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#16
16.11.2006, 22:37
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Thak you Vadim for saving me some time.
Even interventionalists in USA now know that stents only treat symptoms in stable angina patients but do it anyway to pay mortgage  . Now since Medicare rightly is cutting down on the reimbursement rates the number of stents needed for cardiologists to survide almost DOUBLED. If 3 years ago patient would get one stent now he gets 4-5 stents . All the studies done so far have failed to show any significant difference in hard outcomes. If you know of any RCT large enough wich did not get included in the above analysis please feel free to post it here. On the AHA this idea was debated in length. The only reason to to PCI in stable patient with normal EF is to impvore quality of life afret the medical therapy proves inadequate. 
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#17
16.11.2006, 22:38
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Цитата:
 И потом мы обсуждаем только конечные точки (смерть, ИМ, покзания к экстренной реваскуляризации) или еще что-то, например, исчезновение симптомов?
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#18
16.11.2006, 23:16
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1. Цель любого лечения/вмешательства - увеличение продолжительности и качества жизни. Оба эти показателя важны, а какой предпочесть при прочих равных условиях?
2. Если бляшка стабильна, то крайне сложно предположить когда она лопнет (может и никогда, и пациент скорее доживёт до Альцгеймера, чем до инфаркта, принимая статин, аспирин, Б-блокатор и иАПФ). Зачем же своими руками делать диссекцию (пардон, ТБКА), ставить туда стент чтобы предотвратить тромбоз/инфаркт после стентирования и долго, долго кормить пациента клопидогрелем? 3. Когда бляшка уже лопнула, то преимущества ТБКА vs медикаментозное лечение очевидны. Вот бы найти предикторы дестабилизации бляшки..
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#19
16.11.2006, 23:17
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New York Times Offers Lessons from Late PCI Findings
This morning's New York Times comments on the larger implications of research (summarized here yesterday) showing the futility of reopening persistently blocked coronary arteries in stable patients. The analysis reminds readers that medical dogma changes, especially in the face of new, unexpected findings -- the role of bacteria in gastric ulcers being another such example. James N. Weinstein, a Dartmouth orthopedist, is quoted as saying "As a nation, we're not doing ourselves any favors by going after the next new thing without doing the studies." Otherwise, he says, "everybody's going to lose trust in the system."
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#20
16.11.2006, 23:27
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Цитата:
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#21
16.11.2006, 23:31
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Вот бы найти предикторы дестабилизации бляшки..
The size of the plaque does not matter. Most of MIs happen on the plaques less than 50%. CAD is not just about plumbing, this is a disease. There are hundreds and hundreds lessions in the arteries and PCI can only treat 0.01% of them. We all know the parameters of destabilisation 1.BP 2.LDL particle number 3. HDL 4. Smoking 5. A1c 6. GFR 7. (?) CRP All simple office tests
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#22
16.11.2006, 23:32
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Цитата:
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#23
16.11.2006, 23:50
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Цитата:
Цитата:
Мне кажется,очевидным, что группа т.н. стабильных больных не однородна. У одного при стресс-Эхо ФВ падает в 2 раза. У другого на фоне приступа появляется ЖТ, а стенокардия умеренная. У третьего со стенокардией 3 ФК все родственники умерли до 50 лет от ИМ и тд... И что не делать им КАГ? И напротив некая бабушка 85 лет при ходьбе на 500 м описывает стенокардию, купирующуюся в покое. Все эти больные формально стабильные - однако ясное дело прогноз различный и тактика должна быть разной. Мое мнение, когда нет очевидного консенсуса надо действовать в соответствии с официальными рекомендациями (там эти особенности больных отражены), экспертными мнениями с поправкой на возможности той клиники где работаешь. P.S. А многие предикторы разрыва бляшки известны. Просто в широкой практике еще не исследуются.
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#24
16.11.2006, 23:55
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Цитата:
Patients With Known or Suspected CAD Who Are Currently Asymptomatic or Have Stable Angina Class I 1. CCS class III and IV angina on medical treatment. (Level of Evidence: B) 2. High-risk criteria on noninvasive testing regardless of anginal severity (Table 1). (Level of Evidence: A) 3. Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 seconds) monomorphic ventricular tachycardia or nonsustained (<30 seconds) polymorphic ventricular tachycardia. (Level of Evidence: B) Class IIa 1. CCS class III or IV angina, which improves to class I or II with medical therapy. (Level of Evidence: C) 2. Serial noninvasive testing with identical testing protocols, at the same level of medical therapy, showing progressively worsening abnormalities. (Level of Evidence: C) 3. Patients with angina and suspected coronary disease who, due to disability, illness, or physical challenge, cannot be adequately risk stratified by other means. (Level of Evidence: C) 4. CCS class I or II angina with intolerance to adequate medical therapy or with failure to respond, or patients who have recurrence of symptoms during adequate medical therapy as defined above. (Level of Evidence: C) 5. Individuals whose occupation involves the safety of others (eg, pilots, bus drivers, etc) who have abnormal but not high-risk stress test results or multiple clinical features that suggest high risk. (Level of Evidence: C) Это официальные рекомендации. Пациент на соседней ветке, которого привел в пример др. Гиляров попадает под эти критерии.
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#25
17.11.2006, 00:10
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#26
17.11.2006, 00:12
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#27
17.11.2006, 00:28
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Diabetes and stents do not mix together very well. All subgroup analysis from stent studies (not DES) show that diabetics do very badly with the stents and probably need CABG anyway. Those with left main, triple vessel and low EF do need CABG in my opinion instead of stents (see old CASS study).
So is I ever need a revascularisation I want off-pump CABG for myself. I dont want any metal in my arteries .
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#28
17.11.2006, 00:33
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Цитата:
Цитата:
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#29
17.11.2006, 00:49
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Мнения зарубежных коллег:
Surgical revascularization of the left anterior descending artery (LAD) with the internal thoracic artery (ITA) in patients with multivessel disease is still the only proved method of improving event-free survival.4 and 5 In the subset of patients with diabetes mellitus in the Bypass Angioplasty Revascularization Investigation study,6 and 7 which compared PCI with CABG, LAD revascularization with the ITA was found to be an independent predictor of survival. Similar findings were reported later in the subgroup of patients with diabetes in the Arterial Revascularization Therapy Study.8 In that study 3-year survival of patients treated surgically was significantly better than that of diabetic patients treated with bare-metal stents. In the prestent era, studies comparing results of CABG and PCI showed similar occurrence of death and MI but higher rates of reinterventions and early return of angina in the patients in the PCI group.15 Comparable long-term survival was demonstrated in most patients, with the exception of diabetics.6, 7 and 16 In the Arterial Revascularization Therapy Study similar findings were reported in a subgroup of 207 diabetic patients treated with stents.8 Survival of diabetic patients treated surgically was better than survival of patients treated with bare-metal stents. The improved clinical and angiographic outcome reported recently with DESs also included the subset of diabetic patients.10 and 11 However, the reported occurrence of MACEs and TVR was still higher in diabetic patients when compared with that seen in nondiabetic patients. The current report is a retrospective cohort study describing our initial and midterm experience with Cypher stenting in diabetic patients. Results are compared with those of diabetic patients undergoing surgical arterial myocardial revascularization. Propensity score analysis was used to control for differences in preprocedural patient data. Propensity scores identified 186 patients, 93 for each group, with comparable preprocedural and periprocedural characteristics. After a mean follow-up of 19 months, which is long enough for the development of in-stent restenosis,17 survival was similar. However, more than 40% of the Cypher-treated patients experienced early return of angina, and only 83% were free of reintervention. Two-year (Kaplan-Meier) angina-free survival and reintervention-free survival of the surgical patients were significantly better (88% and 95% vs 47% and 83%, respectively). In conclusion, the midterm clinical outcome of diabetic patients treated surgically is still better than that of patients treated with Cypher stents. Из J Thorac Cardiovasc Surg. 2006 Oct;132(4):861-6. Drug-eluting stents versus arterial myocardial revascularization in patients with diabetes mellitus.Ben-Gal Y, Mohr R, Uretzky G, Medalion B, Hendler A, Hansson N, Herz I, Moshkovitz Y. Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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#30
17.11.2006, 01:29
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EVIDENCE SYNTHESIS: We identified 6 RCTs comparing CABG surgery and PCI in a total of 950 diabetic patients. A mortality benefit for CABG over balloon-only PCI has been demonstrated in diabetic patients with multivessel coronary artery disease but has not been clearly established against stent-assisted PCI or in high-risk CABG patients. Use of glycoprotein IIb/IIIa receptor inhibitors has improved survival in diabetic patients undergoing PCI. Restenosis after PCI in diabetic patients has led to substantially higher repeat revascularization rates than after CABG. The use of drug-eluting stents has led to dramatic reductions in restenosis in diabetic patients. Ongoing RCTs comparing CABG and PCI using drug-eluting stents in diabetic patients will clarify the impact of these advances on outcomes. CONCLUSIONS: There is a relative lack of data from RCTs specifically comparing CABG surgery and PCI as currently practiced in diabetic patients. The mortality advantage and decreased rates of revascularization seen with CABG in subgroups from early trials may not be applicable in the era of drug-eluting stents, glycoprotein IIb/IIIa inhibitors, and the latest medical therapies.
JAMA. 2005 Mar 23;293(12):1501-8. Diabetes and coronary revascularization. [Ссылки доступны только зарегистрированным пользователям ]
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