Recent Advances in the Management of Coronary Artery Disease: Highlights From the Literature (original) (raw)
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Current Clinical Outcomes of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting
The Annals of Thoracic Surgery, 2008
Background. Randomized trials have compared coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). However, results of these trials in select patients may not accurately reflect current clinical practice using drug-eluting stents (DES) and off-pump CABG. We undertook a prospective registry of coronary revascularization by CABG on-pump and offpump, and PCI with or without DES, to determine clinical outcomes. Methods. All patients undergoing isolated coronary revascularization in 8 community-based hospitals were enrolled. Preprocedural, intraprocedural, and postprocedural data were captured, with outcomes obtained at 18 months by patient and physician contact, and the Social Security Death Index. Results. The study enrolled 4336 patients, 71.2% PCI and 28.8% CABG. DESs were used in 2249 PCIs (73.1%), and 596 CABG procedures (47.8%) were off-pump. Incidence of major adverse cardiac events at 18 months was 14.7% for CABG vs 23.3% for PCI (p < 0.001). Cardiac death and myocardial infarction had similar rates. The need for repeat revascularization was significantly less with CABG (6.2% vs 13.6%, p < 0.001). Hazard ratio of CABG to PCI was 0.76 (95% confidence interval, 0.571 to 0.872). CABG outcome was similar on-pump and offpump, as was repeat revascularization with DES (12.1%) vs BMS (14.9%; p ؍ 0.096). Overall event-free survival was 85.3% in CABG and 76.8% in PCI (p < 0.001). Conclusions. Rates of repeat revascularization were significantly higher for PCI than for CABG, but mortality and myocardial infarction were the same. There were no significant differences in outcomes between DES and BMS or between on-pump and off-pump CABG.
OBJECTIVES: Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagu-lation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up. METHODS: Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation. RESULTS: The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns). CONCLUSIONS: In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.
Journal of Cardiothoracic Surgery
Background Guidelines suggest that patients discontinue Clopidogrel at least 5 days prior to coronary artery bypass grafting (CABG). Those with acute coronary syndrome (ACS) are at high risk for myocardial infarction (MI) if not treated with dual antiplatelet therapy (DAPT). We sought to assess pre and post-operative outcomes of patients maintained on Clopidogrel and aspirin up to the time of surgery and compare them with those on aspirin alone. Methods From the cardiac surgery database, 240 patients were retrospectively registered between January and May 2017. There were 126 patients with ACS who underwent CABG on DAPT (Clopidogrel group [CG]) and 114 patients who underwent elective CABG on aspirin alone (control). The CG received intraoperative prophylactic platelet transfusion (PPT). Demographics, comorbidities, and laboratory data were prospectively entered at the time of surgery and were subsequently retrieved for analysis. Per and postoperative findings were identified and com...
BMC Surgery, 2021
Background Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. Methods In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. Results The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9–20.5; p = 0.071)....
Antiplatelet therapy at the time of coronary artery bypass grafting: a multicentre cohort study
European Journal of Cardio-Thoracic Surgery, 2013
OBJECTIVES: The purpose of this multicentre cohort study was to examine the relationship between antiplatelet therapy (APT) at the time of coronary artery bypass grafting (CABG) and postoperative bleeding complications, transfusion requirements and adverse cardiovascular events. METHODS: A matched-pair analysis was carried out on 6350 consecutive patients undergoing CABG at the three university hospitals in Western Denmark. Patients exposed to aspirin or clopidogrel within 5 days before surgery were compared with those not exposed to these drugs. The data used in the study were retrieved from the Western Denmark Heart Registry. RESULTS: Of the 6350 patients enrolled, 1846 (29%) had been exposed to aspirin or clopidogrel within 5 days prior to CABG (the APT group). Matching with the remaining 4504 (71%) patients of the control group resulted in 1132 pairs of patients. Patients in the APT group had greater mean chest tube drainage volumes (946 vs 775 ml; P < 0001) and greater transfusion requirements (ranging from 37.4-57.5 vs 29.8%; P < 0.0001) than control group patients. Preoperative aspirin therapy was not associated with greater reoperation rates (4.0 vs 3.9%; P = 0.005); nor was it an independent risk factor for severe postoperative bleeding >1000 ml (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.55-1.34). Preoperative clopidogrel use, on the other hand, was associated with greater reoperation rates (10.2 vs 3.9% in the control group; P = 0.005) and was an independent predictor of severe postoperative bleeding (OR: 2.08, 95% CI: 1.55-2.80). Overall, preoperative APT had no significant effect on postoperative 30-day mortality, incidence of myocardial infarction, stroke or need for dialysis. CONCLUSIONS: Preoperative APT is associated with increased bleeding and greater transfusion requirements after CABG. Clopidogrel exposure is associated with greater reoperation rates and is an independent risk factor for severe postoperative bleeding.