among patients requiring insulin. In the registry, all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (Pϭ0.86, RRϭ1.10), with corresponding cardiac mortality rates of 7.5% and 6.0%, respectively (Pϭ0.73; RRϭ1.07). These RRs in the registry increased to 1.29 and 1.41, respectively, after adjustment for all known differences between treatment groups. Conclusions-BARI registry results are not inconsistent with the finding in the randomized trial that initial CABG is associated with better long-term survival than PTCA in treated diabetic patients with multivessel coronary disease suitable for either surgical or catheter-based revascularization. (Circulation. 1999;99:633-640.)
Cardiovascular Revascularization Medicine, 2012
Aims: Percutaneous coronary interventions (PCI) in patients with diabetes mellitus (DM) are associated with a high incidence of coronary restenosis, myocardial infarction (MI) and death. This study was to assess the potential role of a paclitaxel-eluting balloon (PEB) treatment in patients with DM with coronary lesions compared to those treated either with bare-metal stents (BMS) or drug-eluting stents (DES). Methods and Results: The Diabetic Argentina Registry (DEAR) was an observational, prospective, nonrandomised, open-label study that enrolled 92 patients with diabetes mellitus in three centers from Buenos Aires, Argentina, between April 2009 and March 2011, to be treated with PEB. Results were compared with previous outcome data in all patients with DM treated with DES (n=129 pts) or BMS (n=96 pts) in clinical studies conducted at our institutions. At one-year follow-up, patients with DM who received PEB followed by BMS implantation (96%) had a significantly lower incidence of major adverse cardiac events (MACE) compared to the BMS group (BMS 32.3%, PEB 13.2%; P=.003). The incidence of target-vessel failure (TVF) was 30.2% (BMS) and 11% (PEB) (P=.003), that of target-vessel revascularization (TVR) was 22.9% (BMS) and 8.3% (PEB) (P=.005) and the composite of death/MI occurred in 13.5% (BMS) and in 2.2% for PEB (P= .05). These positive results are persistent even after subgroups analysis. When comparing with previous DES patients, TVF was 18.6% in DES vs. 11.0% in PEB (P=.13), MACE was 18.6% in DES vs. 13.2% in PEB (P=.29), TVR rate was 14.0% in DES vs. 8.3% in PEB (P=.14) and the composite death/MI was 9.3% in DES vs. 4.4% in PEB (0.18) Conclusions: Diabetic patients treated with PEB followed by BMS resulted in a significantly better outcome than BMS alone and appeared to be comparable to DES treatment.
Circulation, 2009
Background-The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial in 2368 patients with stable ischemic heart disease assigned before randomization to percutaneous coronary intervention or coronary artery bypass grafting strata reported similar 5-year all-cause mortality rates with insulin sensitization versus insulin provision therapy and with a strategy of prompt initial coronary revascularization and intensive medical therapy or intensive medical therapy alone with revascularization reserved for clinical indication(s). In this report, we examine the predefined secondary end points of cardiac death and myocardial infarction (MI). Methods and Results-Outcome data were analyzed by intention to treat; the Kaplan-Meier method was used to assess 5-year event rates. Nominal P values are presented. During an average 5.3-year follow-up, there were 316 deaths (43% were attributed to cardiac causes) and 279 first MI events. Five-year cardiac mortality did not differ between revascularization plus intensive medical therapy (5.9%) and intensive medical therapy alone groups (5.7%; Pϭ0.38) or between insulin sensitization (5.7%) and insulin provision therapy (6%; Pϭ0.76). In the coronary artery bypass grafting stratum (nϭ763), MI events were significantly less frequent in revascularization plus intensive medical therapy versus intensive medical therapy alone groups (10.0% versus 17.6%; Pϭ0.003), and the composite end points of all-cause death or MI (21.1% versus 29.2%; Pϭ0.010) and cardiac death or MI (Pϭ0.03) were also less frequent. Reduction in MI (Pϭ0.001) and cardiac death/MI (Pϭ0.002) was significant only in the insulin sensitization group. Conclusions-In many patients with type 2 diabetes mellitus and stable ischemic coronary disease in whom angina symptoms are controlled, similar to those enrolled in the percutaneous coronary intervention stratum, intensive medical therapy alone should be the first-line strategy. In patients with more extensive coronary disease, similar to those enrolled in the coronary artery bypass grafting stratum, prompt coronary artery bypass grafting, in the absence of contraindications, intensive medical therapy, and an insulin sensitization strategy appears to be a preferred therapeutic strategy to reduce the incidence of MI. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.