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Из последнего BMJ
Редакционные статьи являются выражением "современной линии партии" и предназначены для врачей всех специальностей. Вот о чём нам поведали в последнем выпуске.
BMJ 2011; 342 (Published 2 June 2011) Editorial Medical treatment, PCI, or CABG for coronary artery disease? Andre Lamy, cardiac surgeon, Madhu Natarajan, interventional cardiologist, Salim Yusuf, non-interventional cardiologist The three approaches should complement one another, not compete Medical treatments of coronary artery disease have improved in the past decade because of the availability of statins, effective blood pressure lowering drugs (in particular angiotensin converting enzyme inhibitors), calcium blockers, and antiplatelet agents. 1 In addition, improvements in percutaneous coronary interventions (PCI) have revolutionised the management of high risk people with acute myocardial infarction (primary PCI and rescue PCI) and non-ST elevation myocardial infarction and unstable angina. The use of stents, together with antiplatelet and antithrombotic treatments, has reduced procedural complications and made PCI safer. 2 Drug eluting stents have reduced restenosis after PCI, although they increase late stent thrombosis, for which long term dual antiplatelet treatment is required. 3 Improvements in coronary artery bypass (CABG) surgery have been slow because only a few randomised controlled trials have been performed. Surgeons still debate the benefits of off-pump CABG (beating heart surgery) versus on-pump surgery, 4 and whether double internal mammary artery grafts are superior to single internal mammary grafting. Both questions are currently being evaluated in large randomised trials. 5 Given that CABG surgery is increasingly performed in older people who are at high risk of cardiac, neurological, and renal complications, it is notable that CABG surgery results are improving worldwide. In October 2010, a joint task force of the European Society of … [Full text of this article] [Ссылки могут видеть только зарегистрированные пользователи. ] [Ссылки могут видеть только зарегистрированные пользователи. ] |
да вроде и нет великой конкуренции...
таблетки выводим за скобки, ни одно из вмешательств их не исключает. конкурентное пересечение между АКШ и ЧКВ если и есть, то не очень серьезное, если конечно говорить о разумном подходе... в наших условиях конкуренция заключается в мастерстве. что лучше умеют в данном конкретном заведении - то и лучше |
холивар есть на фоне квот немного
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Цитата:
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Перекосы всегда встречаются там, где решение принимают манипуляционисты. Это может быть и квото-ориентированное мышление, и добросовестное заблуждение в собственном невиданном мастерстве. Идеально, чтобы решение принимал неинвазивный кардиолог. К сожалению, это мало где бывает. С другой стороны, многие неинвазивные стали инвазивней инвазивных и хирургов. Ребаунт предыдущих уговоров?
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rsp одобрил(а): есть ли у кого взоможность выложить полный текст?
Medical treatment, PCI, or CABG for coronary artery disease? The three approaches should complement one another, not compete Andre Lamy cardiac surgeon, Madhu Natarajan interventional cardiologist, Salim Yusuf non-interventional cardiologist Population Health Research Institute, Hamilton, ON, Canada L8L 2X2 Medical treatments of coronary artery disease have improved in the past decade because of the availability of statins, effective blood pressure lowering drugs (in particular angiotensin converting enzyme inhibitors), calcium blockers, and antiplatelet agents.1 In addition, improvements in percutaneous coronary interventions (PCI) have revolutionised the management of high risk people with acute myocardial infarction (primary PCI and rescue PCI) and non-ST elevation myocardial infarction and unstable angina. The use of stents, together with antiplatelet and antithrombotic treatments, has reduced procedural complications and made PCI safer.2 Drug eluting stents have reduced restenosis after PCI, although they increase late stent thrombosis, for which long term dual antiplatelet treatment is required.3 Improvements in coronary artery bypass (CABG) surgery have been slow because only a few randomised controlled trials have been performed. Surgeons still debate the benefits of off-pump CABG (beating heart surgery) versus on-pump surgery,4 and whether double internal mammary artery grafts are superior to single internal mammary grafting. Both questions are currently being evaluated in large randomised trials.5 Given that CABG surgery is increasingly performed in older people who are at high risk of cardiac, neurological, and renal complications, it is notable that CABG surgery results are improving worldwide. In October 2010, a joint task force of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery published new guidance about managing patients with coronary artery disease.6 Three overarching considerations are emphasised. Firstly, a multidisciplinary heart team, including an interventional cardiologist, a non-interventional cardiologist, and a cardiac surgeon should guide decision making in individual patients. The patient should be included in decisions regarding the most balanced and evidence based clinical approach. Each heart team could also use international guidelines to develop local guidelines and document whether decisions meet these preset criteria. Clinical decisions generally need to balance adherence to guidelines against judgments based on specific patient, operator, and local (social, economic, and cultural) factors. Periodic reviews of the decisions will allow each heart team to evaluate their performance in relation to local and international guidelines. Although perfect adherence to guidelines should not be expected, substantial and consistent deviations will prompt review of the approach taken. Some doctors may be concerned at the curtailment of their freedom, but unchecked, non- evidence based, and expensive approaches simply cannot be defended. Others may be concerned that the use of a heart team will be cumbersome and time consuming. This need not be the case if advanced local guidelines about how to approach different clinical scenarios are developed and followed. Secondly, the guidelines recommend that ad hoc PCI should not automatically be applied after angiography, and they describe potential indications for ad hoc PCI. Situations where ad hoc PCI is appropriate include direct PCI or rescue PCI of the culprit lesions (but not of other lesions) in people with ST elevation myocardial infarction and in those with acute coronary syndrome and high risk.7 8 Selected patients with stable coronary artery disease and angina may also be considered for ad hoc PCI, such as those with frequent angina in whom medical treatment does not relieve symptoms and surgery is not indicated to improve prognosis or is risky because of comorbidities. However, guidelines should be followed in everyone else, and cases that are uncertain should be discussed with the heart team, resisting the temptation of ad hoc PCI. Thirdly, the guidelines emphasise the usefulness of conventional medical treatments for selected patients. Optimal medical treatment can reduce angina and the risk of myocardial infarction and stroke substantially and prevent progression of atherosclerosis in the entire vasculature. Patients with even a single stenosis in their coronary tree have underlying extensive atherosclerosis even if coronary imaging fails to show it. These patients are therefore at risk of occlusive events in multiple |
territories, which could lead to myocardial infarction, stroke,
or limb ischaemia. In contrast, PCI and CABG surgery deal only with specific obstructive lesions and leave atherosclerosis in the coronary vascular disease unaltered. It makes sense to use immediate revascularisation with PCI or CABG when there is critical ischaemia—for example, to prevent necrosis of distal myocardium in the next few hours in the acutely ruptured plaque superimposed on a coronary obstruction. There are several scenarios in stable coronary artery disease where CABG surgery improves survival (and PCI does not) compared with medical treatment.9 These include patients with left main disease, triple vessel disease, and one and two vessel disease involving the proximal left anterior descending artery. In such circumstances, CABG surgery is the preferred approach if one of the main goals of treatment is to improve prognosis. The immediate “cosmetic” fix of an obstructive lesion is appealing, but it may not improve the long term prognosis. CABG surgery remains superior to PCI and medical treatment for the long term relief of angina, with little difference in overall costs between PCI (with the need for repeat procedures) and CABG by five years for multivessel disease. The recent SYNTAX trial confirms the value of CABG surgery over PCI for high risk patients with left main disease even with a one year follow-up.10 Longer term follow-up (such as five years) is needed before PCI can be advocated as an alternative for CABG in lower risk people with left main disease. For the moment, CABG surgery should be the standard approach in those with left main disease. What are the practical obstacles to implementing these guidelines? Some patients and doctors may perceive any delay (for example, not performing immediate PCI in stable patients) as problematic. Reassurance and education are needed to emphasise that a small delay is a worthwhile trade-off for the best strategy to be identified and unnecessary risks avoided. Will consultation with a heart team be cumbersome and increase bureaucracy? Not necessarily, if local guidelines can be agreed in each centre and only difficult cases discussed by the heart team members. Medical treatment, PCI, and CABG should not be seen as competing strategies but rather as complementary approaches with overlapping roles. All three have their limitations and no single one will suffice. Each approach will continue to improve with time, and coronary artery disease will become a relatively benign disease. Competing interests: All authors have completed the Unified Competing Interest form at [Ссылки могут видеть только зарегистрированные пользователи. ] (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Provenance and peer review: Commissioned; not externally peer reviewed. 1 Yusuf S. Two decades of progress in preventing vascular disease. Lancet 2002;360:2-3. 2 Garg S, Serruys PW. Coronary stents: current status. J Am Coll Cardiol 2010;56(10 suppl):S1-42. 3 Holmes DR Jr, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG, et al. Stent thrombosis. J Am Coll Cardiol 2010;56:1357-65. 4 Coronary Artery Bypass Surgery (CABG) Off or On Pump Revascularization Study (CORONARY). NCT 00463294. 2010. [Ссылки могут видеть только зарегистрированные пользователи. ]. 5 Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, et al; ART Investigators. Randomized trial to compare bilateral vs single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J 2010;31:2470-81. 6 Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on myocardial revascularization. Eur Heart J 2010;31:2501-55. 7 Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet 2006;367:579-88. 8 Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, et al; TIMACS Investigators. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009;360:2165-75. 9 Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563-70. 10 Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961-72. |
Мне понравилась такая фраза: "Will consultation with a heart team be cumbersome and increase bureaucracy? Not necessarily, if local guidelines can be agreed in each centre and only difficult cases discussed by the heart team members."
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