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Mauro MS, Finocchiaro S, Calderone D, Rochira C, Agnello F, Scalia L, Capodanno D. Antithrombotic strategies for preventing graft failure in coronary artery bypass graft. J Thromb Thrombolysis 2024; 57:547-557. [PMID: 38491265 PMCID: PMC11026197 DOI: 10.1007/s11239-023-02940-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 03/18/2024]
Abstract
Coronary artery bypass graft (CABG) procedures face challenges related to graft failure, driven by factors such as acute thrombosis, neointimal hyperplasia, and atherosclerotic plaque formation. Despite extensive efforts over four decades, the optimal antithrombotic strategy to prevent graft occlusion while minimizing bleeding risks remains uncertain, relying heavily on expert opinions rather than definitive guidelines. To address this uncertainty, we conducted a review of randomized clinical trials and meta-analyses of antithrombotic therapy for patients with CABG. These studies examined various antithrombotic regimens in CABG such as single antiplatelet therapy (aspirin or P2Y12 inhibitors), dual antiplatelet therapy, and anticoagulation therapy. We evaluated outcomes including the patency of grafts, major adverse cardiovascular events, and bleeding complications and also explored future perspectives to enhance long-term outcomes for CABG patients. Early studies established aspirin as a key component of antithrombotic pharmacotherapy after CABG. Subsequent randomized controlled trials focused on adding a P2Y12 inhibitor (such as clopidogrel, ticagrelor, or prasugrel) to aspirin, yielding mixed results. This article aims to inform clinical decision-making and guide the selection of antithrombotic strategies after CABG.
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Affiliation(s)
- Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy.
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Rezaee M, Fallahzadeh A, Sheikhy A, Ajam A, Sadeghian S, Bsc MP, Shirzad M, Mansourian S, Bagheri J, Hosseini K. The prognostic role of the low and very low baseline LDL-C level in outcomes of patients with cardiac revascularization; comparative registry-based cohort design. J Cardiothorac Surg 2023; 18:240. [PMID: 37507734 PMCID: PMC10386279 DOI: 10.1186/s13019-023-02333-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Although low-density lipoprotein-cholesterol (LDL-C) level is considered one of the main prognostic factors in patients with coronary artery bypass grafting (CABG), the question about "the lower the better" is still unanswered. We aimed to evaluate and compare the outcomes of patients with CABG and low or very low baseline LDL-C, regardless of statin usage. METHODS In this registry-based cohort study, 10,218 patients with low/very low (70-100 and ≤ 70 mg/dL) baseline LDL-C who underwent isolated and the first-time CABG without known previous history of cardio-cerebrovascular events, were included and compared. The median follow-up was 73.33 (72.15-74.51) months. Primary outcomes were all-cause mortality and major adverse cardio-cerebrovascular events (MACCE) (consisted of all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization [percutaneous coronary intervention or redo-CABG]). Cox regression analyses before and after the propensity score matching (PSM) model were applied to evaluate and compare outcomes. RESULTS The mean age of the study population was 66.17 ± 9.98 years old and 2506 (24.5%) were women. Diabetes mellitus and a history of cigarette smoking were significantly higher in the very low LDL group (P-value ≤ 0.001). In Cox regression analyses before applying PSM model, both all-cause mortality (14.2% vs. 11.9%, P-value = 0.004 and MACCE (26.0% vs. 23.6%, P-value = 0.006) were significantly higher in the very low LDL group compared to low LDL. However, these results were no longer significant after applying the PSM model (all-cause mortality HR: 1.115 [95% CI: 0.986-1.262], P = 0.083 and MACCE HR: 1.077 [95%CI: 0.984-1.177], P = 0.095). The sensitivity analysis to remove the statin effect demonstrated that very low LDL-C level was correlated to higher risk of all-cause mortality in both unmatched and PSM analyses. CONCLUSION Very low serum LDL-C levels (≤ 70 mg/dl) could increase long-term all-cause mortality and cardiovascular events in patients who have undergone isolated CABG.
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Affiliation(s)
- Malihe Rezaee
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Non-Communicable Disease Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Aida Fallahzadeh
- Non-Communicable Disease Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Ali Sheikhy
- Non-Communicable Disease Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Ali Ajam
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Saeed Sadeghian
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
- Department of Cardiac Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Pashang Bsc
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
| | - Mahmoud Shirzad
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
- Department of Cardiac Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Mansourian
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
- Department of Cardiac Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran
- Department of Cardiac Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, North Karegar Ave, P.O. Box: 1411713138, Tehran, Iran.
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Lim K, Wong CHM, Lee ALY, Fujikawa T, Wong RHL. Influence of cholesterol level on long-term survival and cardiac events after surgical coronary revascularization. JTCVS OPEN 2022; 10:195-203. [PMID: 36004261 PMCID: PMC9390627 DOI: 10.1016/j.xjon.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/17/2022] [Indexed: 11/22/2022]
Abstract
Objective Statins have been shown to delay the inevitable progression of atherosclerosis in native coronaries and saphenous vein grafts, thereby reducing ischemic events after surgical coronary revascularization. However, there is significant controversy as to whether titrating statin therapy to concrete cholesterol targets is appropriate. Methods A single-center retrospective analysis of 309 consecutive patients who underwent isolated coronary artery bypass graft in 2007 and 2008 was performed. Measurements of lipid profile subcomponents, namely total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides, in mmol/L, were obtained by retrospective review of electronic health records. The primary end point was cardiac death. The secondary end point was the composite of cardiac events, including cardiac death, nonfatal myocardial infarction, hospitalization for unstable angina, and target lesion revascularization. Database lock date was August 15, 2020. Results The median follow-up duration was 12.5 years. Cardiac death occurred in 6.8% of the cohort. Cardiac events occurred in 21.7% of the cohort. New-onset myocardial infarction occurred in 8.7% (n = 27), of which 48.1% (n = 13) underwent repeat revascularization. A 2-level nested Cox proportional hazards regression model was constructed to determine whether cholesterol target attainment was independently associated with cardiac events. After risk adjustment, LDL-C, non–HDL-C, total cholesterol (TC), and TC/HDL-C ratio were independently associated with cardiac death. In receiver operating characteristics analyses, the optimal cut-off values for non–HDL-C, LDL-C, and TC/HDL-C ratio were 3.2 mmol/L, 2.3 mmol/L, and 3.5, respectively. Conclusions Exposure to elevated LDL-C and non–HDL-C cholesterol levels independently predicted long-term cardiac death after coronary artery bypass graft.
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Affiliation(s)
- Kevin Lim
- Address for reprints: Kevin Lim, MRCS(Ed), Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Hospital Authority, Hong Kong, 30-32 Ngan Shing St, Sha Tin, Hong Kong.
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6524992. [DOI: 10.1093/ejcts/ezac048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
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Wang Y, Tao M, Wei H, Arslan Ahmad M, Ma Y, Mao X, Hao L, Ao Q. PLCL vascular external sheath carrying prednisone for improving patency rate of the vein graft. Tissue Eng Part A 2021; 28:394-404. [PMID: 34605672 DOI: 10.1089/ten.tea.2021.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Coronary artery bypass graft surgery (CABG) is an impactful treatment for coronary heart disease. Intimal hyperplasia is the central reason for the restenosis of vein grafts after CABG. The introduction of external vascular sheaths around VGs (VGs) can effectively inhibit intimal hyperplasia and ensure the patency of VGs. In this study, the well-known biodegradable copolymer poly (ε-caprolactone-co-L, L-lactide) (PLCL) was electrospun into high porosity external sheaths. The prednisone loaded in the PLCL sheath was slowly released during the degradation process of PLCL. Under the combined effects of sheath and prednisone, intimal hyperplasia was inhibited. For the cell experiments, all sheaths show low cytotoxicity to L929 cells at different concentrations at different time intervals. The ultrasonography and histological results showed prominent dilation and intimal hyperplasia of VG without sheath after two months of surgery. But there was no dilation in PLCL and PLCLPrednisone groups. Notably, the prednisone-loaded sheath group exhibited efficacy in inhibiting intimal hyperplasia and ensured graft patency.
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Affiliation(s)
- Yang Wang
- China Medical University, 38019, School of Forensic Medicine, Shenyang, China.,China Medical University, School of Intelligent Medicine, Shenyang, China;
| | - Meihan Tao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Huan Wei
- The First Affiliated Hospital of China Medical University, 159407, Shenyang, Liaoning, China;
| | | | - Yizhan Ma
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Xiaoyan Mao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Liang Hao
- China Medical University, School of Forensic Medicine, Shenyang, China;
| | - Qiang Ao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China.,Sichuan University, 12530, Chengdu, Sichuan, China;
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Abdalwahab A, Al-atta A, Zaman A, Alkhalil M. Intensive lipid-lowering therapy, time to think beyond low-density lipoprotein cholesterol. World J Cardiol 2021; 13:472-482. [PMID: 34621492 PMCID: PMC8462038 DOI: 10.4330/wjc.v13.i9.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/25/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
Statins have been shown to be effective in reducing cardiovascular events. Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol (LDL-c). Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes. Unselective application of these treatments is undesirable and unaffordable and, therefore, has been guided by LDL-c level. Nonetheless, the residual risk in the post-statin era is markedly heterogeneous, including thrombosis and inflammation risks. Moreover, the lipo-protein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a). Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease, post coronary artery bypass graft and diabetes. Notably, these clinical entities share similar phenotype of large burden of atherosclerotic plaques. Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites. Those patients may be suitable candidates for intensive lipid lowering treatment.
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Affiliation(s)
- Ahmed Abdalwahab
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
- Department of Cardiovascular Medicine, Faculty of Medicine, Tanta University, Tanta 35127, Egypt
| | - Ayman Al-atta
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
- Vascular Biology, Newcastle University, Newcastle upon Tyne NE7 7DN, United Kingdom
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
- Vascular Biology, Newcastle University, Newcastle upon Tyne NE7 7DN, United Kingdom
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Farkouh ME, Godoy LC, Brooks MM, Mancini GBJ, Vlachos H, Bittner VA, Chaitman BR, Siami FS, Hartigan PM, Frye RL, Boden WE, Fuster V. Influence of LDL-Cholesterol Lowering on Cardiovascular Outcomes in Patients With Diabetes Mellitus Undergoing Coronary Revascularization. J Am Coll Cardiol 2021; 76:2197-2207. [PMID: 33153578 DOI: 10.1016/j.jacc.2020.09.536] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elevated low-density lipoprotein cholesterol (LDL-C) is associated with increased cardiovascular events, especially in high-risk populations. OBJECTIVES This study sought to evaluate the influence of LDL-C on the incidence of cardiovascular events either following a coronary revascularization procedure (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) or optimal medical therapy alone in patients with established coronary heart disease and type 2 diabetes (T2DM). METHODS Patient-level pooled analysis of 3 randomized clinical trials was undertaken. Patients with T2DM were categorized according to the levels of LDL-C at 1 year following randomization. The primary endpoint was major adverse cardiac or cerebrovascular events ([MACCE] the composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke). RESULTS A total of 4,050 patients were followed for a median of 3.9 years after the index 1-year assessment. Patients whose 1-year LDL-C remained ≥100 mg/dl experienced higher 4-year cumulative risk of MACCE (17.2% vs. 13.3% vs. 13.1% for LDL-C between 70 and <100 mg/dl and LDL-C <70 mg/dl, respectively; p = 0.016). When compared with optimal medical therapy alone, patients with PCI experienced a MACCE reduction only if 1-year LDL-C was <70 mg/dl (hazard ratio: 0.61; 95% confidence interval: 0.40 to 0.91; p = 0.016), whereas CABG was associated with improved outcomes across all 1-year LDL-C strata. In patients with 1-year LDL-C ≥70 mg/dl, patients undergoing CABG had significantly lower MACCE rates as compared with PCI. CONCLUSIONS In patients with coronary heart disease with T2DM, lower LDL-C at 1 year is associated with improved long-term MACCE outcome in those eligible for either PCI or CABG. When compared with optimal medical therapy alone, PCI was associated with MACCE reductions only in those who achieved an LDL-C <70 mg/dl.
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Affiliation(s)
- Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Lucas C Godoy
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil. https://twitter.com/lucascgodoy
| | - Maria M Brooks
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - G B John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Helen Vlachos
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bernard R Chaitman
- Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis, Missouri
| | | | | | | | - William E Boden
- Boston University School of Medicine, VA New England Healthcare System, VA Boston-Jamaica Plain Campus, Boston, Massachusetts
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, New York, New York; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
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Kulik A, Abreu AM, Boronat V, Ruel M. Impact of lipid levels and high-intensity statins on vein graft patency after CABG: Midterm results of the ACTIVE trial. J Card Surg 2020; 35:3286-3293. [PMID: 33025656 DOI: 10.1111/jocs.15014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/31/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND High-dose atorvastatin did not improve 1-year vein graft patency in the recent Aggressive Cholesterol Therapy to Inhibit Vein Graft Events trial. However, it remains unknown whether high-intensity statins may impact graft disease in the years that follow. METHODS In the trial, patients (N = 173) were randomized to receive atorvastatin 10 or 80 mg for 1 year after coronary bypass surgery (CABG). Beyond 1 year, the choice of statin was left to the patient's physician. In this study of participants who agreed to follow-up (N = 76), low-density lipoprotein (LDL) levels were measured and graft patency was assessed 3 years after surgery. RESULTS The rate of vein graft disease 3 years after surgery was not significantly reduced with atorvastatin 80 mg during the first postoperative year or the use of open-label high-intensity statin thereafter (p = NS). However, a trend was observed between higher LDL levels during the first postoperative year and a greater incidence of vein graft disease at 3 years (p = .12). Among patients who had LDL levels more than 90 mg/dl in the first year after CABG, 38.5% had vein graft disease at 3 years, compared to 19.0% for those with LDL levels less than 90 mg/dl (p = .15). Higher mean LDL levels during the first postoperative year were associated with a higher rate of vein disease 3 years after surgery both at the graft level (p = .03) and at the patient level (p = .03) in multivariate analysis. CONCLUSIONS Higher LDL levels during the first postoperative year were associated with significantly greater vein graft disease 3 years after CABG.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Amy M Abreu
- Division of Cardiac Surgery, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Viviana Boronat
- Division of Cardiac Surgery, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Marc Ruel
- Division of Cardiac Surgery, The University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Rostami F, Tamjid E, Behmanesh M. Drug-eluting PCL/graphene oxide nanocomposite scaffolds for enhanced osteogenic differentiation of mesenchymal stem cells. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 115:111102. [PMID: 32600706 DOI: 10.1016/j.msec.2020.111102] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
Recently, drug-eluting nanofibrous scaffolds have attracted a great attention to enhance the cell differentiation through biomimicking the extracellular matrix (ECM) in regenerative medicine. In this study, electrospun nanocomposite polycaprolactone (PCL)-based scaffolds containing synthesized graphene oxide (GO) nanosheets and osteogenic drugs, i.e. dexamethasone and simvastatin were fabricated. The physicochemical and surface properties of the scaffolds were investigated through FTIR, wettability, pH, and drug release studies. The cell viability, differentiation, and biomineralization were studied on mesenchymal stem cells (MSCs) by Alamar Blue, alkaline phosphatase (ALP) activity, and Alizarin Red-S staining, respectively. Uniformly distributed GO (thickness < 1 nm) in PCL nanofibers was observed by electron microscopy. It was revealed that the addition of GO and the drugs improved the hydrophilicity, cell viability, and osteogenic differentiation, in addition to pH changes, in comparison with PCL scaffolds. Despite the notable reduction in the cell viability, significant differentiation was revealed by ALP assay on PCL/GO-Dex scaffolds. Noteworthy, a twofold increase in the osteogenic differentiation was observed in comparison with the cells cultured in osteogenic differentiation medium, while a significant biomineralization was observed. The results of this study indicate the synergistic effect of GO and dexamethasone on improving osteogenic differentiation of drug-eluting nanocomposite scaffolds in bone tissue engineering applications.
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Affiliation(s)
- Fatemeh Rostami
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Elnaz Tamjid
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran.
| | - Mehrdad Behmanesh
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran; Department of Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran.
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The Impact of Statins before High-Risk CABG on Postoperative Multiple Organ Function. Cardiol Res Pract 2020; 2020:9519736. [PMID: 32411451 PMCID: PMC7201446 DOI: 10.1155/2020/9519736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this cohort study was to investigate the independent relationship between preoperative statin therapy (PST) and postoperative severe multiorgan failure, measured by the Sequential Organ Failure Assessment (SOFA) maximum greater than 11, in high-risk patients undergoing isolated coronary artery bypass grafting (CABG). Methods The present study is a perspective, single-center, cohort analysis enrolling high-risk patients undergoing CABG from Jan 1, 2018, to Dec 31, 2018, in Beijing Anzhen hospital. Results Among a total of 880 high-risk patients undergoing isolated CABG included in this study, 503 (57.2%) experienced statin therapy before CABG. The SOFA maximum was significantly lower in the PST group compared with the control group (7.8 ± 3.0 v 9.2 ± 3.4, P < 0.0001). Multivariate logistic regression analysis demonstrated the incidence of the severe multiorgan dysfunction, measured by SOFA maximum ≥11, was dramatically reduced in the PST group (OR, 0.68, 95% CI 0.50-0.92, P=0.013). Furthermore, preoperative statin therapy (PST) might be associated with a decreased risk of postoperative major adverse cardiovascular and cerebral events and acute kidney injury, but an increased risk of postoperative hepatic inadequacy. Conclusion SOFA maximum was significantly lower in the PST group compared with the control group and the incidence of the severe multiorgan dysfunction was dramatically reduced in the PST group. The findings of this study might shed new light on questions of positive or negative effects of PST on multiple organ function after high-risk CABG, so as to ultimately improve high-risk patient in-hospital outcomes from CABG.
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Goodman SG, Aylward PE, Szarek M, Chumburidze V, Bhatt DL, Bittner VA, Diaz R, Edelberg JM, Hanotin C, Harrington RA, Jukema JW, Kedev S, Letierce A, Moryusef A, Pordy R, Ramos López GA, Roe MT, Viigimaa M, White HD, Zeiher AM, Steg PG, Schwartz GG. Effects of Alirocumab on Cardiovascular Events After Coronary Bypass Surgery. J Am Coll Cardiol 2020; 74:1177-1186. [PMID: 31466614 DOI: 10.1016/j.jacc.2019.07.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/17/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with acute coronary syndrome (ACS) and history of coronary artery bypass grafting (CABG) are at high risk for recurrent cardiovascular events and death. OBJECTIVES This study sought to determine the clinical benefit of adding alirocumab to statins in ACS patients with prior CABG in a pre-specified analysis of ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab). METHODS Patients (n = 18,924) 1 to 12 months post-ACS with elevated atherogenic lipoprotein levels despite high-intensity statin therapy were randomized to alirocumab or placebo subcutaneously every 2 weeks. Median follow-up was 2.8 years. The primary composite endpoint of major adverse cardiovascular events (MACE) comprised coronary heart disease death, nonfatal myocardial infarction, ischemic stroke, or unstable angina requiring hospitalization. All-cause death was a secondary endpoint. Patients were categorized by CABG status: no CABG (n = 16,896); index CABG after qualifying ACS, but before randomization (n = 1,025); or CABG before the qualifying ACS (n = 1,003). RESULTS In each CABG category, hazard ratios (95% confidence intervals) for MACE (no CABG 0.86 [0.78 to 0.95], index CABG 0.85 [0.54 to 1.35], prior CABG 0.77 [0.61 to 0.98]) and death (0.88 [0.75 to 1.03], 0.85 [0.46 to 1.59], 0.67 [0.44 to 1.01], respectively) were consistent with the overall trial results (0.85 [0.78 to 0.93] and 0.85 [0.73 to 0.98], respectively). Absolute risk reductions (95% confidence intervals) differed across CABG categories for MACE (no CABG 1.3% [0.5% to 2.2%], index CABG 0.9% [-2.3% to 4.0%], prior CABG 6.4% [0.9% to 12.0%]) and for death (0.4% [-0.1% to 1.0%], 0.5% [-1.9% to 2.9%], and 3.6% [0.0% to 7.2%]). CONCLUSIONS Among patients with recent ACS and elevated atherogenic lipoproteins despite intensive statin therapy, alirocumab was associated with large absolute reductions in MACE and death in those with CABG preceding the ACS event. (ODYSSEY OUTCOMES: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402).
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Affiliation(s)
- Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada and St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Michael Szarek
- State University of New York, Downstate School of Public Health, Brooklyn, New York
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | | | - Robert A Harrington
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, California
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sasko Kedev
- University Clinic of Cardiology, Skopje, Macedonia
| | | | | | - Robert Pordy
- Regeneron Pharmaceuticals Inc., Tarrytown, New York
| | | | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Harvey D White
- Green Lane Cardiovascular Services Auckland City Hospital, Auckland, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | - Ph Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France; National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
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Kulik A. Commentary: Yin and Yang: Antiplatelet and lipid-lowering therapies to prevent vein graft thrombosis and atherosclerosis after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2020; 163:1042-1043. [PMID: 32381333 DOI: 10.1016/j.jtcvs.2020.03.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander Kulik
- Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, Boca Raton, Fla.
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Zhu J, Zhu Y, Zhang M, Xue Q, Hu J, Liu H, Wang R, Wang X, Zhao Q. Influence of lipoproteins and antiplatelet agents on vein graft patency 1 year after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2020; 163:1030-1039.e4. [PMID: 32359899 DOI: 10.1016/j.jtcvs.2020.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE It remains unclear whether aggressive low-density lipoprotein cholesterol (LDL-C) management (<1.8 mmol/L) can slow the process of vein graft stenosis. This study aimed to explore the impact of baseline LDL-C levels on vein graft patency in patients on ticagrelor with or without aspirin 1 year after coronary artery bypass grafting (CABG). METHODS This was a post hoc analysis of the DACAB (Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery) trial (NCT02201771), a randomized controlled trial (ticagrelor + aspirin or ticagrelor vs aspirin) of patients undergoing CABG in China. The study subjects were stratified as LDL-low (baseline LDL-C <1.8 mmol/L, 148 patients with 430 vein grafts) versus LDL-high (baseline LDL-C ≥1.8 mmol/L, 352 patients with 1030 vein grafts). The primary outcome was the 1-year vein graft patency (Fitzgibbon grade A) assessed by coronary computed tomographic angiography or coronary angiography. RESULTS Baseline/1-year LDL-C were 1.4/1.6 and 2.6/2.4 mmol/L in the LDL-low and LDL-high subgroups, respectively. Regardless of antiplatelet regimen, no significant inter-subgroup difference was observed for 1-year graft patency (LDL-low: 83.8% [359/430 grafts]; LDL-high: 82.3% [848/1030 grafts]; adjusted OR for non-patency [ORadj], 0.96; 95% confidence interval [CI], 0.62-1.50, P = .857). For both subgroups, the 1-year graft patency rates were greater with ticagrelor + aspirin versus aspirin (LDL-low: ORadj, 0.41; 95% CI, 0.17-0.97; LDL-high: ORadj, 0.38; 95% CI, 0.20-0.71; inter P = .679). CONCLUSIONS In general, baseline LDL-C is not associated with 1-year vein graft patency after CABG. Regardless of the baseline LDL-C levels, ticagrelor + aspirin was superior to aspirin alone in maintaining vein graft patency. The primary factor causing early vein graft disease might not be atherosclerosis but thrombosis.
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Affiliation(s)
- Jiaxi Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minlu Zhang
- Department of Cancer Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Qing Xue
- Department of Cardiovascular Surgery, Changhai Hospital of Shanghai, Shanghai, China
| | - Junlong Hu
- Department of Cardiovascular Surgery, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Hao Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Wang
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing, China
| | - Xiaowei Wang
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Effects of intensive lipid-lowering therapy on mortality after coronary bypass surgery: A meta-analysis of 7 randomised trials. Atherosclerosis 2019; 293:75-78. [PMID: 31865057 DOI: 10.1016/j.atherosclerosis.2019.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The recent reported analysis from the ODYSSEY OUTCOMES trial showed that patients with previous coronary bypass graft surgery (CABG) had enhanced clinical benefits in response to intensive low-density lipoprotein-cholesterol (LDL-c). Nonetheless, the impact on cardiovascular and all-cause mortality was difficult to ascertain given the relatively small number. METHODS We conducted a meta-analysis investigating the role of more versus less intensive lipid-lowering treatment, taking into consideration the difference in studies duration when reporting treatment effect. RESULTS A significant 14% reduction in deaths from any cause [RR 0.86 (95% CI, 0.74 to 0.99)] and 25% reduction in cardiovascular mortality [RR 0.75, (95% CI, 0.65 to 0.86)] were associated with intensive LDL-c reduction in patients post CABG. Importantly, this reduction was apparent in patients who were stable or developed an acute coronary syndrome following CABG. CONCLUSIONS Patients with previous CABG incurred reduction in all-cause mortality and particularly cardiovascular mortality in response to intensive LDL-c reduction. Patient's clinical presentation following CABG did not modulate the associated benefits with intensive LDL-c reduction. Characterising atherosclerotic disease may help identify other high-risk groups who may benefit maximally from additional lipid-lowering therapies.
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Abstract
An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the "no-reflow phenomenon," which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.
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Does Early Graft Patency Benefit from Perioperative Statin Therapy? A Propensity Score-Matched Study of Patients Undergoing Off-Pump Coronary Artery Bypass Surgery. Cardiovasc Ther 2019; 2019:1582183. [PMID: 31772605 PMCID: PMC6739783 DOI: 10.1155/2019/1582183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/01/2019] [Accepted: 07/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background Decreased graft patency after off-pump coronary artery bypass grafting (OPCAB) leads to substantial increases in cardiac events. However, there is paucity of data on efficacy and safety of perioperative statin therapy for OPCAB populations. Methods 582 patients undergoing OPCAB in a single-institution database (October 1, 2009–September 30, 2012) were stratified by perioperative continuation of statin therapy (CS group, n=398) or not (DS group, n=184). Inverse probability weighted propensity adjustment was used to account for treatment assignment bias, resulting in a well-matched cohort. Primary outcomes were graft patency at an average of five days after operation and in-hospital mortality. Secondary outcomes included intraoperative blood loss, liver, and renal functions. Results No in-hospital death occurred in this study. Early graft patency rates after OPCAB were 98.4% (1255 of 1275 grafts) in the CS group and 98.0% (583 of 595 grafts, P=0.486) in the DS group. Secondary outcomes showed a reduction in blood loss during operation (438.53 mL versus 480.47 mL, P=0.01). Continuation of statin therapy is associated with alanine transaminase (ALT) elevation (49.67 U/L versus 34.52 U/L, P<0.001), as well as aspartate transaminase (33.54 U/L versus 28.10 U/L, P<0.001). Abnormal ALT elevation was observed in 8.9% of the CS group and 3.1% in DS (odds ratio 3.06, 95% confidence interval, 1.77 to 5.29, P<0.001). There was no significant difference in estimated glomerular filtration rate (76.28 mL/min/1.73m2 versus 76.13 mL/min/1.73m2, P=0.90). Subgroup analyses suggested that graft occlusion was less common in CS than in DS group among smoking patients (odds ratio 0.41, 95% confidence interval, 0.20 to 0.86, P=0.026). Conclusions Perioperative continuation of statin therapy did not improve early graft patency in OPCAB patients. A lower risk of graft occlusion was observed among smoking patients. Continuous statin use correlated with liver function elevation (Clinical Trials.gov number, NCT 01268917).
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Rivaroxaban, Aspirin, or Both to Prevent Early Coronary Bypass Graft Occlusion: The COMPASS-CABG Study. J Am Coll Cardiol 2019; 73:121-130. [PMID: 30654882 DOI: 10.1016/j.jacc.2018.10.048] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/03/2018] [Accepted: 10/08/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients with recent coronary artery bypass graft (CABG) surgery are at risk for early graft failure, which is associated with a risk of myocardial infarction and death. In the COMPASS (Cardiovascular OutcoMes for People Using Anticoagulation StrategieS) trial, rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily compared with aspirin 100 mg once daily reduced the primary major adverse cardiovascular events (MACE) outcome of cardiovascular death, stroke, or myocardial infarction. Rivaroxaban 5 mg twice daily alone did not significantly reduce MACE. OBJECTIVES This pre-planned substudy sought to determine whether the COMPASS treatments are more effective than aspirin alone for preventing graft failure and MACE after CABG surgery. METHODS The substudy randomized 1,448 COMPASS trial patients 4 to 14 days after CABG surgery to receive the combination of rivaroxaban plus aspirin, rivaroxaban alone, or aspirin alone. The primary outcome was graft failure, diagnosed by computed tomography angiogram 1 year after surgery. RESULTS The combination of rivaroxaban and aspirin and the regimen of rivaroxaban alone did not reduce the graft failure rates compared with aspirin alone (combination vs. aspirin: 113 [9.1%] vs. 91 [8.0%] failed grafts; odds ratio [OR]: 1.13; 95% confidence interval [CI]: 0.82 to 1.57; p = 0.45; rivaroxaban alone vs. aspirin: 92 [7.8%] vs. 92 [8.0%] failed grafts; OR: 0.95; 95% CI: 0.67 to 1.33; p = 0.75). Compared with aspirin, the combination was associated with fewer MACE (12 [2.4%] vs. 16 [3.5%]; hazard ratio [HR]: 0.69; 95% CI: 0.33 to 1.47; p = 0.34), whereas rivaroxaban alone was not (16 [3.3%] vs. 16 [3.5%]; HR: 0.99, CI: 0.50 to 1.99; p = 0.98). There was no fatal bleeding or tamponade within 30 days of randomization. CONCLUSIONS The combination of rivaroxaban 2.5 mg twice daily plus aspirin or rivaroxaban 5 mg twice daily alone compared with aspirin alone did not reduce graft failure in patients with recent CABG surgery, but the combination of rivaroxaban 2.5 mg twice daily plus aspirin was associated with similar reductions in MACE, as observed in the larger COMPASS trial. (Cardiovascular OutcoMes for People Using Anticoagulation StrategieS [COMPASS]; NCT01776424).
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Dianati Maleki N, Ehteshami Afshar A, Parikh PB. Management of Saphenous Vein Graft Disease in Patients with Prior Coronary Artery Bypass Surgery. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:12. [DOI: 10.1007/s11936-019-0714-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Zhang Y, Fang Q, Niu K, Gan Z, Yu Q, Gu T. Time-dependently slow-released multiple-drug eluting external sheath for efficient long-term inhibition of saphenous vein graft failure. J Control Release 2019; 293:172-182. [DOI: 10.1016/j.jconrel.2018.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/19/2018] [Accepted: 12/01/2018] [Indexed: 12/22/2022]
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Kulik A, Abreu AM, Boronat V, Ruel M. Intensive versus moderate statin therapy and early graft occlusion after coronary bypass surgery: The Aggressive Cholesterol Therapy to Inhibit Vein Graft Events randomized clinical trial. J Thorac Cardiovasc Surg 2019; 157:151-161.e1. [DOI: 10.1016/j.jtcvs.2018.05.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/24/2018] [Accepted: 05/21/2018] [Indexed: 01/21/2023]
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Fitzpatrick T, Perrier L, Shakik S, Cairncross Z, Tricco AC, Lix L, Zwarenstein M, Rosella L, Henry D. Assessment of Long-term Follow-up of Randomized Trial Participants by Linkage to Routinely Collected Data: A Scoping Review and Analysis. JAMA Netw Open 2018; 1:e186019. [PMID: 30646311 PMCID: PMC6324362 DOI: 10.1001/jamanetworkopen.2018.6019] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/26/2018] [Indexed: 12/21/2022] Open
Abstract
Importance Follow-up of participants in randomized trials may be limited by logistic and financial factors. Some important randomized trials have been extended well beyond their original follow-up period by linkage of individual participant information to routinely collected data held in administrative records and registries. Objective To perform a scoping review of randomized clinical trials extended by record linkage to characterize this literature and explore any additional insights into treatment effectiveness provided by long-term follow-up using record linkage. Data Sources A literature search in Embase, CINAHL, MEDLINE, and the Cochrane Register of Controlled Trials was performed for the period January 1, 1945, through November 25, 2016. Study Selection Various combinations of search terms were used, as there is no accepted terminology. Determination of study eligibility and extraction of information about trial characteristics and outcomes, for both original and extended trial reports, were performed in duplicate. Data Extraction and Synthesis Assessment of study eligibility and data extraction were performed independently by 2 reviewers. All analyses were descriptive. Main Outcomes and Measures Outcomes in the pairs of original and extended trials were categorized according to whether any benefits or harms from interventions were sustained, were lost, or emerged during long-term follow-up. Results A total of 113 extended trials were included in the study. Linkage to administrative and registry data extended follow-up by between 1 and 55 years. The most common interventions were pharmaceuticals (47 [41.6%]), surgery (19 [16.8%]), and disease screening (19 [16.8%]). End points most frequently studied through record linkage included mortality (88 [77.9%]), cancer (41 [36.3%]), and cardiovascular events (37 [32.7%]). One hundred four trial extensions (92.0%) were analyzed according to the original trial randomization. The reports provided details of 155 analyses of study outcomes. Seventy-four analyses (47.7%) identified statistically significant benefits in the trial extension phase. In 21 of these (28.4%), benefits were significant only in this period. Null results in both the original and extended trials were seen in 34 of the analyses (21.9%). Loss of significant benefits of an intervention were seen in 12 analyses (7.7%). Statistically significant harms were seen in 16 trial extension analyses (10.3%), and in 14 of these (87.5%), the harms were significant only in the trial extension phase. Conclusions and Relevance Trial extension by linkage to routinely collected data is a versatile underused approach that may add critical insights beyond those of the original trial. Some beneficial and harmful outcomes of interventions are captured only in the extension phase of randomized trials.
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Affiliation(s)
- Tiffany Fitzpatrick
- Ontario Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Laure Perrier
- University of Toronto Libraries, Toronto, Ontario, Canada
| | - Sharara Shakik
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zoe Cairncross
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea C. Tricco
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Merrick Zwarenstein
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Laura Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - David Henry
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland, Australia
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Current role of saphenous vein graft in coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 2018; 34:245-250. [PMID: 33060945 DOI: 10.1007/s12055-018-0759-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022] Open
Abstract
Saphenous vein was the conduit used in the first series of coronary artery bypass grafting (CABG), and, with the exception of surgical revascularization of the left anterior descending artery, it remains the most commonly used bypass conduit. However, its durability and longevity are not ideal. Arterial grafts have better patency than saphenous vein grafts and therefore should be preferred over them. However, in certain situations, like grafting right coronary arteries with lesser degree of proximal stenosis and higher competitive flow, or in certain patient populations, like those at very high risk of wound infections and octogenarians, arterial grafting may not be the best option and saphenous vein grafting should be considered instead.
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Siskos D, Tziomalos K. The Role of Statins in the Management of Patients Undergoing Coronary Artery Bypass Grafting. Diseases 2018; 6:diseases6040102. [PMID: 30423861 PMCID: PMC6313444 DOI: 10.3390/diseases6040102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/03/2018] [Accepted: 11/08/2018] [Indexed: 11/29/2022] Open
Abstract
Each year, a large number of patients undergo coronary artery bypass grafting surgery (CABG) worldwide. Accumulating evidence suggests that the preoperative administration of statins might be useful in preventing adverse events after CABG. In the present review, we discuss the role of statins in the perioperative management of patients undergoing CABG. Preoperative administration of statins in these patients substantially reduces the risk of postoperative atrial fibrillation and shortens hospital and intensive care unit (ICU) stay. Atorvastatin appears to be more effective, particularly when administered at high doses. Given these benefits and the safety of statins, their administration should be considered in patients undergoing CABG, even though the statins do not appear to affect the incidence of cardiovascular events and overall mortality perioperatively.
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Affiliation(s)
- Dimitrios Siskos
- Department of Cardiothoracic Surgery, Heart Center, University Hospital Cologne, 50937 Cologne, Germany.
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece.
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Bianchi CF, Petrucci O. A better treatment for saphenous vein graft disease after coronary artery bypass surgery: Might statins be the answer at the right dose to the right patient at the right time? J Thorac Cardiovasc Surg 2018; 157:162-163. [PMID: 30104062 DOI: 10.1016/j.jtcvs.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Cesario F Bianchi
- Technological and Biotechnological Research Centers, School of Medicine, University of Mogi das Cruzes, Mogi das Cruzes, São Paulo, Brazil.
| | - Orlando Petrucci
- Department of Surgery, Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field. RECENT FINDINGS Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation. SUMMARY Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.
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Alburikan KA, Nazer RI. Use of the guidelines directed medical therapy after coronary artery bypass graft surgery in Saudi Arabia. Saudi Pharm J 2017; 25:819-822. [PMID: 28951664 PMCID: PMC5605885 DOI: 10.1016/j.jsps.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 12/15/2016] [Indexed: 11/29/2022] Open
Abstract
Background: incidence of cardiovascular diseases in Saudi Arabia is growing and more patients are expected to have cardiac revascularization surgery. Optimal pharmacotherapy management with Guideline Directed Medical Therapy (GDMT) post coronary artery bypass grafting (CABG) plays an important role in the prevention of adverse cardiovascular outcomes. The objective of this study was to assess the utilization of GDMT for secondary prevention in CABG patients and determine whether specific patients' characteristics can influence GDMT utilization. Method: A retrospective chart review of patients discharged from the hospital after CABG surgery from April 2015 to April 2016. The primary outcome was the utilization of secondary prevention GDMT after CABG surgery - aspirin, B-blockers, statin and angiotensin-converting enzyme inhibitors (ACEI) (or angiotensin receptor blockers (ARB) in ACEI-intolerant patients). The proportions of eligible and ideal patients who received treatment were calculated, and mixed-effects logistic regression was used to estimate odds ratios (OR) for the association of age, gender or patient nationality with the use of GDMT. Results: A total number of 119 patients included in the analysis. The median age of the cohort was 57.3 ± 11 years, and 83% were male (83.2%). Nearly 69.7% of patients had diabetes, and 82% had a previous diagnosis of hypertension. Nearly 91% received aspirin therapy and the rate was lower for B-blocker and statin. The rate of GDMT utilization did not change with the change in patient’s age, gender or nationality. Conclusion: Despite adjustments for contraindications to GDMT, the rate of GDMT utilization was suboptimal.
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Affiliation(s)
- Khalid A. Alburikan
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Corresponding author at: College of Pharmacy, King Saud University, P.O. Box 2475, Riyadh 11451, Saudi Arabia. Fax: +966 11 4678847.College of PharmacyKing Saud UniversityP.O. Box 2475Riyadh11451Saudi Arabia
| | - Rakan I. Nazer
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Cumulative in-trial and post-trial effects of blood pressure and lipid lowering: systematic review and meta-analysis. J Hypertens 2017; 35:905-913. [PMID: 28060187 DOI: 10.1097/hjh.0000000000001233] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Persistent long-term benefits after discontinuation of treatment have been suggested for blood pressure-lowering and lipid-lowering treatment. We conducted a systematic review to assess the long-term effects of blood pressure (BP) lowering (BPL) and lipid lowering on all-cause and cardiovascular mortality after discontinuation of randomized treatment. METHODS We systematically searched Medline, Embase, and the Cochrane Central Register of Controlled Trials. We included large-scale randomized controlled trials of BPL or lipid lowering of at least 1 year with post-trial follow-up. We identified 13 BPL trials with 48 892 participants and 10 lipid-lowering trials with 71 370 participants. Mean in-trial and post-trial follow-up was approximately 4 and 6 years, respectively. RESULTS BP and lipid levels tended to come together soon in the post-trial period. There was significant benefit of BPL on all-cause mortality during the in-trial period (relative risk 0.85, 95% confidence interval 0.81-0.89), and significant, but attenuated, benefit during overall follow-up (0.91, 0.87-0.94). Likewise, lipid lowering with statins reduced the risk of all-cause mortality during the in-trial period (0.88, 0.81-0.95), and this effect persisted during overall follow-up (0.92, 0.87-0.97). Similar findings were observed for cardiovascular death. In BPL trials, the cumulative reduction in all-cause mortality was significantly lower in trials with at least 5 years of post-trial follow-up compared with those with less than 5 years, and a similar tendency was observed for lipid-lowering trials. CONCLUSION Benefits of BPL and lipid lowering on all-cause and cardiovascular mortality were persistent, but attenuated, after discontinuation of randomized treatment, indicating the importance of continuing therapy.
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Kulik A, Abreu AM, Boronat V, Ruel M. Intensive versus moderate atorvastatin therapy and one-year graft patency after CABG: Rationale and design of the ACTIVE (Aggressive Cholesterol Therapy to Inhibit Vein Graft Events) randomized controlled trial (NCT01528709). Contemp Clin Trials 2017; 59:98-104. [DOI: 10.1016/j.cct.2017.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/04/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022]
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An J, Shi F, Liu S, Ma J, Ma Q. Preoperative statins as modifiers of cardiac and inflammatory outcomes following coronary artery bypass graft surgery: a meta-analysis. Interact Cardiovasc Thorac Surg 2017; 25:958-965. [DOI: 10.1093/icvts/ivx172] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/26/2017] [Indexed: 12/14/2022] Open
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McKavanagh P, Yanagawa B, Zawadowski G, Cheema A. Management and Prevention of Saphenous Vein Graft Failure: A Review. Cardiol Ther 2017; 6:203-223. [PMID: 28748523 PMCID: PMC5688971 DOI: 10.1007/s40119-017-0094-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 12/16/2022] Open
Abstract
Coronary artery bypass grafting (CABG) remains a vital treatment for patients with multivessel coronary artery disease (CAD), especially diabetics. The long-term benefit of the internal thoracic artery graft is well established and remains the gold standard for revascularization of severe CAD. It is not always possible to achieve complete revascularization through arterial grafts, necessitating the use of saphenous vein grafts (SVG). Unfortunately, SVGs do not have the same longevity, and their failure is associated with significant adverse cardiac outcomes and mortality. This paper reviews the pathogenesis of SVG failure, highlighting the difference between early, intermediate, and late failure. It also addresses the different surgical techniques that affect the incidence of SVG failure, as well as the medical and percutaneous prevention and treatment options in contemporary practice.
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Affiliation(s)
- Peter McKavanagh
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Bobby Yanagawa
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - George Zawadowski
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Asim Cheema
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
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Salinas HM, Khan SI, McCormack MC, Fernandes JR, Gfrerer L, Watkins MT, Redmond RW, Austen WG. Prevention of vein graft intimal hyperplasia with photochemical tissue passivation. J Vasc Surg 2017; 65:190-196. [DOI: 10.1016/j.jvs.2015.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
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Boire TC, Balikov DA, Lee Y, Guth CM, Cheung-Flynn J, Sung HJ. Biomaterial-Based Approaches to Address Vein Graft and Hemodialysis Access Failures. Macromol Rapid Commun 2016; 37:1860-1880. [PMID: 27673474 PMCID: PMC5156561 DOI: 10.1002/marc.201600412] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/15/2016] [Indexed: 12/19/2022]
Abstract
Veins used as grafts in heart bypass or as access points in hemodialysis exhibit high failure rates, thereby causing significant morbidity and mortality for patients. Interventional or revisional surgeries required to correct these failures have been met with limited success and exorbitant costs, particularly for the US Centers for Medicare & Medicaid Services. Vein stenosis or occlusion leading to failure is primarily the result of neointimal hyperplasia. Systemic therapies have achieved little long-term success, indicating the need for more localized, sustained, biomaterial-based solutions. Numerous studies have demonstrated the ability of external stents to reduce neointimal hyperplasia. However, successful results from animal models have failed to translate to the clinic thus far, and no external stent is currently approved for use in the US to prevent vein graft or hemodialysis access failures. This review discusses current progress in the field, design considerations, and future perspectives for biomaterial-based external stents. More comparative studies iteratively modulating biomaterial and biomaterial-drug approaches are critical in addressing mechanistic knowledge gaps associated with external stent application to the arteriovenous environment. Addressing these gaps will ultimately lead to more viable solutions that prevent vein graft and hemodialysis access failures.
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Affiliation(s)
- Timothy C Boire
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Daniel A Balikov
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Yunki Lee
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Christy M Guth
- Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37235, USA
| | - Joyce Cheung-Flynn
- Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37235, USA
| | - Hak-Joon Sung
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
- Severance Biomedical Science Institute, College of Medicine, Yonsei University, Seoul, 120-752, Republic of Korea
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Collins R, Reith C, Emberson J, Armitage J, Baigent C, Blackwell L, Blumenthal R, Danesh J, Smith GD, DeMets D, Evans S, Law M, MacMahon S, Martin S, Neal B, Poulter N, Preiss D, Ridker P, Roberts I, Rodgers A, Sandercock P, Schulz K, Sever P, Simes J, Smeeth L, Wald N, Yusuf S, Peto R. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388:2532-2561. [PMID: 27616593 DOI: 10.1016/s0140-6736(16)31357-5] [Citation(s) in RCA: 1141] [Impact Index Per Article: 142.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023]
Abstract
This Review is intended to help clinicians, patients, and the public make informed decisions about statin therapy for the prevention of heart attacks and strokes. It explains how the evidence that is available from randomised controlled trials yields reliable information about both the efficacy and safety of statin therapy. In addition, it discusses how claims that statins commonly cause adverse effects reflect a failure to recognise the limitations of other sources of evidence about the effects of treatment. Large-scale evidence from randomised trials shows that statin therapy reduces the risk of major vascular events (ie, coronary deaths or myocardial infarctions, strokes, and coronary revascularisation procedures) by about one-quarter for each mmol/L reduction in LDL cholesterol during each year (after the first) that it continues to be taken. The absolute benefits of statin therapy depend on an individual's absolute risk of occlusive vascular events and the absolute reduction in LDL cholesterol that is achieved. For example, lowering LDL cholesterol by 2 mmol/L (77 mg/dL) with an effective low-cost statin regimen (eg, atorvastatin 40 mg daily, costing about £2 per month) for 5 years in 10 000 patients would typically prevent major vascular events from occurring in about 1000 patients (ie, 10% absolute benefit) with pre-existing occlusive vascular disease (secondary prevention) and in 500 patients (ie, 5% absolute benefit) who are at increased risk but have not yet had a vascular event (primary prevention). Statin therapy has been shown to reduce vascular disease risk during each year it continues to be taken, so larger absolute benefits would accrue with more prolonged therapy, and these benefits persist long term. The only serious adverse events that have been shown to be caused by long-term statin therapy-ie, adverse effects of the statin-are myopathy (defined as muscle pain or weakness combined with large increases in blood concentrations of creatine kinase), new-onset diabetes mellitus, and, probably, haemorrhagic stroke. Typically, treatment of 10 000 patients for 5 years with an effective regimen (eg, atorvastatin 40 mg daily) would cause about 5 cases of myopathy (one of which might progress, if the statin therapy is not stopped, to the more severe condition of rhabdomyolysis), 50-100 new cases of diabetes, and 5-10 haemorrhagic strokes. However, any adverse impact of these side-effects on major vascular events has already been taken into account in the estimates of the absolute benefits. Statin therapy may cause symptomatic adverse events (eg, muscle pain or weakness) in up to about 50-100 patients (ie, 0·5-1·0% absolute harm) per 10 000 treated for 5 years. However, placebo-controlled randomised trials have shown definitively that almost all of the symptomatic adverse events that are attributed to statin therapy in routine practice are not actually caused by it (ie, they represent misattribution). The large-scale evidence available from randomised trials also indicates that it is unlikely that large absolute excesses in other serious adverse events still await discovery. Consequently, any further findings that emerge about the effects of statin therapy would not be expected to alter materially the balance of benefits and harms. It is, therefore, of concern that exaggerated claims about side-effect rates with statin therapy may be responsible for its under-use among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.
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Affiliation(s)
- Rory Collins
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Christina Reith
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Armitage
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lisa Blackwell
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Roger Blumenthal
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Danesh
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - David DeMets
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Stephen Evans
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Malcolm Law
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stephen MacMahon
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Seth Martin
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Neil Poulter
- International Centre for Circulatory Health & Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - David Preiss
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Schulz
- FHI 360, University of North Carolina School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - John Simes
- National Health and Medical Research Council Clinical Trial Centre, University of Sydney, Sydney, Australia
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Nicholas Wald
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Richard Peto
- Clinical Trial Service Unit & Epidemiological Studies Unit and MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Li M, Zou H, Xu G. The prevention of statins against AKI and mortality following cardiac surgery: A meta-analysis. Int J Cardiol 2016; 222:260-266. [DOI: 10.1016/j.ijcard.2016.07.173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
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Samak M, Fatullayev J, Sabashnikov A, Zeriouh M, Schmack B, Ruhparwar A, Karck M, Popov AF, Dohmen PM, Weymann A. Total Arterial Revascularization: Bypassing Antiquated Notions to Better Alternatives for Coronary Artery Disease. Med Sci Monit Basic Res 2016; 22:107-114. [PMID: 27698339 PMCID: PMC5063431 DOI: 10.12659/msmbr.901508] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Total arterial revascularization is the leading trend in coronary artery bypass grafting (CABG) for the treatment of coronary artery disease (CAD). Adding to its superiority to vein conduits, arteries allow for a high degree of versatility and long-term patency, while minimizing the need for reintervention. This is especially important for patients with multi-vessel coronary artery disease, as well as young patients. However, arterial revascularization has come a long way before being widely appreciated, with some yet unresolved debates, and advances that never cease to impress. In this review, we discuss the evolution of this surgical technique and its clinical success, as well as its most conspicuous limitations in light of accumulated published date from decades of experience.
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Affiliation(s)
- Mostafa Samak
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Javid Fatullayev
- Department of Cardiothoracic Surgery, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Bastian Schmack
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, London, United Kingdom
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, London, United Kingdom
| | - Pascal M Dohmen
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Eisen A, Cannon CP, Blazing MA, Bohula EA, Park JG, Murphy SA, White JA, Giugliano RP, Braunwald E. The benefit of adding ezetimibe to statin therapy in patients with prior coronary artery bypass graft surgery and acute coronary syndrome in the IMPROVE-IT trial. Eur Heart J 2016; 37:3576-3584. [PMID: 27569841 DOI: 10.1093/eurheartj/ehw377] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/08/2016] [Accepted: 08/08/2016] [Indexed: 02/07/2023] Open
Abstract
AIMS To examine the efficacy and safety of ezetimibe added to statin in patients with prior coronary artery bypass graft surgery (CABG) following hospitalization for an acute coronary syndrome (ACS). METHODS AND RESULTS In the IMPROVE-IT trial, post-ACS patients with mean low density lipoprotein cholesterol (LDL-C) of 93.8 mg/dL at presentation were randomized to simvastatin/ezetimibe or simvastatin/placebo. The primary endpoint was cardiovascular death, major coronary event or stroke, and the median follow-up was 6 years. Efficacy and safety endpoints were examined by prior CABG status. Among 18 134 patients, 1684 (9.3%) had a prior CABG (median age 69 years, 82% male). During the trial, the median time-weighted LDL-C level was 55.0 mg/dL with simvastatin/ezetimibe vs. 69.9 mg/dL with simvastatin/placebo in patients with prior CABG (P < 0.001), and it was 53.6 mg/dL vs. 69.5 mg/dL, respectively, in patients without prior CABG (P < 0.001). The rate of the primary endpoint was higher in patients with vs. without prior CABG [56% vs. 32%, adj. hazard ratio 1.45, 95% confidence interval (CI) 1.33-1.58]. Patients with prior CABG receiving simvastatin/ezetimibe had an 8.8% (95% CI 3.1-14.6%) lower absolute risk over simvastatin/placebo in the primary endpoint, whereas patients without prior CABG had a 1.3% (95% CI 0-2.6%) lower absolute risk (P-interaction = 0.02). There were no between-group significant differences in safety endpoints. CONCLUSION The clinical benefit of adding ezetimibe to statin appears to be enhanced in patients with prior CABG, supporting the use of intensive lipid lowering therapy in these high-risk patients following ACS.
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Affiliation(s)
- Alon Eisen
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | - Christopher P Cannon
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | | | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | | | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
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Kuhn EW, Slottosch I, Wahlers T, Liakopoulos OJ. WITHDRAWN: Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2016; 2016:CD008493. [PMID: 27219528 PMCID: PMC6483147 DOI: 10.1002/14651858.cd008493.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This review has been withdrawn as authors are unable to complete the updating process. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Elmar W Kuhn
- Heart Center, University of CologneDepartment of Cardiothoracic SurgeryKerpener Strasse 62CologneGermany50924
| | - Ingo Slottosch
- Heart Center, University of CologneDepartment of Cardiothoracic SurgeryKerpener Strasse 62CologneGermany50924
| | - Thorsten Wahlers
- Heart Center, University of CologneDepartment of Cardiothoracic SurgeryKerpener Strasse 62CologneGermany50924
| | - Oliver J Liakopoulos
- Heart Center, University of CologneDepartment of Cardiothoracic SurgeryKerpener Strasse 62CologneGermany50924
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Collet JP, Halvorsen S, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Ricci F, Sibbing D, Siegbahn A, Storey RF, Ten Berg J, Verheugt FWA, Weitz JI. Oral anticoagulants in coronary heart disease (Section IV). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2016; 115:685-711. [PMID: 26952877 DOI: 10.1160/th15-09-0703] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 01/29/2016] [Indexed: 11/05/2022]
Abstract
Until recently, vitamin K antagonists (VKAs) were the only available oral anticoagulants evaluated for long-term treatment of patients with coronary heart disease (CHD), particularly after an acute coronary syndrome (ACS). Despite efficacy in this setting, VKAs are rarely used because they are cumbersome to administer. Instead, the more readily manageable antiplatelet agents are the mainstay of prevention in ACS patients. This situation has the potential to change with the introduction of non-VKA oral anticoagulants (NOACs), which are easier to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. The NOACs include dabigatran, which inhibits thrombin, and apixaban, rivaroxaban and edoxaban, which inhibit factor Xa. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischaemia in ACS patients, most of whom were also receiving dual antiplatelet therapy with aspirin and clopidogrel. Although at the doses tested rivaroxaban was effective and apixaban was not, both agents increased major bleeding. The role for the NOACs in ACS management, although promising, is therefore complicated, because it is uncertain how they compare with newer antiplatelet agents, such as prasugrel, ticagrelor or vorapaxar, and because their safety in combination with these other drugs is unknown. Ongoing studies are also now evaluating the use of NOACs in non-valvular atrial fibrillation patients, where their role is established, with coexistent ACS or coronary stenting. Focusing on CHD, we review the results of clinical trials with the NOACs and provide a perspective on their future incorporation into clinical practice.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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Indications, algorithms, and outcomes for coronary artery bypass surgery in patients with acute coronary syndromes. Coron Artery Dis 2016; 27:319-26. [PMID: 26945187 DOI: 10.1097/mca.0000000000000364] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
For patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), guideline recommendations and treatment pathways focus on revascularization for definitive treatment if the patient is an appropriate candidate. Despite the widespread use of revascularization for NSTE-ACS, most patients undergo a percutaneous coronary intervention, whereas a minority of patients undergo coronary artery bypass grafting. Focusing specifically on the USA, the contemporary utilization, preoperative and perioperative considerations, and outcomes of NSTE-ACS patients undergoing coronary artery bypass grafting have not been comprehensively reviewed.
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Meta-Analysis of Medium and Long-Term Efficacy of Loading Statins After Coronary Artery Bypass Grafting. Ann Thorac Surg 2016; 101:990-5. [DOI: 10.1016/j.athoracsur.2015.08.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 11/20/2022]
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Leunissen TC, Janssen PW, ten Berg JM, Moll FL, Korporaal SJ, de Borst GJ, Pasterkamp G, Urbanus RT. The use of platelet reactivity testing in patients on antiplatelet therapy for prediction of bleeding events after cardiac surgery. Vascul Pharmacol 2016; 77:19-27. [DOI: 10.1016/j.vph.2015.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
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Kuhn EW, Slottosch I, Wahlers T, Liakopoulos OJ. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2015:CD008493. [PMID: 26270008 DOI: 10.1002/14651858.cd008493.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients referred to cardiac surgery for cardiovascular disease are at significant risk for the development of major postoperative adverse events despite significant advances in surgical techniques and perioperative care. Statins (5-hydroxy-3-methylglutaryl-co-enzyme A (HMG-CoA) reductase inhibitors) have gained a pivotal role in the primary and secondary prevention of coronary artery disease and are thought to improve perioperative outcomes in patients undergoing cardiac surgery. This review is an updated version of a review that was first published in 2012. OBJECTIVES To determine the effectiveness of preoperative statin therapy in patients undergoing cardiac surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11), MEDLINE (1950 to November 2013 Week 3), EMBASE (1980 to 3 December 2013 (Week 48)) and the metaRegister of Controlled Trials. Additionally, we searched ongoing trials through the National Research Register, the ClinicalTrials.gov registry and grey literature. We screened online conference indices from relevant scientific meetings (2006 to 2014) to look for eligible trials. We applied no language restrictions. SELECTION CRITERIA All randomised controlled trials comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. DATA COLLECTION AND ANALYSIS Two review authors evaluated trial quality and extracted data from titles and abstracts identified by electronic database searches according to predefined criteria. Accordingly, we retrieved full-text articles of potentially relevant studies that met the inclusion criteria to assess definitive eligibility for inclusion. We reported effect measures as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). MAIN RESULTS We identified 17 randomised controlled studies including a total of 2138 participants undergoing on-pump or off-pump cardiac surgical procedures, and added to this review six studies with 1154 additional participants. Pooled analysis showed that statin treatment before surgery reduced the incidence of postoperative atrial fibrillation (AF) (OR 0.54, 95% CI 0.43 to 0.67; P value < 0.01; 12 studies, 1765 participants) but failed to influence short-term mortality (OR 1.80, 95% CI 0.38 to 8.54; P value = 0.46; two studies, 300 participants) or postoperative stroke (OR 0.70, 95% CI 0.14 to 3.63; P value = 0.67; two studies, 264 participants). In addition, statin therapy was associated with a shorter stay for patients on the intensive care unit (ICU) (WMD -3.19 hours, 95% CI -5.41 to -0.98; nine studies, 721 participants) and in the hospital (WMD -0.48 days, 95% CI -0.78 to -0.19; 11 studies, 1137 participants) when significant heterogeneity was observed. Results showed no reduction in myocardial infarction (OR 0.48, 95% CI 0.21 to 1.13; seven studies, 901 participants) or renal failure (OR 0.57, 95% CI 0.30 to 1.10; five studies, 467 participants) and were not affected by subgroup analysis. Trials investigating this safety endpoint reported no major or minor perioperative side effects of statins. AUTHORS' CONCLUSIONS Preoperative statin therapy reduces the odds of postoperative atrial fibrillation (AF) and shortens the patient's stay on the ICU and in the hospital. Statin pretreatment had no influence on perioperative mortality, stroke, myocardial infarction or renal failure, but only two of all included studies assessed mortality. As analysed studies included mainly individuals undergoing myocardial revascularisation, results cannot be extrapolated to patients undergoing other cardiac procedures such as heart valve or aortic surgery.
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Affiliation(s)
- Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Kerpener Strasse 62, Cologne, Germany, 50924
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Preoperative Statin Therapy and Renal Outcomes After Cardiac Surgery: A Meta-analysis and Meta-regression of 59,771 Patients. Can J Cardiol 2015; 31:1051-60. [DOI: 10.1016/j.cjca.2015.02.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/21/2015] [Accepted: 02/21/2015] [Indexed: 11/21/2022] Open
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Liakopoulos OJ, Kuhn EW, Hellmich M, Kuhr K, Krause P, Reuter H, Thurat M, Choi YH, Wahlers T. Statin Recapture Therapy before Coronary Artery Bypass Grafting Trial: Rationale and study design of a multicenter, randomized, double-blinded controlled clinical trial. Am Heart J 2015; 170:46-54, 54.e1-2. [PMID: 26093863 DOI: 10.1016/j.ahj.2015.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Patients undergoing coronary artery bypass grafting (CABG) are still at significant risk for postoperative major adverse cardiac and cerebrovascular events (MACCEs). Recent clinical evidence shows that cardioprotection in patients receiving a chronic statin treatment can be "recaptured" by a high-dose statin therapy given shortly before an ischemia-reperfusion sequence. Evaluation of this novel therapeutic approach in the setting of CABG seems promising because myocardial ischemia-reperfusion injury plays a pivotal role in poor clinical outcomes that may be improved by a simple preoperative statin recapture treatment. METHODS The investigator-initiated StaRT-CABG trial is a multicenter, randomized, double-blinded, 2-parallel group controlled clinical study in 2,630 patients. The trial aims to evaluate whether a high-dose statin recapture therapy given shortly before CABG reduces the incidence of MACCE at 30 days after surgery (primary composite outcome: all-cause mortality, nonfatal myocardial infarction, and cerebrovascular events). Consenting patients who are on chronic statin therapy before surgery will be randomized to receive either oral statin reloading therapy or matching placebo 12 and 2 hours before CABG. Key secondary end points include enzymatic myocardial injury; new-onset atrial fibrillation; length of stay in the intensive care unit and hospital; need for repeat coronary revascularization at 30 days; and, finally, all-cause mortality at 12 months after surgery. IMPLICATIONS The StaRT-CABG trial is expected to provide highly relevant clinical data on the efficacy of this novel therapeutic approach to optimize the care for patients with coronary artery disease undergoing CABG.
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Hermans MP, Bouenizabila E, Amoussou-Guenou DK, Ahn SA, Rousseau MF. Baseline diabetes as a way to predict CV outcomes in a lipid-modifying trial: a meta-analysis of 330,376 patients from 47 landmark studies. Cardiovasc Diabetol 2015; 14:60. [PMID: 25990410 PMCID: PMC4489105 DOI: 10.1186/s12933-015-0226-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetes is a major cardiovascular risk factor. However, its influence on the rate of occurrence of cardiovascular (CV) events during a clinical trial that included a diabetes subgroup has not yet been quantified. AIMS To establish equations relating baseline diabetes prevalence and incident CV events, based on comparator arms data of major lipid-modifying trials. METHODS Meta-analysis of primary outcomes (PO) rates of key prospective trials, for which the baseline proportion of diabetics was reported, including studies having specifically reported CV outcomes within their diabetic subgroups. RESULTS 47 studies, representing 330,376 patients (among whom 124,115 diabetics), were analyzed as regards the relationship between CV outcomes rates (including CHD) and the number of diabetics enrolled. Altogether, a total of 18,445 and 16,156 events occurred in the comparator and treatment arms, respectively. There were significant linear relationships between diabetes prevalence and both PO and CHD rates (%/year): y = 0.0299*x + 3.12 [PO] (p = 0.0128); and y = 0.0531*x + 1.54 [CHD] (p = 0.0094), baseline diabetes predicting PO rates between 3.12 %/year (no diabetic included) and 6.11 %/year (all patients diabetic); and CHD rates between 1.54 %/year (no diabetic) and 6.85 %/year (all patients diabetic). The slopes of the equations did not differ according to whether they were derived from primary or secondary prevention trials. CONCLUSIONS Absolute and relative CV risk associated with diabetes at inclusion can be readily predicted using linear equations relating diabetes prevalence to primary outcomes or CHD rates.
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Affiliation(s)
- Michel P Hermans
- Division of Endocrinology & Nutrition, Cliniques universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium.
| | - Evariste Bouenizabila
- Service de Maladies Métaboliques et Endocriniennes, Centre Hospitalier et Universitaire de Brazzaville, Brazzaville, Congo.
| | - Daniel K Amoussou-Guenou
- Service d'Endocrinologie et Métabolisme, CNHU HKM Cotonou, Université d'Abomey-Calavi, Abomey-Calavi, Bénin.
| | - Sylvie A Ahn
- Division of Cardiology, Cliniques universitaires St-Luc and Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium.
| | - Michel F Rousseau
- Division of Cardiology, Cliniques universitaires St-Luc and Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium.
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The Risk-Benefit Paradigm vs the Causal Exposure Paradigm: LDL as a primary cause of vascular disease. J Clin Lipidol 2014; 8:594-605. [DOI: 10.1016/j.jacl.2014.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 08/16/2014] [Accepted: 08/19/2014] [Indexed: 11/19/2022]
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Sur S, Sugimoto JT, Agrawal DK. Coronary artery bypass graft: why is the saphenous vein prone to intimal hyperplasia? Can J Physiol Pharmacol 2014; 92:531-45. [PMID: 24933515 DOI: 10.1139/cjpp-2013-0445] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proliferation and migration of smooth muscle cells and the resultant intimal hyperplasia cause coronary artery bypass graft failure. Both internal mammary artery and saphenous vein are the most commonly used bypass conduits. Although an internal mammary artery graft is immune to restenosis, a saphenous vein graft is prone to develop restenosis. We found significantly higher activity of phosphatase and tensin homolog (PTEN) in the smooth muscle cells of the internal mammary artery than in the saphenous vein. In this article, we critically review the pathophysiology of vein-graft failure with detailed discussion of the involvement of various factors, including PTEN, matrix metalloproteinases, and tissue inhibitor of metalloproteinases, in uncontrolled proliferation and migration of smooth muscle cells towards the lumen, and invasion of the graft conduit. We identified potential target sites that could be useful in preventing and (or) reversing unwanted consequences following coronary artery bypass graft using saphenous vein.
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Affiliation(s)
- Swastika Sur
- a Department of Biomedical Science, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
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Min JJ, Nam K, Kim TK, Kim HJ, Seo JH, Hwang HY, Kim KB, Murkin JM, Hong DM, Jeon Y. Relationship between early postoperative C-reactive protein elevation and long-term postoperative major adverse cardiovascular and cerebral events in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study. Br J Anaesth 2014; 113:391-401. [PMID: 24829443 DOI: 10.1093/bja/aeu099] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammation plays a key role in the pathogenesis of vascular occlusive diseases, such as myocardial infarction and stroke. Additionally, these conditions are predicted by C-reactive protein (CRP), a general inflammation marker. We hypothesized that the inflammation induced by surgery itself augments vascular occlusive disease. We retrospectively evaluated the relationship between postoperative CRP elevation and postoperative major adverse cardiovascular and cerebral events (MACCE) in patients undergoing off-pump coronary artery bypass surgery (OPCAB). METHODS The electronic medical records of 1046 patients who underwent OPCAB were reviewed retrospectively. The relationship between postoperative serum CRP and long-term postoperative MACCE (median follow-up 28 months) was investigated. RESULTS Patients were divided into quartiles according to maximum postoperative CRP levels (<18, 18-22, 22-27, ≥27 mg dl(-1)). The adjusted hazard ratios (HRs) were 2.15, 2.45, and 2.81, respectively (P=0.004), compared with the lowest quartile (<18 mg dl(-1)). In the multivariate analysis, the postoperative CRP quartile (HR 2.81; P=0.004), postoperative non-use of statins (HR 1.86; P=0.003), and postoperative maximum troponin I (HR 1.02; P<0.001) independently predicted postoperative MACCE, while preoperative CRP did not (P=0.203). Several parameters were correlated with postoperative maximum CRP level: body temperature (P=0.001) and heart rate (P<0.001) at the end of surgery; intraoperative last lactate (P<0.001) and base excess (P<0.001); and red blood cell transfusion (P=0.019). CONCLUSIONS Postoperative CRP elevation was associated with long-term postoperative MACCE in OPCAB patients. This was mitigated by postoperative statin medication. Furthermore, postoperative CRP elevation was associated with intraoperative parameters reflecting hypoperfusion and inflammation.
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Affiliation(s)
- J J Min
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - K Nam
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - T K Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - H J Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J H Seo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - H Y Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Daehakro 101, Jongno-gu 110-744, Seoul, Republic of Korea
| | - K B Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Daehakro 101, Jongno-gu 110-744, Seoul, Republic of Korea
| | - J M Murkin
- Department of Anesthesiology and Perioperative Medicine, Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - D M Hong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Y Jeon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Siegbahn A, Verheugt FWA, Weitz JI. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110:1087-107. [PMID: 24226379 DOI: 10.1160/th13-06-0443] [Citation(s) in RCA: 290] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/19/2013] [Indexed: 12/27/2022]
Abstract
Oral anticoagulants are a mainstay of cardiovascular therapy, and for over 60 years vitamin K antagonists (VKAs) were the only available agents for long-term use. VKAs interfere with the cyclic inter-conversion of vitamin K and its 2,3 epoxide, thus inhibiting γ-carboxylation of glutamate residues at the amino-termini of vitamin K-dependent proteins, including the coagulation factors (F) II (prothrombin), VII, IX and X, as well as of the anticoagulant proteins C, S and Z. The overall effect of such interference is a dose-dependent anticoagulant effect, which has been therapeutically exploited in heart disease since the early 1950s. In this position paper, we review the mechanisms of action, pharmacological properties and side effects of VKAs, which are used in the management of cardiovascular diseases, including coronary heart disease (where their use is limited), stroke prevention in atrial fibrillation, heart valves and/or chronic heart failure. Using an evidence-based approach, we describe the results of completed clinical trials, highlight areas of uncertainty, and recommend therapeutic options for specific disorders. Although VKAs are being increasingly replaced in most patients with non-valvular atrial fibrillation by the new oral anticoagulants, which target either thrombin or FXa, the VKAs remain the agents of choice for patients with atrial fibrillation in the setting of rheumatic valvular disease and for those with mechanical heart valves.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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