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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J Acute Cardiovasc Care 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 309] [Impact Index Per Article: 309.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Sharon A, Fishman B, Massalha E, Itelman E, Mouallem M, Fefer P, Barbash IM, Segev A, Matetzky S, Guetta V, Grossman E, Maor E. Management and outcome of patients with non-ST elevation myocardial infarction and intercurrent non-coronary precipitating events. Eur Heart J Acute Cardiovasc Care 2022; 11:922-930. [PMID: 36229932 DOI: 10.1093/ehjacc/zuac134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/25/2022] [Accepted: 10/11/2022] [Indexed: 12/29/2022]
Abstract
AIMS To evaluate the effect of an intercurrent non-coronary illness on the management and outcome of patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS AND RESULTS Consecutive hospitalized patients with a primary diagnosis of NSTEMI between August 2008 and December 2019 at Sheba Medical Center. All patients' records were reviewed for the presence of a non-coronary precipitating event (NCPE): a major intercurrent acute non-coronary illness or condition, either cardiac or non-cardiac. The primary outcome was all-cause mortality. Cox regression with interaction analysis was applied. Final study population comprised 6491 patients, of whom 2621 (40%) had NCPEs. Patients with NCPEs were older (77 vs. 69 years) and more likely to have comorbidities. The most prevalent event was infection (35%, n = 922). During a median follow-up of 30 months, 2529 patients died. Patients with NCPEs were 43% more likely to die during follow-up in a multivariable model (95% CI: 1.31-1.55). Invasive strategy was associated with a 55% lower mortality among patients without NCPE and only 44% among patients with NCPE (P for interaction < 0.001). Dual antiplatelet therapy (DAPT) was associated with a 20% lower mortality in patients without NCEP and a non-significant mortality difference among patients with NCPE (P for interaction = 0.014). Sub-analysis by the specific NCPE showed the highest mortality risk among patients with infectious precipitant. The lower mortality associated with invasive strategy was not observed in this subgroup. CONCLUSION Among NSTEMI patients, the presence of an NCPE is associated with poor survival and modifies the effect of management strategies.
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Affiliation(s)
- Amir Sharon
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Fishman
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eias Massalha
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward Itelman
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel
| | - Meir Mouallem
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paul Fefer
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel M Barbash
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Segev
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victor Guetta
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Grossman
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- The Olga & Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Li Y, Wang C, Nan Y, Zhao H, Cao Z, Du X, Wang K. Early invasive strategy for non-ST elevation acute coronary syndrome: a meta-analysis of randomized, controlled trials. J Int Med Res 2020; 48:300060520966500. [PMID: 33115315 PMCID: PMC7607294 DOI: 10.1177/0300060520966500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Patients with non-ST elevation acute coronary syndrome (NSTE-ACS) benefit from coronary intervention, but the optimal timing for an invasive strategy is not well defined. This study aimed to determine whether an early invasive strategy (<12 hours) is superior to a delayed invasive strategy. METHODS Twelve studies of nine randomized, controlled trials of 8586 patients were included. RESULTS There were no significant differences in all-cause death (risk ratio [95% confidence interval]) (0.90, [0.77-1.06), re-myocardial infarction (re-MI) (0.95 [0.70-1.29]), major bleeding (0.97 [0.77-1.23]), and refractory ischemia (0.74 [0.53-1.05]) when we compared use of early and delayed invasive strategies. Furthermore, analysis of the effect of the chosen strategy on high-risk patients showed that the rate of composite death or re-MI was significantly decreased in patients with either a Global Registry of Acute Coronary Events (GRACE) risk score >140 or with elevated troponin levels (risk ratio 0.82 [0.72-0.92]; risk ratio 0.84 [0.76-0.93], respectively). CONCLUSIONS This meta-analysis shows that an early angiographic strategy does not improve clinical outcome in patients with NSTE-ACS. An early invasive strategy might reduce the rate of composite death or re-MI in high-risk patients with GRACE risk scores >140 or elevated cardiac markers.
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Affiliation(s)
- Ying Li
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Cuancuan Wang
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Yue Nan
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Hui Zhao
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Zhongnan Cao
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Xinping Du
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Kuan Wang
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
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Siow SL, Goo ZQ, Mahendran HA, Wong CM. Laparoscopic versus open management of adult intussusception. Surg Endosc 2020; 34:4429-35. [PMID: 31617099 DOI: 10.1007/s00464-019-07220-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparotomy has been the traditional approach for the treatment of adult intussusception. The aim of the present study was to compare the short-term clinical outcomes of laparoscopic surgery to those of open surgery in adult patients with intussusception. METHODS We retrospectively reviewed data of all adult patients with intussusception admitted to our hospital between 2007 and 2017. The patients' characteristics, presentation, operation details, postoperative outcomes and pathology were analyzed. Comparisons were made between the laparoscopic and open surgery procedures performed during the study period. RESULTS Seventeen open and 20 laparoscopic-assisted resections were performed. No significant differences were found between the two groups for the following parameters: age (45.3 ± 16.8 vs. 54.9 ± 19.1, p = 0.160); gender (41 vs. 60% males, p = 0.330); American Society of Anesthesiologists score (p = 0.609); history of cardiovascular disease (5.9% vs. 5.6%, p = 0.950), COPD/asthma (0% vs. 5.6%, p = 0.950), diabetes (11.8% vs. 11.1%, p = 0.950), and renal impairment (5.9% vs. 0%, p = 0.486); body mass index (20.6 vs. 21.9, p = 0.433); timing of presentation (p = 1.000); type of intussusception (p = 0.658); type of procedures (p = 0.446); operative time (173.7 ± 45.4 vs. 191.5 ± 43.9, p = 0.329); and length of postoperative stay (6.7 ± 5.4 vs. 4.5 ± 1.1 days, p = 0.153). However, the open surgery group had fewer patients with hypertension (17.6% vs. 61.1%, p = 0.009) and demonstrated a delayed oral intake (4.0 ± 1.7 days vs. 2.5 ± 0.7 days, p = 0.010) and a higher comprehensive complication index (11.5 ± 27.1 vs. 0, p = 0.038). CONCLUSIONS The laparoscopic approach was associated with earlier oral intake and a lower comprehensive complication index. It is a safe and feasible technique that confers the advantages of minimally invasive surgery. It can be considered the preferred surgical option when the surgical expertise is available.
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Kvakkestad KM, Gran JM, Eritsland J, Holst Hansen C, Fossum E, Andersen GØ, Halvorsen S. Long-Term Survival after Invasive or Conservative Strategy in Elderly Patients with non-ST-Elevation Myocardial Infarction: A Prospective Cohort Study. Cardiology 2019; 144:79-89. [PMID: 31689705 DOI: 10.1159/000503442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/18/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) is still discussed. We aimed to study short- and long-term survival in NSTEMI patients ≥75 years managed with an invasive or a conservative strategy. METHODS NSTEMI patients admitted to Oslo University Hospital Ulleval during 2005-2011 were included consecutively in a prospective registry. Vital status until December 31, 2013, was obtained from the Norwegian Cause of Death Registry. Patients ≥75 years were identified, and 30-day and 7-year survival were analyzed. Logistic- and Cox regression was used to estimate OR and hazard ratio (HR) for death in the invasive versus conservative group, adjusting for registered confounders. RESULTS There were 2,064 NSTEMI patients ≥75 years (48.2% women); 1,200 (58.1%) were treated with an invasive strategy, and were younger, more likely to be male and previously revascularized compared to 864 (41.9%) patients treated conservatively (p < 0.0001 for all). Survival at 30-day was 94.9% in the invasive and 76.6% in the conservative group. For 30-day survivors, 7-year survival was 47.4% (95% CI 42.9-51.8) and 11.6% (95% CI 8.3-15.6), respectively. After multivariate adjustment, an invasive strategy was associated with lower long-term risk (adjusted HR [aHR] 0.49 [95% CI 0.41-0.59]). Actual revascularization was associated with lower risk of long-term mortality compared to angiography only (aHRPCI 0.73 [95% CI 0.59-0.90], aHRCABG 0.43 [95% CI 0.28-0.65]). CONCLUSION In this real-life cohort of NSTEMI patients ≥75 years, 30-day survival was 95%, and 7-year survival was 47% with an invasive strategy. Revascularized patients had a superior long-term prognosis. With a conservative strategy, short- and long-term survival was lower, probably due to selection bias and unmeasured confounding.
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Affiliation(s)
- Kristin Marie Kvakkestad
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway, .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway, .,Department of Medicine, Østfold Hospital, Kalnes, Grålum, Norway,
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jan Eritsland
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Eigil Fossum
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Sui YG, Teng SY, Qian J, Wu Y, Dou KF, Tang YD, Qiao SB, Wu YJ. Invasive versus conservative strategy in consecutive patients aged 80 years or older with non-ST-segment elevation myocardial infarction: a retrospective study in China. J Geriatr Cardiol 2019; 16:741-8. [PMID: 31700513 DOI: 10.11909/j.issn.1671-5411.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To investigate whether the very elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) will benefit from an invasive strategy versus a conservative strategy. METHODS 190 consecutive patients aged 80 years or older with NSTEMI were included in the retrospective study from September 2014 to August 2017, of which 69 patients received conservative strategy and 121 patients received invasive strategy. The primary outcome was death. Multivariate Cox regression models were used to assess the statistical association between strategies and mortality. The survival probability was further analyzed. RESULTS The primary outcome occurred in 17.4% patients in the invasive group and in 42.0% patients in the conservative group (P = 0.0002). The readmission rate in the invasive group (14.9%) was higher than that in the conservative group (7.2%). Creatinine level (OR = 1.01, 95% CI: 0.10-1.03, P = 0.05) and use of diuretic (OR = 3.65, 95% CI: 1.56-8.53, P = 0.003) were independent influential factors for invasive strategy. HRs for multivariate Cox regression models were 3.45 (95% CI: 1.77-6.75, P = 0.0003), 3.02 (95% CI: 1.52-6.01, P = 0.0017), 2.93 (95% CI: 1. 46-5.86, P = 0.0024) and 2.47 (95% CI: 1.20-5.07, P = 0.0137). Compared with the patients received invasive strategy, the conservative group had remarkably reduced survival probability with time since treatment (P < 0.001). CONCLUSIONS An invasive strategy is superior to a conservative strategy in reducing mortality of patients aged 80 years or older with NSTEMI. Our results suggest that an invasive strategy is more suitable for the very elderly patients with NSTEMI in China.
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Llaó I, Gómez-Hospital JA, Aboal J, Garcia C, Montero S, Sambola A, Ortiz J, Tomás C, Bonet G, Viñas D, Oliveras T, Sans-Roselló J, Cantalapiedra J, Andrea R, Hernández I, Pérez-Rodriguez M, Gual M, Cequier A, Ariza-Solé A. Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units. Med Intensiva 2019; 44:475-484. [PMID: 31362838 DOI: 10.1016/j.medin.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/27/2019] [Accepted: 06/01/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU). DESIGN A prospective cohort study was carried out. SETTING The ICCUs of 8 hospitals in Catalonia (Spain). PATIENTS Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria. INTERVENTIONS EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients. OUTCOME VARIABLES Mortality or readmission at 6 months. RESULTS A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035). CONCLUSIONS The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.
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Affiliation(s)
- I Llaó
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - J A Gómez-Hospital
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - J Aboal
- Unidad de Cuidados Intensivos Cardiolígicos, Servicio de Cardiología, Hospital Universitari Josep Trueta, Girona, España
| | - C Garcia
- Unidad de Cuidados Intensivos Cardiolígicos, Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - S Montero
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica IIB Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - A Sambola
- Unidad de Cuidados Intensivos cardiológicos. Hospital Universitari de la Vall d'Hebron, Barcelona, España
| | - J Ortiz
- Unidad de Cuidados Intensivos cardiológicos. Hospital Clínic i Provincial, Barcelona, España
| | - C Tomás
- Unidad de Cuidados Intensivos cardiológicos. Hospital Arnau de Vilanova, Lleida, España
| | - G Bonet
- Unidad de Cuidados Intensivos cardiológicos. Hospital Joan XXIII, Tarragona, España
| | - D Viñas
- Unidad de Cuidados Intensivos Cardiolígicos, Servicio de Cardiología, Hospital Universitari Josep Trueta, Girona, España
| | - T Oliveras
- Unidad de Cuidados Intensivos Cardiolígicos, Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - J Sans-Roselló
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica IIB Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - J Cantalapiedra
- Unidad de Cuidados Intensivos Cardiolígicos, Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - R Andrea
- Unidad de Cuidados Intensivos cardiológicos. Hospital Arnau de Vilanova, Lleida, España
| | - I Hernández
- Unidad de Cuidados Intensivos cardiológicos. Hospital Arnau de Vilanova, Lleida, España
| | - M Pérez-Rodriguez
- Unidad de Cuidados Intensivos cardiológicos. Hospital Joan XXIII, Tarragona, España
| | - M Gual
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - A Cequier
- Servicio de Cardiología. Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - A Ariza-Solé
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
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Ma W, Liang Y, Zhu J. Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis. Heart Lung Circ 2017; 27:611-620. [PMID: 28802810 DOI: 10.1016/j.hlc.2017.06.725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 04/11/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld. METHODS We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy. RESULTS Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies. CONCLUSION Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.
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Affiliation(s)
- Wenfang Ma
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Yan Liang
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Jun Zhu
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Olivari Z, Chinaglia A, Gonzini L, Falsini G, Pilleri A, Valente S, Gregori G, Rollo R, My L, Scrimieri P, Lanzillo T, Corrado L, Chiti M, Picardi E. Invasive strategy in non-ST-segment elevation acute coronary syndrome: What should be the benchmark target in the real world patients? Insights from BLITZ-4 Quality Campaign. Int J Cardiol 2016; 220:761-7. [PMID: 27393863 DOI: 10.1016/j.ijcard.2016.06.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/20/2016] [Accepted: 06/21/2016] [Indexed: 11/28/2022]
Abstract
AIMS To define a benchmark target for an invasive strategy (IS) rate appropriate for performance assessment in intermediate-to-high risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS). METHODS AND RESULTS During the BLITZ-4 campaign, which aimed at improving the quality of care in 163 Italian coronary care units, 4923/5786 (85.1%) of consecutive patients admitted with NSTE-ACS with troponin elevation and/or dynamic ST-T changes on the electrocardiogram were managed with IS. The reasons driving the choice (RDC) for a conservative strategy (CS) in the remaining 863 patients were prospectively recorded. In 33.8%, CS was mandatory because of patients refusal, known coronary anatomy or death before coronary angiography; in 52.8% it was clinically justified because of active stroke, bleeding, advanced frailty, severe comorbidities, contraindication to antiplatelet therapy or because they were considered to be at low risk; only in 13.4% the reasons, such as renal failure, advanced age or other, were less stringent. As compared to patients undergoing IS, those in the CS were 12years older and had significantly more severe comorbidities. The in-hospital and 6-month all-cause mortality were 9.0% vs 0.9% and 22.0% vs 3.9% in CS and IS groups respectively (p<0.0001 for both). CONCLUSION As the RDC for CS were clinically correct in vast majority of cases the observed 85% invasive strategy rate may be considered as the desirable benchmark target in patients with NSTE-ACS. For the same reason, it remains questionable if the higher rate of IS could have improved the prognosis in CS patients, despite their highly unfavorable prognosis.
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Affiliation(s)
- Zoran Olivari
- UOC Cardiologia, Ospedale Cà Foncello, Treviso, Italy.
| | | | | | | | | | - Serafina Valente
- Clinica Cardiologia Gen. Interventistica, AOU Careggi, Firenze, Italy
| | | | | | - Luigi My
- Cardiologia, Casa di Cura Villa Verde, Taranto, Italy
| | - Pietro Scrimieri
- UOC Cardiologia UTIC Emodinamica, Ospedale Belcolle, Viterbo, Italy
| | | | - Luigi Corrado
- SC Cardiologia, Ospedale Sant'Andrea, Vercelli, Italy
| | | | - Elisa Picardi
- SC Cardiologia, Ospedale Maria Vittoria, Turin, Italy
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Liu J, Zhu Y, Shen Y, Liu S, Wang M, Zhao X, Nie Y, Chen J. The feasibility of laparoscopic management of incarcerated obturator hernia. Surg Endosc 2016; 31:656-660. [PMID: 27287915 DOI: 10.1007/s00464-016-5016-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting. METHODS Data pertaining to patients diagnosed with incarcerated OH between 2011 and April 2015 at our hospital were reviewed. Patients' characteristics, operation details and postoperative outcomes were retrospectively analyzed. RESULTS All ten patients diagnosed with incarcerated obturator hernia during the reference period were females (average age 72.1 ± 11.8 years; average weight 44.1 ± 6.9 kg; average body mass index 17.8 ± 2.1 kg/m2; average operating time 63 ± 15 min; average hospital stay 6.2 ± 6.6 days). Twelve occult hernias, including six contralateral OHs, two ipsilateral femoral hernias and two bilateral femoral hernias were detected in six patients (60 %), which were simultaneously repaired after laparoscopic exploration. Nine patients (90 %) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Postoperative period was uneventful in the other nine patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6-54 months). CONCLUSION In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. In addition to being a safe and minimally invasive strategy, it allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.
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Affiliation(s)
- Jing Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yilin Zhu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yingmo Shen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Sujun Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Minggang Wang
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Xuefei Zhao
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yusheng Nie
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Jie Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China.
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Wayangankar SA, Roe MT, Chen AY, Gupta RS, Giugliano RP, Newby LK, de Lemos JA, Alexander KP, Sanborn TA, Saucedo JF. Trends in use of anti-thrombotic agents and outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) managed with an invasive strategy. Indian Heart J 2016; 68:464-72. [PMID: 27543467 PMCID: PMC4990733 DOI: 10.1016/j.ihj.2015.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/09/2015] [Accepted: 09/29/2015] [Indexed: 11/28/2022] Open
Abstract
Objective To analyze trends in utilization of anti-thrombotic agents (ATA) and in-hospital clinical outcomes in non-ST-elevation myocardial infarction (NSTEMI) patients managed with an invasive strategy from 2007 to 2010. Methods & results Using ACTION Registry®-GWTG™ data, we analyzed trends in use of ATA and in-hospital clinical outcomes among 64,199 NSTEMI patients managed invasively between 2007 and 2010. ATA included unfractionated heparin (UFH), low molecular weight heparin (LMWH), glycoprotein IIb/IIIa inhibitors (GPI) and bivalirudin. Although the proportion of NSTEMI patients treated with PCI within 48 h of hospital arrival was similar in 2007 and 2010, percentage use of bivalirudin (13.4–27.3%; p < 0.01) and UFH increased (60.0–67.5%, p < 0.01), and that of GPI (62.3–41.0%; p < 0.01) and LMWH (41.5–36.8%; p < 0.01) declined. Excess dosing of UFH (75.9–59.3%, p < 0.01), LMWH (9.6–5.2%; p < 0.01) and GPI (8.9–5.9%, p < 0.01) was also significantly lower in 2010 compared with 2007. Though in-hospital mortality rates were similar in 2007 and 2010 (2.3–1.9%, p = 0.08), the rates of in-hospital major bleeding (8.7–6.6%, p < 0.01) and non-CABG related RBC transfusion (6.3–4.6%, p < 0.01) were significantly lower in 2010 compared with 2007. Conclusion Compared with 2007, patients with NSTEMI, who were managed invasively in 2010 received GPI and LMWH less often and bivalirudin and UFH more frequently. There were sizeable reductions in the rates of excess dosing of UFH (though still occurred in 67% of patients), GPI and LMWH. In-hospital major bleeding complications and post-procedural RBC transfusion were lower in 2010 compared with 2007.
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Affiliation(s)
- S A Wayangankar
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States.
| | - M T Roe
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - A Y Chen
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - R S Gupta
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - R P Giugliano
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - L K Newby
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - J A de Lemos
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - K P Alexander
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - T A Sanborn
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
| | - J F Saucedo
- Cleveland Clinic, Cleveland, OH, United States; Duke Clinical Research Institute, Durham, NC, United States; Deaconess Hospital, Oklahoma City, OK, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; University of Texas Southwestern Medical Center, Dallas, TX, United States; Northshore University Health System, Evanston, IL, United States
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Kocas B, Abaci O, Cetinkal G, Arslan S, Dalgic Y, Kocas C, Yildiz A, Ersanli M. Contrast-induced acute kidney injury in patients with non-ST-segment elevation myocardial infarction undergoing early versus delayed invasive strategy. Int J Cardiol 2016; 203:638-9. [PMID: 26580347 DOI: 10.1016/j.ijcard.2015.10.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Betul Kocas
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Okay Abaci
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey.
| | - Gokhan Cetinkal
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Sukru Arslan
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Yalcin Dalgic
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Cuneyt Kocas
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Ahmet Yildiz
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
| | - Murat Ersanli
- Istanbul University, Institute of Cardiology, Department of Cardiology, Turkey
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