Podcasts about ptca

N Engl J Med 1993;328:673-679Background: Previous trials established that thrombolysis improves mortality in patients with acute myocardial infarction, as seen in the GISSI-1 and ISIS-2 trials. However, thrombolysis has limitations, including an increased risk of bleeding and the inability to achieve arterial patency in approximately 20% of the cases. As a result, there was a growing interest in the use of percutaneous transluminal coronary angioplasty (PTCA).Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The Primary Angioplasty in Myocardial Infarction Study Group sought to test the hypothesis that PTCA compared to thrombolysis, improves outcomes and reduces bleeding in patients with acute myocardial infarction.Patients: Eligible patients presented within 12 hours of ischemic chest pain and had ST elevation of at least 1 mm in two or more contiguous electrocardiographic leads. Patients were excluded if they had dementia, LBBB, cardiogenic shock or elevated bleeding risk.Baseline characteristics: The study enrolled 395 patients – 195 assigned to the PTCA arm and 200 assigned to the thrombolysis arm. The average age of patients was 60 years with 73% being men. Approximately 14% had prior myocardial infarction, 43% had hypertension, 12% had diabetes and 2% had congestive heart failure. The average ejection fraction 52%.The infarct was anterior in 34% of the patients, inferior in 59% and lateral in 8%.Procedures: All patients were given 325 mg of aspirin plus 10,000-unit bolus of intravenous heparin. After that, patients were randomly assigned to thrombolytic therapy or PTCA. The thrombolytic agent used was tissue plasminogen activator (t-PA) at a dose of 100 mg (or 1.25 mg/kg of body weight for patients weighing less than 65 kg) over three hours. Patients randomly assigned to PTCA underwent immediate diagnostic catheterization.Angiographic criteria for exclusion from PTCA included left main stenosis of more than 70%, infarct-related vessel was patent, three-vessel disease, morphologic features of the lesion known to indicate high risk, small infarct-related vessels or stenosis 70 years or admission heart rate > 100 bpm. PTCA reduced in-hospital mortality in the “not low risk” group (2.0% vs 10.4%; p= 0.01) but not in the low risk group (3.1% vs 2.2%; p= 0.69).Conclusion: In patients with ST-elevation myocardial infarction, PTCA compared to t-PA reduced death and reinfarction at the hospital and at 6 months with a number needed to treat of approximately 14 and 12, respectively.This was one of the trials that established the foundation for the use of PTCA in patients with acute myocardial infarction. While the treatment effect was large, there are important considerations to keep in mind. First, the sample size was small. In comparison, GISSI-1 had almost 12,000 patients and ISIS-2 had over 17,000. The results of small trials are not always replicated in larger pragmatic trials. Second, the use of aspirin + heparin + t-PA likely increased bleeding in the t-PA arm as heparin plus thrombolysis compared to thrombolysis without heparin increased bleeding without improving outcomes, as seen in the GISSI-2 and ISIS-3 trials. Third, two thirds of the patients had inferior or lateral infarcts and these subgroups did not benefit from thrombolysis in the GISSI-1 trial. Finally, standalone angioplasty is infrequently performed nowadays and patients often receive a stent which has improved vessel patency.In the current era, patients with ST-elevation myocardial infarction receive early revascularization with stent placement, which improved outcomes in these patients. We discussed the limitations above to help readers and learners appraise clinical trials, as these limitations were important at the time of this trial's publication.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 1999;341:70-76Background: Percutaneous transluminal coronary angioplasty (PTCA) was widely used in the 1990s for its potential benefit in improving symptoms in patients with stable coronary artery disease, as discussed in the ACME and RITA-2 trials. However, the RITA-2 trial showed that PTCA worsened hard outcomes, and ACME was underpowered for such comparison. At the same time, trials demonstrating the ability of statin drugs to reduce cardiovascular events and improve survival had led to an increase in use of the lipid-lowering drugs. Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The Atorvastatin versus Revascularization Treatment Investigators sought to test the unique hypothesis that atorvastatin is superior to angioplasty in reducing ischemic events in patients with stable coronary artery disease. *It is important to note that the historical trials of CABG versus medical therapy that led to the widespread adoption of coronary revascularization, in general, were completed prior to the adoption of statin therapy. Thus a weakness of the CABG literature, which we have addressed in detail in prior posts and podcasts, is that the efficacy of CABG is inconsistent at best and medical therapy, at the time, was very limited. This makes this study of atorvastatin versus angioplasty of particular interest.Patients: Eligible patients had stenosis of 50% or more in one or two coronary arteries and had been recommended for treatment with percutaneous revascularization. The patients were asymptomatic or had Canadian Cardiovascular Society (CCS) class I or II angina. LDL levels had to be least 115 mg/dL and triglyceride levels of 500 mg/dL or less.Patients were excluded if they had left main coronary artery disease, 3-vessel disease, unstable angina or myocardial infarction within the previous 2 weeks, or if the ejection fraction was

Lancet 1997;350(9076):461-468Background: In the ACME trial, percutaneous transluminal coronary angioplasty (PTCA) improved symptoms in patients with single-vessel stable coronary artery disease, but it did not lead to reduction in myocardial infarction or mortality, which were not primary endpoints and the study was under powered for these endpoints. The available data on the efficacy of PTCA for reducing hard endpoints were limited. Moreover, the findings from surgery trials had been inconsistent, as discussed in prior reviews.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The second Randomized Intervention Treatment of Angina (RITA-2) trial sought to test the hypothesis that coronary angioplasty compared to medical therapy improves outcomes in patients with coronary artery disease.Patients: Eligible patients were recruited from the United Kingdom and Ireland. Patients had to have significant stenosis amenable to dilation, in at least one major coronary artery. A significant coronary lesion was defined as a 50% or greater diameter stenosis in at least two radiographic projections or at least 70% diameter stenosis in one projection.Patients were not required to have current symptoms. Patients with multivessel coronary disease, occluded coronaries or who had abnormal left ventricular function were allowed to be enrolled, as well as patients with unstable angina if the most recent episode was at least 7 days before randomization. Patients were excluded if they had left main disease, prior revascularization procedure or recent myocardial infarction.Baseline characteristics: There were about 70,000 patients who underwent coronary angiogram during the recruitment phase. Around, 2,750 patients were eligible and among them 1,018 were randomized – 504 randomized to the PTCA arm and 514 to the medical therapy arm. The main reasons for not randomizing eligible patients were clinician's decision or patient's refusal.The average age of enrolled patients was 58 years and 82% were men. Approximately 47% had prior myocardial infarction and 9% took medications for diabetes.Approximately 20% reported no angina at the time of randomization. Single-vessel coronary artery disease was present in 60% of the patients, 2-vessel in 33% and 3-vessel in 7%.Approximately 87% were taking aspirin, 13% were taking lipid lower drugs, 67% were taking beta-blockers, 50% were taking calcium channel blockers, and 44% were taking long acting nitrates.Procedures: Patients were randomized to coronary angioplasty or medical therapy. Randomization was stratified by center, extent of coronary disease and the presence of recent unstable angina. PTCA was to be performed within 3 months of randomization. In patients with multivessel disease, not all lesions had to be dilated. Multivessel dilatation could be staged over more than one procedure. Conventional balloon dilatation was the intended strategy, but stents were permissible if the initial angioplasty result was unsatisfactory.Aspirin was recommended in all patients. Lipid lowering drugs were prescribed at the discretion of the treating physician.Patients were followed at 3 months, 6 months, then yearly.Endpoints: The primary endpoint was a composite of all-cause death or non-fatal myocardial infarction at 5-years. Secondary endpoints included unstable angina, heart failure, arrhythmias, angina based on the Canadian Cardiovascular Society classification, anti-anginal drug use, and exercise duration on a symptom-limited treadmill test.Analysis was performed based on the intention-to-treat principle. The sample size to achieve 80% power at an alpha level of 0.05 was 1,400. This was based on the assumption that the event rate of the primary outcome is 15% at 5-years in the medical arm, and that PTCA would reduce the primary outcome by 33%. The study enrolled less patients than planned due to slow recruitment.Results: The median follow up time was 2.7 years. Among the 504 patients randomized to PTCA, the procedure was performed in 417 (93%) patients. Among the 514 patients randomized to medical therapy, 118 (23%) underwent PTCA or coronary bypass surgery.PTCA increased the risk of the primary composite outcome (6.3% vs 3.3%, RR: 1.92, 95% CI: 1.08 – 3.41; p= 0.02). This difference was primarily driven by more non-fatal myocardial infarction with PTCA (4.2% vs 1.9%; p value not provided). All-cause death was not significantly different between both groups (2.2% with PTCA vs 1.4% with medical therapy; p= 0.32).No significant differences noted in unstable angina (9.9% with PTCA vs 9.1% with medical therapy; p value not provided), heart failure (1.6% with PTCA vs 2.9% with medical therapy; p= 0.15) or arrhythmias (3.0% with PTCA vs 1.4% with medical therapy; p= 0.08).Symptoms improved significantly in both treatment groups. The improvement in symptoms was greater with PTCA at 3 months (16.5% more patients with grade 2+ angina in the medical arm; p< 0.0001) but the difference was smaller at 2 years (7.6% more patients with grade 2+ angina in the medical arm; p= 0.02). These differences disappeared at 3 years. More patients in the PTCA arm were not taking anti-anginal medications at 3 years (36.2% vs 13.8%). PTCA led to greater improvement in exercise time compared to medical therapy but the differences were small (mean difference favoring PTCA was 35s at 3 months and 25s at 1 year).No subgroup analysis was provided for the primary outcome.Conclusion: In patients with coronary artery disease without recent myocardial infarction, PTCA compared to medical therapy worsened the primary outcome of all-cause death or non-fatal myocardial infraction with a number needed to harm of approximately 33 patients over 2.7 years follow up. This difference was largely due to more non-fatal myocardial infarction in the PTCA arm. PTCA led to greater improvement in symptoms at 3 months but there were no significant differences at 3 years.Read the results above and compare our conclusion with the authors' conclusion: [In patients with coronary artery disease considered suitable for either PTCA or medical care, early intervention with PTCA was associated with greater symptomatic improvement, especially in patients with more severe angina. When managing individuals with angina, clinicians must balance these benefits against the small excess hazard associated with PTCA due to procedure-related complications].Medical and percutaneous interventions for coronary artery disease have advanced since the publication of this trial. However, reviewing older trials remains crucial to understand the evolution of the cardiology field and why certain interventions are no longer used. Studying the history of these treatments is important because it sheds light on how current practices have been shaped.This trial serves as a reminder that a bias toward interventions exists in medicine; the authors' conclusion downplayed the harms associated with PTCA while emphasizing its potential benefits for symptom relief, even though this was not the primary outcome and is highly subject to bias based on the study design. The trial also has reporting bias; subgroup analysis was not provided for the primary outcome but rather for the secondary endpoints of symptom relief and exercise tolerance. Additionally, the effects of PTCA on symptom relief and exercise tolerance were reported at various time points that seem to have been chosen to emphasize the protentional benefits of PTCA.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 1992;326:10-16Background: Revascularization with coronary artery bypass surgery improves symptoms in patients with chronic stable angina as seen in the European Coronary Surgery Study. Percutaneous transluminal coronary angioplasty (PTCA) is less invasive compared to surgery and is associated with less mortality and morbidity. Consequently, its use increased significantly in the late 1980s and early 1990s, driven by its perceived benefits over medical therapy alone due to the ability of PTCA to reduce coronary artery luminal stenosis.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The Angioplasty Compared to Medicine (ACME) study sought to test the hypothesis that PTCA improves symptoms in patients with single vessel sable coronary artery disease.Patients: Eligible patients were recruited from Veterans Affairs centers. Patients had to have 70 – 99% stenosis in the proximal two thirds of one major epicardial coronary artery plus one of the following: stable angina pectoris, very positive exercise-tolerance test (ST-segment depression ≥3 mm) or a myocardial infarction within the past 3 months.Baseline characteristics: The study screened 9,573 patients and among them only 212 (2.2%) were enrolled – 107 randomized to medical therapy and 105 to PTCA. The reasons for patients' exclusion were provided in table 1 of the manuscript. Some key exclusion criteria were previous CABG, unstable angina, prior PTCA, 3-vessel disease or lesions not suitable for PTCA.The average age of enrolled patients was 63 years. Approximately 30% had prior myocardial infarction, 53% had hypertension, 18% had diabetes, 1% had congestive heart failure, and 31% were current smokers. There were more employed participants in the PTCA arm 42% vs 29%. The average systolic blood pressure was 136 mm Hg. The average total cholesterol was 230 mg/dl.The average duration participants did on the treadmill was 8.8 minutes. Approximately 38% had LAD disease, 25% had LCx disease, and 37% had RCA disease.Procedures: All patients were admitted to the hospital. Anti-anginal medications were stopped for at least 24 hours and exercise stress test that included thallium Scintigraphy was performed. The test was considered positive if there was horizontal or down-sloping ST-segment depression ≥ 1.0 mm in one or more leads measured 80 msec after the J point that occurred during or after treadmill exercise testing. Patients who had angina during the test but did not meet the above criteria could be included if there was evidence on thallium scanning of a reversible defect in the area corresponding to the index lesion. If the test showed ischemia, patients were then assigned to PTCA or medical therapy.All patients received aspirin 325 mg/day. Patients in the medical arm received one or combination of the following: nitrates, beta-blockers or calcium channel blockers. Patients in the PTCA arm received calcium channel blockers before and for one month after the procedure, and nitroglycerin during and for 12 hours after the procedure.Patients were followed monthly. Patients were admitted to the hospital 6 months after randomization, for repeat exercise testing and coronary angiogram. For patients in the medical arm, this exercise testing was performed while they continued their anti-anginal medications. In contrast, patients in the PTCA arm stopped their anti-anginal medications for at least 24 hours before the test.Endpoints: The primary end points were changes in exercise tolerance, angina attacks and the use of nitroglycerin. Change in the degree of stenosis in the index lesion was measured as a secondary endpoint.Analysis was performed based on the intention-to-treat principle. The sample size to achieve 95% power at an alpha level of 0.05 was 192. This was based on the assumption that PTCA would increase exercise duration by 1-minute compared to medical therapy. To account for potential loss to follow-up, the recruitment goal was set at 200 patients.Results: Among the 105 patients assigned to PTCA, 95% underwent the procedure, and among them, the procedure was considered successful in 82%. Successful PTCA was defined >20% decrease in percent stenosis of all lesions in which dilation was attempted. Among the 107 patients assigned to medical therapy, 10% underwent PTCA.The mean duration from randomization to follow-up exercise testing was approximately 7 months. PTCA led to greater increase in exercise time compared to medical therapy alone (2.1 minutes vs 0.5 minutes; p< 0.0001) as well as time to onset of angina (2.6 minutes vs 0.8 minutes; p

Noteikti katram interneta lietotājam ir nācies ielūkoties kādā mājaslapā, kurā piedāvātajām precēm tiek solītas vilinošas cenas un atlaides. Ne vienmēr aiz šāda piedāvājuma slēpjas krāpnieki vai negodprātīgi uzņēmēji. Kā atdalīt sēklas no pelavām, iepērkoties virtuālajā vidē, interesējamies raidījumā Kā labāk dzīvot. Skaidro un stāsta Patērētāju tiesību aizsardzības centrs (PTAC) Patērētāju tiesību uzraudzības departamenta galvenā juriste Zanda Dāvida, PTAC Preču un pakalpojumu uzraudzības departamenta direktora vietnieks Ivars Jorniņš un "Cert.lv" kiberdrošības eksperts Gints Mālkalnietis. "Kā pazaudēt naudu vienkārši tāpat internetā – tas nekur nav pazudis," atzīst Gints Mālkalnietis Ir pikšķerēšanas un viltus lapu uzbrukumi, viltus investīciju platformas, kas vērstas pret privātpersonām, viltus rēķini, dažādas kontu mainīšanas, kas ir problēma uzņēmējiem. (..) darījumu summas mēdz būt lielas." "Ja jums rāda [Facebook], ka draugs iesaka kaut ko ļoti dīvainu, ja ir reāls kontakts ar šiem cilvēkiem, paziņot, ka, man šķiet, ka no tava konta redzējām kaut kādu krāpniecību," atzīst Gints Mālkalnietis. "Bieži saskaramies ar to, ka uztaisa profilu ar tā paša cilvēka vārdu un uzvārdu, citu lietotājvārdu kādā no virtuālajām lietotājvidēm, pēc tam tās vārdā piesakās draugos, mēģina iziet uz sarunām. Ļoti bieži sarunas ved pie šīm viltus investīciju platformām. Šāda metode, kas arī nav jauna, atkal ir uzpeldējusi. Ir problēma, ka virtuālā vidē pārbaudīt identitāti nav lielas." "Ja jūsu draugs sāks pēkšņi runāt krieviski, kas to nav darījis, neticiet. Bet mēs redzam arī reālus uzbrukumus latviski," turpina Gints Mālkalnietis. "Reklāmas visbiežāk būs angļu vai iztulkotā angļu valodā. Lapas, kur pāradresē apmeklētājus, ir ar sagatavi angliski, kas automātiski tiek tulkota latviski. Tāpēc brīži izskatās stipri jocīgi."  Gints Mālkalnietis arī min, ka ala lietotāji jūt to, ko nevar ietekmēt, un tie ir uzbrukumi pakalpojumu sniedzējiem, finanšu iestādēm. PTCA ir gan "melnais saraksts" un aizdomīgo vietņu saraksts, kurā iesaka ielūkoties patērētājam. Klausītājs jautā, vai PTCA ir ziņas dažādiem kursu piedāvājumiem, kas sākumā ir bezmaksas un tikai pēc tam parādās abonēšanas maksa. "Sūdzas ne tikai par dažādiem kursiem, bet sūdzas arī par cita veida pakalpojumiem, kur princips ir viens - cilvēkam piedāvā kaut ko uz laiku bez maksas un cilvēks neizlasa, kā parasti, līdz galam un noslēdz abonēšanas līgumu. Kad atnāk rēķins, saprot, ka piesaistīts uz gadu vai diviem, vai beztermiņa līgums. Bieži var redzēt, ka cilvēks devis piekrišanu, pats visu atzīmējis. Neizlasīja," atzīst Zanda Dātava. "Patērētāju uzvedības pētījumi parāda, ka viņi nelasa līgumus un arī nelasīs līgumus, līdz ar to mums kā uzraudzības iestādei un arī likumdevējam ir jādomā, ka izveidot normatīvos aktus tā, lai cilvēkus pasargātu." "Metodes šādai nejaušai iesaistei ir dažādas, viens no aktuālākajiem - tu spēlē kādu spēlīti, pēkšņi izlec ārā aicinājums kaut ko pamēģināt bez maksas, tu ievadi savu telefona numuru un ar to pietiek. Nevajag pat ievadīt kartes datus, jo tu pieslēdz pakalpojumu un rēķins tiek piesaistīts mobilo sakaru pakalpojumu maksai. Tev pēkšņi atnāk lielāks rēķins. Pat nav jāievada nekādi dati," skaidro Zanda Dātava.

Håkan Dahlbo, som gästar podden för andra gången, har många järn i elden. Grundare, manager och head coach på Estess samt medgrundare till Professional Tennis Coaches Association. Håkan har coachat mängder av professionella spelare i Grand Slam-turneringar samt varit en del av det österrikiska Davis Cup- och Fed Cup-lagen. I den här tombolan samtalar vi kring ljudklipp från avsnitten med: * Stefan Svensson, avsnitt 50 säsong 1 * Jonas Arnesen, avsnitt 48 säsong 2 * Joakim Alvetoft, avsnitt 27 säsong 2 Vi kommer in på samtalsämnen om vad talang är, hur viktig teamet runt spelaren är, hur mycket av tennisen som är business, om en tränare får tjäna mycket pengar och om den röda tråden inom svensk tennis. Skulle ni kunna tänka er att stötta poddens fortlevnad genom att bli patreon-supporter? Klicka här för att läsa mer och om hur du gör: https://www.patreon.com/linuspabaslinjen

World-renowned physician, venture capitalist and prolific entrepreneur, John Simpson, MD, rejoins Andrew Cleeland to discuss the impact he's had on the future generation of medtech innovators. Credited with inventing and commercializing the first over-the-wire balloon catheter used for percutaneous transluminal coronary angioplasty (PTCA) and helping to create the field of interventional cardiology, John also founded and successfully exited numerous companies, including Advanced Cardiovascular Systems (ACS) and Devices for Vascular Intervention (DVI), which were both acquired by Eli Lily; CVIS, acquired by Boston Scientific; Perclose, sold to Abbott; LuMend, acquired by Cordis Corporation; and Fox Hollow, acquired by ev3, which is now part of Medtronic. Today, he continues to innovate in his work as a senior advisor to Cordis-X.

A husband, father, world-renowned physician, venture capitalist and prolific entrepreneur, John Simpson, MD, has helped revolutionize the field of cardiology via his innovations.   Credited with inventing and commercializing the first over-the-wire balloon catheter used for percutaneous transluminal coronary angioplasty (PTCA) and helping to create the field of interventional cardiology, John also founded and successfully exited numerous companies, including Advanced Cardiovascular Systems (ACS) and Devices for Vascular Intervention (DVI), which were both acquired by Eli Lily; CVIS, acquired by Boston Scientific; Perclose, sold to Abbott; LuMend, acquired by Cordis Corporation; and Fox Hollow, acquired by ev3, which is now part of Medtronic. Today, he continues to innovate in his work as a senior advisor to Cordis-X. Andrew Cleeland had the pleasure of chatting with John to learn more about his career as a serial entrepreneur as well as his insights on what it takes to drive innovation.  

Giriş Spontan dolaşımın geri dönmesi (ROSC) sonrası EKG'de ST elevasyonu, non-spesifik ST-T dalga değişiklikleri, sol dal bloğu ve nodal ritm başta olmak üzere tüm ritmiler görülebilmektedir. ROSC sonrası EKG'de ST segment yükselmesi olan hastaların %98'inde ve diğer EKG paternleri olan hastaların %77'sinde koroner arter hastalığı (KAH) gözlendiğini bildiren çalışmalar mevcuttur​1​. Hastanın hikayesi ile birlikte değerlendirildiğinde erken Koroner Anjiografi (KAG) özellikle ST elevasyonu saptanan hastalarda AHA (Amerikan Kalp Derneği ) kılavuzunda güçlü bir şekilde önerilmektedir. Ancak EKG'de ST elevasyonu olmayan hastaların erken KAG planı ile ilgili uzlaşı henüz sağlanamamıştır.  ROSC sonrası hangi hastalara ne zaman KAG yapılması gerektiği daha önce Çağlar Kuas tarafından yazılan ‘Post Resüsitasyon Anjiyografi: Kime ? Ne Zaman?' adlı yazıda ayrıntılı olarak anlatılmıştır. Olgu 44 yaşında erkek hasta evde nefes darlığı ve fenalık hissi yaşaması üzerine eşi tarafından 112 KKM aranmış. 112 ekiplerince acil servise getirildiği sırada kardiyopulmoner arrest gelişen hastaya 8 dk KPR uygulanmış ve spontan dolaşımın geri dönüşü sağlanmış. Bu  hali ile acil servise getirilen hastanın çekilen ilk EKG'si şekildeki gibidir. ROSC sonrası ST elevasyonu ROSC sonrası çekilen ilk EKG İnferior STEMI gösteren hasta KAG amaçlı Kardiyolojiye hızlıca konsulte edilmiş ancak hastanın mevcut eleveasyonu KPR sonrası bulgular olarak düşünülüp erken KAG yapılmamış ve takip önerilmiş. Peki şimdi planımız ne olmalı? Bu hasta STEMI olamaz mı? Nasıl karar vermeliyiz? Ne zaman erken KAG için kardiyoloji hekimine ısrarcı olmalıyız? Bu soruların kesin cevapları olmamakla birlikte bu konu ile ilgili yapılan birkaç çalışmaya göz atalım. Literatür İncelemesi Avrupa Resüsitasyon Konseyi, Amerikan Kalp Derneği ve Avrupa Kardiyoloji Derneği kılavuzları, ROSC'den sonra EKG önemini vurgulamalarına rağmen ne zaman çekilmesi gerektiği ile ilgili kesin bir öneri yoktur​2–4​. Bu Kılavuzlar ROSC sonrası EKG elevasyonu olan hastalara KAG önerir iken ne Amerikan ne de Avrupa resüsitasyon kılavuzları, ROSC'den sonra EKG çekimi için en iyi zaman hakkında özel talimatlar vermemektedir; sadece 12 derivasyonlu EKG'nin ROSC'den sonra mümkün olan en kısa sürede kaydedilmesini önermektedir. Literatürde veri olmamasına rağmen, ROSC sonrası erken fazda, EKG'nin kardiyak arreste bağlı iskemiyi koroner arter patolojisine bağlı iskemiden daha fazla veya buna ek olarak yansıtabileceğini varsaymak mantıksız değildir. Bugünkü yazımıza konu olan çalışma ise resüsitasyon sonrası ilk 7 dk'da çekilen EKG'deki ST elevasyonunun yanlış pozitif olabileceğini vurgulamıştır​5​. Bu çalışma, retsospektif , çok merkezli bir çalışma olarak İtalya; İsviçre, Avusturya ‘da bulunan 3 hastanede yürütülmüştür. Hastane dışı kardiyak arrest olarak acil servise getirilen 586 hastadan ROSC sonrası EKG'si olmayan 152 hasta ve KAG yapılmayan 64 hasta çalışma dışı  bırakılarak 370 hasta çalışmaya dahil edilip veri taraması yapılmış ve mevcut EKG'leri analiz edilmiştir. Çalışmanın birincil amacı ROSC'den EKG çekilmesine kadar geçen süre ile STEMI için yanlış pozitif EKG bulgularının yüzdesi arasındaki ilişkiyi  değerlendirmek iken birincil sonlanım noktası yanlış pozitif EKG bulgularını belirlemektir. Bu çalışmada yanlış pozitif EKG bulguları;  STEMI kriterlerini karşılayan ancak anjiyografide perkütan koroner anjiyoplasti gerektirmeyen ROSC sonrası EKG bulguları olan hastaların yüzdesi olarak tanımlanmıştır. İkincil amaç ise acil perkütan koroner anjiyoplasti (PTCA) gerektiren hastaları daha iyi seçmek için ROSC sonrası EKG çekilmesi için en uygun zamanın belirlenmeye çalışılması ve bu sayede yanlış pozitif EKG bulgularının oranını azaltıp gerçek negatif EKG bulgularının oranını arttırabilmektir. Çalışmaya dahil edilen 370 hastadan 172 tanesinin EKG'si STEMI için tanısal değil iken, 198 hastada STEMI için tanısal EKG bulguları saptanmıştır.

This week's episode features special Guest Host Mercedes Carnethon, as she interviews author Miriam Cortese-Krott and Associate Editor Charles Lowenstein as they discuss the article "Red Blood Cell and Endothelial eNOS Independently Regulate Circulating Nitric Oxide Metabolites and Blood Pressure." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast, summary, and backstage pass to the journal and its editors. We're your co-host I'm Dr. Carolyn Lam, associate editor from The National Heart Center in Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, today's feature paper is one of those really, really landmark papers that really advance our understanding of Nitric oxide signaling. And it's about red blood cell and Endothelial eNOS, and how they independently regulate circulating nitric oxide, metabolites, and blood pressure. A real, real must, but let's go on and look at the other papers in this issue first. Greg, you want to go first? Dr. Greg Hundley: You bet, Carolyn. Better grab a cup of coffee. And my first paper is from professor Nathan Mewton from Hôpital Louis Pradel Hospices Civils de Lyon. Carolyn, these authors hypothesized that Colchicine a potent anti-inflammatory agent may reduce infarct size in left ventricular remodeling at the acute phase of STEMI. And so to address this hypothesis, they performed a double-blind multi-center trial and randomly assigned patients admitted for a first episode of STEMI referred for primary PTCA to receive oral Colchicine two-milligram loading dose followed by 0.5 milligrams twice a day, or matching placebo from admission to day five and the primary efficacy outcome was infarct size determined by cardiovascular magnetic resonance imaging at five days. And the relative left ventricular end-diastolic volume change at three months and infarct size at three months was also assessed by cardiac MRI. And these were secondary outcomes. Dr. Carolyn Lam: Nice. Okay. So what were the results? Dr. Greg Hundley: Right, Carolyn. So 192 patients were enrolled. 101 in the Colchicine group and 91 in the controls. And as a result of this trial, the oral administration of high dose Colchicine at the time of Reperfusion. And for five days thereafter did not reduce infarct size assessed by cardiac MRI. And so Carolyn, the clinical implications of these results suggest that other studies exploring the timing, pharma kinetics, and dose-response of Colchicine, as well as other anti-inflammatory agents are needed to identify an effective method to reduce infarct size and limit remodeling in this group of patients. Dr. Carolyn Lam: Wow, it's just such a rich field done with all this about Colchicine. Well, our next paper is a pre-specified sub-analysis of the randomized EAST-AFNET 4 Trial and the sub-analysis assess the effect of systematic early rhythm control therapy that is using Antiarrhythmic drugs or catheter ablation compared to usual care, which means allowing rhythm control therapy to improve symptoms in patients with heart failure. And this was defined in the sub-analysis as the presence of heart failure symptoms of New York Heart Association status two to three or a left ventricular ejection fraction of less than 50%. Dr. Carolyn Lam: Now, the authors led by Dr. Kirchhof at University Heart and Vascular Center UKE in Hamburg, Germany included 798 patients in this sub-analysis of whom 442 had HFpEF, 211 had heart failure with mid-range ejection fraction and 132 had HF-rEF over a median of 5.1 years of follow-up the composite primary outcome of cardiovascular death stroke or hospitalization for worsening heart failure, or for acute coronary syndrome occurred less often in patients randomized to early rhythm control therapy compared with patients randomized to usual care. And this was not altered by heart failure status with an interaction P-value of 0.6. Left ventricular function, symptoms, and quality of life improved equally in both treatment strategies. Dr. Greg Hundley: Wow, Carolyn, a lot of information here. So what can we take away from this? Dr. Carolyn Lam: Well, let's remember that this is a sub-analysis, albeit pre-specified of that randomized trial of the EAST-AFNET 4 Trial, but nonetheless, the data supports a treatment strategy of rhythm control therapy with Antiarrhythmic drugs or ablation within a year of diagnosing atrial fibrillation in patients with signs and symptoms of heart failure to reduce cardiovascular outcomes. Dr. Greg Hundley: Very nice, Carolyn. So, Carolyn, my next paper pertains to Alarmin Interleukin-1 Alpha, and it comes to us from Dr. Thimoteus Speer at Saarland University. So, Carolyn, Alarmin Interleukin-1 Alpha is expressed in a variety of cell types, promoting sterile systemic inflammation. And the aim of the present study was to examine the role of Alarmin Interleukin-1 Alpha in mediating inflammation in the setting of acute myocardial infarction and chronic kidney disease. Dr. Carolyn Lam: Wow, sterile inflammation. It's a really hot topic now. So what did these authors find? Dr. Greg Hundley: Right, Carolyn. So we're going to call Alarmin Interleukin-1 Alpha. Let's just call it IL-1 Alpha and so increased IL-1 Alpha surface expression on monocytes from patients with acute myocardial infarction in patients with chronic kidney disease was found to be associated with cardiovascular events. Next, IL-1 Alphas itself served as an adhesion molecule, mediating leukocyte-endothelial adhesion, and finally, abrogation of IL-1 alpha prevented inflammation after myocardial infarction and ameliorated chronic kidney disease in Vivo. Dr. Carolyn Lam: Wow. So what does this mean clinically? Dr. Greg Hundley: Right, Carolyn, so perhaps targeted therapeutic inhibition of IL-1 Alpha might represent a novel anti-inflammatory treatment strategy in patients with myocardial infarction and in patients with chronic kidney disease. Dr. Carolyn Lam: Amazing. Thanks, Greg. Well, in today's issue, there's also an exchange of letters between doctors Lother and Filippatos on Finerenone and risk of hyperkalemia in CKD and type two diabetes. There's an On My Mind paper by Dr. Sattler on the single-cell immunology and cardiovascular METs in, do we know yet what we don't know? Dr. Greg Hundley: And then Carolyn, from the mailbag, a Research Letter from Professor Wehrens entitled “Atrial Specific LK Beta One Knockdown Represents a Novel Mouse Model of Atrial Cardiomyopathy with Spontaneous Atrial Fibrillation.” Well, Carolyn, how about we turn our attention to those red blood cells and endothelial nitric oxide synthase. Dr. Carolyn Lam: Yeah. Can't wait. Dr. Mercedes Carnethon: Well, welcome to this episode of Circulation on the Run. Our podcasts, where we have an opportunity to speak with authors of important papers that are appearing in the journal of circulation. I'm pleased to introduce myself. My name is Mercedes Carnethon, professor and vice-chair of preventive medicine at the Northwestern University Feinberg School of Medicine. And I'm pleased today to invite our guest author, Miriam Cortese-Krott, who is the faculty of the University of Duesseldorf, and a guest professor at the Karolinska Institute in Stockholm. And we have with us as well the other associate editor who handled the piece for circulation, Dr. Charlie Lowenstein from Johns Hopkins University. So welcome to each of you this morning. Miriam Cortese-krott: Thank you. Dr. Charles Lowenstein : Thanks for having me. Dr. Mercedes Carnethon: Well, thank you. I'm really excited to jump right into this piece, Miriam, can you tell me a little bit about the rationale for carrying out the study, why you pursued it? Professor Miriam Cortese-Krott: The reason is because when I was working as a post-doc, I had to isolate an enzyme from red blood cells, which is a very, very difficult. And if you know, this enzyme is endothelial nitric oxide synthase, which produce nitric oxide, and actually, the red blood cell is full of the worst enemy of nitric oxide, which is hemoglobin. So actually, when I was talking about my project, everybody was asking, "Why are you doing that?" And I was actually able to isolate the enzyme and look at activity and be sure that the enzyme was fine, but the function of this enzyme was absolutely unknown. Professor Miriam Cortese-Krott: And the only way to study proteins in red blood cells is to make modification in the bone marrow of the mice. So in the Erythroid cells, because you can not, of course, if there are cells without nucleus you don't have any chance to modify them in culture, something like that. So the only way was to generate mice with modification specifically in the red blood cells. And I had the chance to create, to generate red cell-specific eNOS knockout mice. And of course, as a control endothelial-specific eNOS knockout mice by using the Cre-loxP technology. And with this technology, I could really understand what's happening to the physiology of the mouse if you remove this protein from the red blood cells. And so this was the whole idea. Dr. Mercedes Carnethon: Thank you so much. It was really exciting for me to read this piece. We are on opposite ends of the scientific inquiry spread as I'm an epidemiologist who does things at the population level, and you're identifying things at the basic science level. I thought the paper was extremely well-written and that encouraged people to dig in, even if you're unfamiliar, and in part that's because you provided such a great explanation of how your findings are used and how they're relevant to the process. Do you mind sharing a little bit about your findings and how you expect that they will be used by our scientific community? Professor Miriam Cortese-Krott: I think the main finding of this paper is that if you remove eNOS from the red blood cells if the mice are hypertensive, have hypertension, and this is completely something that you actually will not expect, as I told you that indeed red cells are full of the enemy of nitric oxide that remove it immediately. So you can ask yourself how it is possible. But I think the key finding here in this paper was that I also generated the opposite model. So I created the model a conditional eNOS Knockout model where you can decide in which tissue you want to have your enzyme. And of course, I applied for red blood cells. And what you see in this model is that you start from a global knockout mouse with hypertension, you reintroduce the eNOS just in the red blood cells, you have normal tension. So this means, this is the main finding. You have a switch in the red blood cells, which is the enzyme eNOS, which it's behaving in a completely different way clearly as compared to the vessel wall eNOS and still regulating blood pressure. Dr. Mercedes Carnethon: Well, thank you so much. I think this is the point at which I like to turn to the associate editor who handled the piece. Charlie, you and I don't get to talk as often given the diversity of work that we each pursue, but Charlie, tell me a little bit about what excited you about this piece? Dr. Charles Lowenstein: Thanks, Mercedes. So I love this piece. I thought Miriam, your article is so great. So a couple of thoughts. One is nitric oxide and nitric oxide synthase are so important in biology and medicine, nitric oxide regulates blood pressure. It regulates neurotransmission. It regulates inflammation. And this is true, not only in the lab, looking at cells in mice, but also in the human. So genetic variance in the endothelial nitric oxide synthase gene or NOS3 are associated with risks for diseases like coronary artery disease. So eNOS is just so important in biology and medicine. And now some ancient history. When I was a cardiology fellow, about a hundred years ago, I worked in the lab that first purified nitric oxide synthase proteins, and we cloned two of the nitric oxide synthase genes that was in the lab of Dr. Solomon Snyder at Johns Hopkins back in the 1700s. Dr. Charles Lowenstein: So when we cloned the nitric oxide synthase genes, when we and others did, we made a huge mistake. We chose the names for these isoforms from the tissue where they were first isolated. So we called the brain nitric oxide synthase nNOS, because it's a neurons, macrophages MCnos we called it MCnos and in endothelial cells, we called it the nitric oxide synthase eNOS or endothelial NOS. But in the last 20 years, lots of investigators have found these isoforms are in other cells, not just the original cells at discovery. And so Miriam's question is just so important, which cells make endothelial NOS also called NOS3. That's the history. Now what Miriam has discovered is just so important. I was so fascinated by her work because as she just said, she made two amazing discoveries. One, red blood cells make endothelial nitric oxide synthase. Dr. Charles Lowenstein: And that's been a controversy for a long time. Some people have said, "Yes." Some, "No." And Miriam made the definitive answer. Yes, red blood cells make eNOS, and secondly, she has discovered so much about the physiology of ENO coming from red blood cells, the nitric oxide that's made inside red blood cells regulates blood pressure. What a magical, interesting, and important finding. That's a little bit about the history. Nitric oxide and NOS are important in medicine. The people who originally cloned and purified the nitric oxide synthase isoforms named them after the tissue in which they discovered. And Miriam has made a major discovery that it's not only endothelial cells that make nitric oxide but also red blood cells. Dr. Mercedes Carnethon: Thank you so much for that summary. And I guess, I would have thought perhaps this was something of an Elixir of youth because if you've been working in this area for 200 plus years and Miriam, you started working on this as part of your dissertation work, you both have a lot of insight and background on where we've been and what the advances are. Miriam, can you tell me a little bit about how you'd like to see these findings used by the scientific community? Professor Miriam Cortese-Krott: I think I would like that the scientific community would use my mice first because I think, as Charles has said, it's not only red cells that express eNOS and it's not only endothelial cells. There are other cells producing eNOS and the function in the other cells is not known even in leukocytes, even when they have iNOS of course, but also have eNOS. So you can use my mice since it's a flux model. You can choose whatever you want, what cell you want, and then knock it in and knock it out. So this is one thing that I think the community could really do. I cannot do everything. So I'm happy to give my mice away. Professor Miriam Cortese-Krott: And the second thing is I would like too that in particular, the clinical community would see this link between Emathology and cardiovascular disease. This is something that was started, of course, there are studies looking at anemia and cardiovascular disease, but these studies have sometimes some issues I of course cannot speak as a basic scientist. I cannot speak about huge clinical trials, but I think this link exists and exists at the molecular level and it can be a target for pharmacological therapy. So I think this is what I would like to transport with this study to the clinical community and the basic science community. Dr. Mercedes Carnethon: Yeah. I think this is the point at which Charlie, I turn it to you because you really stand at the intersection of both of those communities. What questions do you have for Miriam going forward, as you think about spreading the word on this important work? Dr. Charles Lowenstein: So Miriam's discovery is just so important and she now has the tools to help answer really, really important questions. How is nitric oxide made in red blood cells? How is it stored in red blood cells? How is it transported throughout the body in red blood cells? What is the chemistry of nitric oxide, when it is stored, when it combines with oxygen when it forms nitrite and nitrate, how is it released from red blood cells? How is it targeted from a red blood cell to the vasculature? So there're these great basic science questions that Miriam and her colleagues are now poised to answer. So there's the science part of it. Then there's the medicine part of it because Miriam's mice and her great discovery have really huge implications for medicine. And so the question is, how can we use ENO? How can we deliver it? How can we target ENO to human tissues? Dr. Charles Lowenstein: How can we turn on erythrocyte, nitric oxide synthase? How can we turn it off? Because there are all these medical diseases where too much nitric oxide is bad, like in sepsis or inadequate amounts, don't protect the vasculature like atherosclerosis. Then there are all these other interesting questions. When we transfuse red blood cells, sometimes if you transfuse aged red blood cells, it's not good. You can harm people. Maybe we can load up or activate eNOS in stored red blood cells and then help deliver more ENO to patients who need red blood cells. So there are all these fascinating medical questions that we can look at based on Miriam's really important discovery. Dr. Mercedes Carnethon: Well, thank you so much. We're coming to the end of this wonderful and informative podcast. And I guess, I'd just ask Miriam, do you have anything else you'd like our listeners to know about your work and about the findings from this study? Professor Miriam Cortese-Krott: I would like people know that hard work help a lot, and that you have to believe in what you are doing and the quality of your science at the end would bring their true discoveries. So I think it's important specifically, for the young women in science that having this message too. So the science per se must be excellent and to proceed, you need a lot of work, but then the work goes to a good end. Dr. Mercedes Carnethon: Miriam, thank you so much for that inspirational note. The hard work that scientists need, the persistence across one's career and building from earlier discoveries, and bringing those forward through one's career are always critically important. And so I hope everyone has really enjoyed this episode and this opportunity to hear from Dr. Cortese-Krott. Miriam, you've done such wonderful work, and thank you as well, Charlie, for your insights about the intersection of this work with clinical care and basic science. Professor Miriam Cortese-Krott: Thank you. Dr. Charles Lowenstein: Thank you. Dr. Mercedes Carnethon: Thank you all very much for joining us today in this episode of Circulation on the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit ahajournals.org.  

Palēnām Eiropas valstis atver robežas. Tomēr uz daudzām valstīm šobrīd iespējams nokļūt tikai ar lidmašīnu. Kā ārkārtas stāvokļa laikā tiek organizēti aviopārvadājumi, interesējamies raidījumā Kā labāk dzīvot. Lidosta “Rīga” pārstāve Laura Karnīte atzīst, kā šobrīd bažas par to, ka lidosta nevarēs apkalpot arvien pieaugošo pasažieru skaitu, nav aktuālas. Prognozes rāda, ka aviācija atkopsies lēni, valstīs saglabāsies ierobežojumi, cilvēki izvēlēsies arī neceļot, tāpēc arī pasažieru plūsma nebūs tik liela. Karnīte norāda, ka, uzturoties lidostā “Rīga”, cilvēkiem noteikti jābūt ar sejas maskai. Nederēs kāds lakats vai cits aizsegs kā pilsētas sabiedriskajā transportā. Arī vairākas aviokompānijas paziņojušas, ka lidojuma laikā maskas būs obligātas. Nebūs atļauta ieeja lidostas terminālī sagaidītājiem un pavadītājiem, tas saistīts ar nepieciešamību nodrošināt distancēšanos un drošības pasākumus. Aicina, ja nav liela nepieciešamība, uz lidostu nebraukt. Karnīte mudina noteikti būt savlaicīgi lidostā. Šobrīd arvien spēkā ir nosacījums lidostā būt divas stundas pirms lidojuma, bet tas var mainīties, ja redzēs, ka papildus drošības prasības palēnina apkalpošanas procesu. Lidostā ir izvietota informācija par drošības nosacījumiem, ka arī izvietoti roku dezinfekcijas aparāti. “airBaltic” pārstāve Valda Vidiņa norāda, ka lidmašīnā pasažieriem būs bezmaksas pamataprūpes komplekts – sejas aizsargmaska un dezinfekcijas salvetes. Pagaidām vidējā sēdvieta lidmašīnā būs tukša, kamēr lidmašīnā būs ne vairāk kā 89 pasažieri. Šobrīd “airBaltic” sola, ka lidmašīnu biļešu cenas būtiski nemainīsies. Arī apkalpei būs aizsargmaskas un cimdi. Lidmašīnās būs arī mainīts apkalpošanas veids, lidojuma žurnāls nebūs pieejams, bet vienreizlietojama informācija par drošības prasībām un piedāvājumu lidmašīnā. Aviokompānijas atceltajiem lidojumiem piedāvā mainīt biļetes, dāvanu kartes, kas derīgas vairāk nekā gadu, līdz 2021.gada 31. decembrim vai arī naudas kompensāciju. Ja lidojums netiek atcelts, bet personīgu apsvērumu dēļ cilvēks izvēlas atcelt rezervāciju, tad naudu atmaksā saistībā ar iegādātās biļetes klases nosacījumiem. Patērētāju tiesību aizsardzības centra (PTAC) vadītāja Baiba Vītoliņa skaidro, ka uz atceltajiem lidojumiem nauda jāatdod 7 dienu laikā, bet šobrīd PTCA neuzstāj uz šī termiņa striktu ievērošanu, jo ir force majore situācija. Arī PTAC iesaka izmantot vaučerus nākamiem ceļojumiem.

The word stent is only used in cardiology circles but these small devices are used to treat well over a million people every year. For over a decade, stents have largely replaced using a balloon alone to unblock arteries (called PTCA). The history of stents is interesting and the proper use of stents is controversial. Everyone should know some information about stents and then work very hard to avoid them!

Dr. John Simpson. Even if you’re a medical device newbie, you’ve probably heard of him. He’s credited with inventing and commercializing the first over-the-wire balloon catheter used for percutaneous transluminal coronary angioplasty (PTCA). This single idea created the field of interventional cardiology as we know it today. Over the course of his renowned medtech career...[read more]Related StoriesWhy Intersect ENT is an Example of Hope for the Medtech IndustryAre Medical Device Models the Key to Building a Lean Medtech Startup?Substantial and Sustainable – 2 Words That Medtech Companies Should Get Used To

Thu, 28 Oct 2010 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/12244/ https://edoc.ub.uni-muenchen.de/12244/1/Omary_Jawid.pdf Omary, Jawid

Überlegene Offenheitsraten der Arteria mammaria interna gegenüber Vena-saphena-magna-Transplantaten sind angiographisch valide. Ziel der vorliegenden Untersuchungsreihe war, Outcome und klinischen Benefit von Patienten mit bilateralem ITA(BITA-)und solchen mit einfachem ITA(SITA-)Bypass im mittelfristigen postoperativen Verlauf zu verifizieren. 1.378 Patienten, die sich zwischen 01/97 und 08/99 einer isolierten aortokoronaren Bypassoperation unterzogen hatten, wurden retrospektiv untersucht. Das Follow-up betrug 4,0 bis 6,6 Jahre (im Mittel 5,3 Jahre). 716 Patienten erhielten einen BITA-Bypass, 662 einen SITA-Bypass sowie zusätzlich Vena-saphena-Transplantate. Wir analysierten Mortalitätsrate, Freiheit von Re-Operationen und Interventionen wie PTCA/Stent, die Inzidenz kardialer Ereignisse sowie die Lebensqualität in Relation zu patientenspezifischen Risikofaktoren. Der Prozentsatz weiblicher Patienten war in der BITA- wie auch in der SITA-Gruppe signifikant niedriger (BITA-Gruppe: 115 weibliche und 601 männliche Patienten, SITA-Gruppe: 150 weibliche und 512 männliche Patienten; p < 0,01). Das mittlere Alter (BITA: 69,2 Jahre, zwischen 42,7 und 88,6 Jahren, SITA: 71,0 Jahre, von 47,3 bis 91,6 Jahren) war nicht signifikant unterschiedlich. Die Prävalenz von Diabetes mellitus (26,0% vs. 25,9%,n.s.)wie auch der mittlere BMI (27,4 vs. 27,0; n.s.) waren in beiden Gruppen vergleichbar. Mittelfristig (im Mittel 5,3 Jahre nach dem Eingriff) profitieren Patienten mehr von einem Doppelmammaria-Bypass als von der Verwendung nur einer A. mammaria interna als Graft. Die kardial bedingte Mortalität und die Zahl der erforderlichen Re-Operationen waren nach der Verwendung von BITA-Transplantaten im Vergleich zum Einsatz von SITA-Transplantaten auf weniger als die Hälfte reduziert. Auch wurden kardiologische Eingriffe wie PTCA und Stentanlage bei Patienten mit BITA-Transplantaten seltener erforderlich, jedoch waren die Unterschiede nicht statistisch signifikant. Klinische Symptome (Einordnung in NYHA- und CCS-Klassifikationen)wurden durch die Anlage eines Doppelmammaria-Bypasses selten beeinflusst. Weitere Studien über einen längeren Nachuntersuchungszeitraum werden erforderlich sein, um endgültig zu klären, ob die Verwendung beider Aa. mammariae internae als Transplantate tatsächlich die Langzeitüberlebensrate verbessern kann und die gegenwärtige Begeisterung für diese Vorgehensweise weiterhin berechtigt ist.

Im Zeitraum von 01/ 1999 bis 07/ 2002 war bei 42 von 1575 (=2,7%) Patienten nach einer koronaren Bypassoperation ein perioperativer Herzinfarkt diagnostizierbar. Diese Patienten wurden hinsichtlich ihres weiteren Vorgehens in Gruppen eingeteilt. Ziel dieser Arbeit war es, unterschiedliche therapeutische Optionen miteinander zu vergleichen. 28 Patienten wurden nach der Diagnose eines PMI einer Herzkatheteruntersuchung zugeführt und mittels PTCA bzw. Stent versorgt. Die restlichen 14 Patienten wurden im postoperativen Verlauf entweder einer Reoperation zugeführt oder sie erhielten eine intraaortale Ballonpumpe (=IABP) bzw. Katecholamine zur Kreislaufstabilisierung.

Thu, 11 Jan 2007 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/6453/ https://edoc.ub.uni-muenchen.de/6453/1/Yildirim_Metin.pdf Yildirim, Metin

Nach den Ergebnissen dieser Pilotstudie ist der Einsatz eines Kombinationssystems aus Ultraschall- Transducer und Stentapplikationseinheit zur Stentimplantation bei koronarer Herzerkrankung sicher und komplikationsarm sowie einfach in der Handhabung. Der Einsatz von IVUS zusätzlich zur Angiographie liefert hilfreiche Informationen zur Durchführung der PTCA und trägt damit zu einer optimalen Implantation des Stents bei. Die mittels IVUS gewonnene Information hatte einen signifikanten Einfluss auf die Interventionsstrategie und veränderte in einem hohen Prozentsatz der Fälle die therapeutische Vorgehensweise. Die Implantationsergebnisse ließen sich auf diese Weise optimieren, woraus im Kontrollzeitraum von 12 Monaten eine niedrige TVR- (6,5%) und TLR- Rate (3,2%) resultierte. Im Vergleich zur rein angiographisch kontrollierten Stentimplantation trug die IVUS- Kontrolle zu einem besseren direkten Implantationsergebnis mit einer geringeren postinterventionellen Diameterstenose bei. Der Einsatz des IVUS verlängerte zwar die Prozedurdauer, beeinflusste die übrigen Interventionsparameter jedoch nicht signifikant. Im Vergleich zur Verwendung separater IVUS- Katheter konnten Prozedurdauer, Durchleuchtungszeit, Kontrastmittelmenge sowie die Anzahl der verwendeten Ballons gesenkt werden. Die postinterventionelle Beurteilung der Läsion mittels IVUS gestaltete sich zum Teil schwierig, da der Ballon nach der Inflation einen größeren Diameter hatte und der Katheter daher bei Läsionen mit einem geringen Lumendiameter nicht mehr über die mit dem Stent versorgte Engstelle hinaus vorgeschoben werden konnte. Eine Umgestaltung des Kombinationssystems mit einer Verlegung der Ultraschalleinheit an die Spitze des Katheters könnte dazu beitragen auch in diesen Fällen eine Beurteilung zu ermöglichen und damit die Ergebnisse noch weiter zu verbessern. Der Einsatz von IVUS und gerade auch von Kombinationssystemen aus Ultraschall- und Stentapplikationseinheit erscheint in Verbindung mit neuen Methoden attraktiv. Zum Beispiel könnten in Kombination mit IVUS die Restenoseraten unter Verwendung von DES unter Umständen noch weiter minimiert werden. Eine andere zukunftsträchtige Möglichkeit ist die Erstellung einer „virtuellen Histologie“ mittels IVUS, die es zum Beispiel ermöglicht vulnerable Plaques zu identifizieren oder den Erfolg einer Therapie mit Lipidsenkern zu erfassen. Bei der Betrachtung der Ergebnisse dieser Studie sollte berücksichtigt werden, dass die Aussagekraft aufgrund der geringen Fallzahl limitiert ist. Die Ergebnisse ermutigen jedoch zur Durchführung weiterer Studien mit höherer Fallzahl.

Die vorliegende Arbeit belegt, dass bei etwa 90% TIMI 3 Fluss nach Stentimplantation mit hoher Sicherheit erzielt werden konnte und dies vor allem in der Gruppe < 24 Stunden mit höherem Anteil an Thrombus und Gefäßokklusion als in der Gruppe ³ 24 Stunden bei überwiegend komplexen Läsionscharakteristika Typ B2 und C. Es zeigte sich in der Angiographie ein geringer Stenosegrad nach Intervention. Und ebenso verzeichnete man auch eine niedrige Rate an Revaskularisierungsmaßnahmen. Aufgrund einer hohen Offenheitsrate des Infarktgefäßes und eine niedrige Revaskularisierungsrate, konnte man die Indikation zur PTCA und Stentimplantation nach Myokardinfarkt am Klinikum Innenstadt München, bei bestehender klinischer Symptomatik, durchaus auch bei später Implantation diskutieren. Unter Berücksichtigung des verhältnismäßig großen Anteils an Risikopatienten in dieser Gruppe, war die Infarktsterblichkeit im Rahmen vergleichbarer Studien. Die Patientengruppe profitierte von einer guten Offenheitsrate des entsprechenden Infarktgefäßes. Die ischämischen Komplikationen blieben im Rahmen vergleichbarer Studien. Die Komplikationsrate war insgesamt mit entsprechenden Studien vergleichbar. Bei den Studien bis März 2003 zeigt sich bei Patienten im akuten Myokardinfarkt sowie im kardiogenen Schock als auch bei Rescue PTCA ein Vorteil der Stentimplantation mit Abciximab gegenüber alleiniger Stentimplantation.

In dieser Fall-Kontroll-Studie wurden präoperative, intra- und postoperative Risikofaktoren sowie Langzeitergebnisse bei Patienten, die sich nach fehlgeschlagener PTCA einer notfallmäßigen aorto-koronaren Bypassoperation (ACB) unterziehen mussten, untersucht. Zur Beurteilung des Mortalitätsrisikos und des Langzeitverlaufs nach notfallmäßiger Bypassoperation diente ein im selben Zeitraum operiertes elektives Vergleichskollektiv mit einem vergleichbaren Risikoprofil. Ein weiterer Aspekt dieser Untersuchung galt der Einschätzung einer erhöhten perioperativen Myokardinfarktinzidenz in der Notfallgruppe. Darüber hinaus wurde untersucht, ob die Verwendung der A. mammaria interna (IMA) die operativen und mittelfristigen Ergebnisse bei den notfallmäßigen ACB-Operationen nach fehlgeschlagener PTCA beeinflusst. Der Gebrauch der IMA wird in der elektiven aorto-koronaren Bypassoperation wegen der vorteilhaften Langzeitergebnisse empfohlen. Bei notfallmäßiger ACB bevorzugen jedoch viele Operateure die Revaskularisation vor allem mit venösen Grafts, da die Operationszeiten kürzer und die initialen Flussraten höher sind. Von Januar 1990 bis März 1993 wurde bei 56 Patienten aus 7 kardiologischen Zentren 1h bis 114 h (durchschnittlich 7,5h) nach fehlgeschlagener PTCA eine notfallmäßige ACB durchgeführt. Diese Patienten wurden auf bestimmte Risikofaktoren und auf Kriterien einer anatomisch ungünstigen Stenose für eine PTCA hin untersucht. Als Kriterien für die Beurteilung einer ungünstigen Stenose galten: langstreckige Stenosen, Verschluss eines anderen Hauptgefäßes, Tandemstenosen, exzentrische Stenosen, Stenosen in oder an einer Gefäßkrümmung/Gefäßaufzweigung und distal gelegene Stenosen. 23,2% der Patienten wiesen ein Kriterium, 41,1% zwei, 8,9% drei und 3,6% vier Kriterien auf. Bei nur 13 Patienten (23,2%) wurden die Stenosen als ideal für eine PTCA eingestuft. Alle Patienten unterzogen sich 14,6 +/- 8,2 Monate post operationem einer echokardiographischen und anamnestischen Nachuntersuchung. Das operative Mortalitätsrisiko nach fehlgeschlagener PTCA war gegenüber den elektiven ACBs signifikant erhöht (10,7% vs. 1,8%; p

In unterschiedlichen Umfragen zum Thema Wetterfühligkeit zeigt sich, daß etwa 30 bis 55 Prozent aller durchschnittlich gesunden Personen ihre Gesundheit durch das Wetter beeinflußt sehen. Frauen reagieren besonders auf die Wetterreize. Die Häufigkeit dieser subjektiven Beschwerden scheint bei Herzinfarkt-Patienten deutlich stärker als in der Normalbevölkerung aufzutreten. Ziel dieser longitudinalen Studie war es, die körperliche Leistungsfähigkeit bei Patienten mit kardiovaskulären Erkrankungen in Zusammenhang mit einzelnen Elementen des Wetters (Lufttemperatur, Luftdruck, Wasserdampfdruck, relative Luftfeuchtigkeit) zu untersuchen. In Timmendorfer Strand wurde mit 872 Patienten (781 Männer, 91 Frauen) mit Herzkrankheiten (u.a. Herzinfarkt, ACVB, KHK, PTCA) während ihres vier- bis sechswöchigen Reha-Aufenthalts eine prospektive Panel-Studie mit sich wiederholenden Messungen durchgeführt. Während der Fahrradergometrie wurden Puls und Blutdruck gemessen. Zusätzlich wurden EKG-Veränderungen und subjektive Symptome während bzw. nach der Ergometrie erfaßt. Die meteorologischen Daten konnten als Tagesmittelwerte aus dem Meßnetz des Deutschen Wetterdienstes gewonnen werden. Um die Assoziation zwischen den 24-Stunden-Mittelwerten der meteorologischen Parameter und der körperlichen Leistungsfähigkeit von Herzreha-Patienten zu modellieren, wurden Generalized Esimating Equations (GEE), Random Effects Modelle und Multilevel Modelle zur linearen Regression verwendet. Die Datenanalyse zeigte zum Teil geringe, medizinisch nicht relevante Veränderungen. Hervorzuheben ist allerdings, daß eine um einen Interquartilsabstand niedrigere Lufttemperatur (9,4°C), als auch ein um einen Interquartilsabstand niedrigerer Wasserdampfdruck (6,2hPa) das Risiko einer ST-Streckensenkung während der Ergometrie verdoppelte. Eine um einen Interquartilsabstand erhöhte relative Luftfeuchtigkeit (14,0%) führte zu einem Risikoanstieg um etwa ein Drittel. Auffällig war außerdem die deutliche Zunahme der Herzfrequenz der Frauen (3-4 Schläge/min.) in Ruhe (vor der Ergometrie) und das zwei- bis dreifach erhöhte Risiko für ventrikuläre Extrasystolen bei höherer Lufttemperatur und höherem Wasserdampfdruck. Die Ergebnisse dieser Analyse legen nahe, daß einzelne meteorologische Parameter Veränderungen der Herzfunktion und damit als Folge auch unerwünschte kardiovaskuläre Ereignisse besonders bei vorgeschädigten, sensiblen Individuen hervorrufen können. Als Indikator für myokardiale Ischämie stellt insbesondere das erhöhte Risiko einer ST-Streckensenkung während körperlicher Belastung eine Verbindung zwischen meteorologischen Parametern und kardialer Morbidität bzw. Mortalität her.

Im Klinikum Heilbronn wurden von Ende 1994 bis Anfang 2000 bei 167 Patienten, 207 Stenosen interventionell angegangen und einer Rot-ablation mit anschließender PTCA zugeführt. Für eine Subgruppe von 62 Patienten wurden zusätzlich umfangreiche anamnestische Daten erhoben. Nach mehreren Monaten erfolgte eine angiographische Nachkontrolle bei 134 Patienten (83,8%) mit 164 Stenosen (82,0%), wobei der Kontrollabstand 3,8 * 0,7 Monate betrug. Keiner der Patienten verstarb in diesem Zeitraum oder musste sich einer Bypass-Operation unterziehen Die angiographische Primärerfolgsquote betrug 93,2%. Durch die Rotablation und die anschließenden PTCA kam es in 16,9% zu angiographischen Ereignissen (Dissekate, Vasospasmen, Gefäßverschlüsse). Wegen technischer Komplikationen konnte der Primäreingriff bei sieben Stenosen nicht erfolgreich durchgeführt werden (3,4%). In 6,6% der Fälle kam es zu klinischen Komplikationen (Myokardinfarkte, Bypass-Operationen, Perikardergüsse, Tod). Bei 70 der nachangiographierten Patienten (52,2%) kam es zu einer Restenose. Für die Intervention mit dem Rotablator lässt sich aus unseren und den Ergebnissen anderer Studien ableiten, dass sich komplexe Stenosen für die Behandlung nicht unbedingt als erfolgsmindernd erweisen, wie dies für die PTCA gilt. Es gibt Hinweise, dass sich durch die Auswahl eines unterdimensionierten Bohrkopfes und eine kurze Passagedauer mit dem Rotablator das Risiko von Komplikationen vermindern lässt. Durch dieses Vorgehen findet eine langsame Verringerung der Stenose statt, wodurch ein gleichmäßiger Partikelabstrom gewährleistet ist. So lassen sich sowohl Mikrokavitationen als auch übermäßiger Partikelabrieb, die beide als mögliche Ursachen distaler Embolisationen dis-kutiert werden, reduzieren. Ideal scheint ein Bohrkopf-Gefäßquotient von 0,7-0,8 zu sein. Zusätzlich beeinflusst eine vorhergehende Rotabla-tion die Ergebnisse der nachfolgenden PTCA im Sinn einer „faciliated angioplasty“ möglicherweise positiv. In unserem Kollektiv fällt die im Vergleich zu anderen Studien mit nur sechs Myokardinfarkten sehr niedrige Rate an ischämischen Komplikationen auf (3,6%). Als Grund dafür könnte die konsequente Anwendung der im vorigen Abschnitt beschriebenen Verfahren sein. Außerdem haben die gute Hydratation mit der Verbesserung der Rheologie und das auch intraoperativ fortgeführte strenge spasmolytische Regime sicher eine wichtige Rolle gespielt. Hinsichtlich der Restenosierung konnte der Rotablator die Erwartungen nicht erfüllen. Die Rate der erneuten Stenosierungen entspricht der der PTCA oder ist in manchen Studien sogar noch höher. Der in der Litera-tur beschriebene Zusammenhang zwischen initialem Lumengewinn/ Gefäßdurchmesser und einem guten Langzeitergebnis scheint auch für unser Kollektiv zuzutreffen, denn bei der Gruppe der Restenosierungen war der initiale Lumengewinn signifikant niedriger, als bei der Gruppe mit guten Langzeitergebnissen. So wurde bei den späteren Restenosen lediglich eine Reduktion auf 36% erzielt, während bei der Gruppe der Langzeiterfolge nur eine 30% Reststenosierung zurückblieb (p