RESUMO
Resumo Fundamento: Enquanto a angiografia coronária invasiva é considerada padrão outro para o diagnóstico da doença arterial coronariana (DAC), envolvendo os vasos coronários epicárdicos, a revascularização coronariana guiada por fisiologia representa uma prática padrão ouro contemporânea para a administração invasiva de pacientes com DAC intermediária. Porém, os resultados de longo prazo da avaliação da gravidade da estenose por meio da fisiologia, em comparação à angiografia como guia para a cirurgia de bypass - enxerto de bypass de artéria coronária (CABG), ainda são incertos. Esta metanálise visa avaliar os resultados clínicos de um CABG guiado por fisiologia em comparação a um CABG guiado pela angiografia. Objetivos: Buscamos determinar se os resultados entre um CABG guiado por fisiologia e os de um CABG guiado por angiografia são diferentes entre si. Métodos: Pesquisamos nas bases Medline, EMBASE e Cochrane Library. A última data de busca foi junho de 2020, e todos os estudos anteriores foram incluídos. Realizamos uma metanálise de razão de risco agrupado para quatro principais resultados: morte por todas as causas, infarto do miocárdio (IM), revascularização do vaso alvo (TVR) e eventos cardiovasculares adversos maiores (MACE). Valor de p <0,05 foi considerado estatisticamente significante. A heterogeneidade foi avaliada com o teste Q de Cochran, e quantificada pelo índice I2. Resultados: Identificamos cinco estudos incluindo um total de 1.114 pacientes. Uma metanálise agrupada não demonstrou diferenças significativas entre a estratégia da fisiologia e da angiografia para IM (razão de risco [RR] = 0,72; IC95%, 0,39-1,33; I2 = 0%; p = 0,65), TVR (RR = 1,25; IC95% = 0,73-2,13; I2 = 0%; p = 0,52), ou MACE (RR = 0,81; IC95% = 0,62-1,07; I2 = 0%; p = 1). A estratégia da fisiologia apresentou 0,63 vezes o risco de morte por todas as causas em comparação à estratégia da angiografia (RR = 0,63; IC95% = 0,42-0,96; I2 = 0%; p = 0,55). Conclusão: Esta metanálise demonstrou uma redução nas mortes por todas as causas quando usada a estratégia do CABG guiado por fisiologia. Porém, o curto período de acompanhamento, o tamanho da amostra pequeno dos estudos incluídos e a não-discriminação das causas de morte podem justificar essas conclusões. Estudos com períodos mais longos de acompanhamento são necessários para tirar conclusões mais robustas e definitivas.
Abstract Background: While invasive coronary angiography is considered the gold standard for the diagnosis of coronary artery disease (CAD) involving the epicardial coronary vessels, coronary physiology-guided revascularization represents a contemporary gold-standard practice for the invasive management of patients with intermediate CAD. Nevertheless, the long-term results of assessing the severity of stenosis through physiology compared to the angiogram as the guide to bypass surgery - coronary artery bypass grafting (CABG) are still uncertain. This meta-analysis aims to assess the clinical outcomes of a physiology guided CABG compared to the angiography-guided CABG. Objectives: We sought to determine if outcomes differ between a physiology guided CABG compared to an angiography-guided CABG. Methods: We searched Medline, EMBASE, and the Cochrane Library. The last date for this search was June 2020, and all of the previous studies were included. We conducted a pooled risk-ratio meta-analysis for four main outcomes: all-cause death, myocardial infarction (MI), target vessel revascularization (TVR) and major adverse cardiovascular events (MACE). P-value <0.05 was considered as statistically significant. Heterogeneity was assessed with Cochran's Q test and quantified by the I2 index. Results: We identified five studies that included a total of 1,114 patients. A pooled meta-analysis showed no significant difference between a physiology guided strategy and an angiography-guided strategy in MI (risk ratio [RR] = 0.72; 95%CI, 0.39-1.33; I2 = 0%; p = 0.65), TVR (RR = 1.25; 95%CI = 0.73-2.13; I2 = 0%; p = 0.52), or MACE (RR = 0.81; 95%CI = 0.62-1.07; I2 = 0%; p = 1). The physiology guided strategy has 0.63 times the risk of all-cause death compared to the angiography-guided strategy (RR = 0.63; 95%CI = 0.42-0.96; I2 = 0%; p = 0.55). Conclusion: This meta-analysis demonstrated a reduction in all-cause death when a physiology guided CABG strategy was used. Nevertheless, the short follow-up period, small sample size of the included studies and the non-discrimination of the causes of death can largely justify these conclusions. Studies with an extended follow-up period of observation are required to draw more robust and definitive conclusions.
RESUMO
Abstract Background Some of the patients admitted for acute myocardial infarction have non-obstructive coronary artery disease (MINOCA). Their prognosis is not always benign, making it necessary the development of tools for risk stratification of these patients. Objectives To describe the characteristics of a sample of patients admitted for suspected MINOCA and to evaluate the prognostic value of GRACE score in this population. Methods This was a retrospective, observational, single-center, cohort study involving 56 consecutive patients with MINOCA. During one-year follow-up, patients were assessed for mortality and major adverse cardiovascular events (MACE) - a composite of all-cause mortality and hospitalization due to acute myocardial infarction, heart failure, ischemic stroke, and acute limb ischemia. Statistical analysis was performed using a non-parametric approach, with the Mann-Whitney U test for quantitative variables and ROC curves for assessing the discriminatory power of the Grace score in predicting cardiovascular events. The level of significance was set at 5%. Results Of the 56 MINOCA patients included in the study (median age 67 years), 55.4% were female. During the one-year follow-up, mortality rate was 5.5% and 9.1% of patients had MACE. A higher GRACE score was associated with mortality (p = 0.019; AUC 0.907; 95%CI 0.812-1.000; cut off 138) and MACE (p =0.034; AUC 0.790; 95%CI 0.632-0.948; cutoff 114). Conclusion The definition of MINOCA includes various diagnoses and prognoses, and the GRACE score is useful for risk stratification of patients with this condition.