Impact of gender on treatment and clinical outcomes in acute ST elevation myocardial infarction patients in Thailand.

BACKGROUND: Coronary heart disease is the leading cause of mortality and morbidity in men as well as in women. Women have their first cardiac event 6 to 10 years later than men do. Whereas, the cardiovascular death rates are declining in men, they remain constant in women. In cardiovascular studies with age limits, women are naturally the minority, amounting to < 40%. Objective: Determine the effect of gender on treatment and clinical outcomes in acute ST elevation myocardial infarction (STEMI) patients. MATERIAL AND METHOD: This is a multicenter study including 13 government and 4 private institutions. Between August 1, 2002 and October 31, 2005, 3,836 consecutive patients with ST elevation myocardial infarction were enrolled. The patient characteristics, treatment, and hospital outcome were collected and validated. In-hospital management and outcomes were compared between men and women, without adjustment, with adjustment for age alone and with adjustment for age and other covariates by means of multivariate stepwise logistic regression analysis. In each model tested, gender was forced into the model, whereas other predictors were selected in a stepwise manner RESULTS: Women were 1,223 patients (31.9%) of all patients and were 8 years older than men (67.5 +/- 12.0 vs. 59.7 +/- 12.4 years). Women had a higher incidence of diabetes and hypertension (46.9% vs. 31.0%, p < 0.001 and 62.1% vs. 45.3%, p < 0.001). Smoking and family risk factor were found in men more than in women (17.5% vs. 52.5%, p < 0.001 and 7.4% vs. 11.2%, p< 0.001). Women presented more frequently with cardiac dyspnea and shock than men (35.3% vs. 22.2%, p < 0.001 and 21.5% vs. 13.8%, p < 0.001). There was no difference in time to admission between men and women. Beta blocker, statin, angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor inhibitor (ARB) were less frequently used in women. Coronary angiogram was performed less often in women and less abnormal angiogram were found (57.8% vs. 65.0%, p < 0.001 and 55.5% vs. 63.9%, p < 0.001). A lower percentage of women received thrombolytic therapy (28.1% vs. 31.4%, p = 0.039) as well as percutaneous coronary intervention (PCI) (39.0% vs. 48.5%, p < 0.001).Unadjusted in-hospital mortality was significantly higher in women than in men (23.6% vs. 13.9%, unadjusted OR (95% CI) 1.90 (1.60-2.26), p < 0.001). After adjustment of other covariables (age group> 75 years, hospital group (metropolitan, regional), chest pain, cardiac dyspnea, shock, post cardiac arrest, diabetes, hypertension, family history, smoking, dyslipidemia, refer time to admission < or = 12 hours (hour), aspirin, beta blocker calcium antagonist, statin, ACEI, ARB, nitrate, coronary angiogram, thrombolysis, PCI, coronary artery bypass grafting, congestive heart failure, arrhythmia, stroke, bleeding), the gender difference in-hospital mortality no longer existed (adjusted OR (95% CI) 1.03 (0.80-1.33), p = 0.814). The incidence of congestive heart failure as a complication was significantly higher in women than in men (55.6% vs. 38.7%, p < 0.001, adjusted OR (95% CI) 1.29 (1.08-1.54), p = 0.005). CONCLUSION: Women with acute ST elevation myocardial infarction were older and had a higher incidence of hypertension and diabetes than men. Women were less likely than men to undergo coronary angioplasty. Women in the authors' registry had a higher risk for in-hospital morbidity and mortality than men. Early and aggressive treatment might improve the clinical outcomes in women with STEMI.

Off-pump coronary artery bypass surgery: evaluation of extubation time and predictors of failed early extubation.

Anesthesia during and after off-pump surgery is critical for the outcome of the procedure. Intubation time has been shown to correlate with ICU time and length of stay. This study is to evaluate the extubation time and predictors of prolonged extubation in this institution. One hundred and sixty consecutive patients during Jan 2001-June 2002, excluding pre-operative tracheostomy (n = 1) were retrospectively reviewed. Anesthetic agents include fentanyl, rocuronium Bromide, midazolam and sevoflurane. Phenylephrine and nitroglycerine were used to maintain adequate arterial pressures. Post-operative pain control was mainly with intravenous fentanyl and oral pain medications. The extubation time was divided into 4 groups; 0-2 h, n = 76, mean = 1.11 +/- 0.5 h; 2-4 h, n = 30, mean = 2.91 +/- 0.5 h; 4-24 h, n = 39, mean = 11.44 +/- 7.3 h; > 24 h, n = 5, mean = 33.3 +/- 21 h. The data were collected and analyzed following the guidelines of National STS cardiac surgery database. All pre-operative risk factors included: Age (> 70 yrs vs < or = 70 yrs), gender (male vs female), diabetes (yes vs no), hypertension (yes vs no), morbid obesity (yes vs no), renal insufficiency (yes vs no), chronic obstructive lung disease (yes vs no), history of cerebrovascular accident (yes vs no), smoking (yes vs no), dyslipidemia (yes vs no), history of myocardial infarction (MI) (yes vs no), history of congestive heart failure (CHF) (yes vs no), unstable angina (yes vs no), left ventricular ejection fraction (LVEF) (> 40% vs < or = 40%), left main (LM) lesion (LM > 50% vs LM < or = 50%), intra-aortic balloon pump (IABP) used (yes vs no) and time between operating and closing (> 4.30 h vs < or = 4.30 h) were used to predict failed early extubation (2 h). More than 50 per cent of the patients were extubated in less than 2 h (1.11 +/- 0.5 h) and only 5 patients were extubated after 24 h. Univariate analysis revealed old age, diabetes, MI, CHF, LVEF < or = 0.4 and the use of IABP are the predictors (p < 0.05) of failed early extubation. Multivariate analysis of these variables revealed old age with adjusted odds ratio of 4.6 (95% CI = 1.5-13.7) p < 0.01, diabetes with adjusted odds ratio of 3.2 (95% CI = 1.3-7.5) p < 0.01 and IABP used with adjusted odds ratio of 4.3 (95% CI = 1.3-14.6) p = 0.02 are the predictors of fail early extubation. The findings suggested early extubation is possible in OPCAB surgery and attention should be made when operate in patients who have old age, diabetes, and IABP used.

The use of gastroepiploic artery for coronary artery bypass surgery.

The use of arterial conduits in surgical treatment of coronary heart disease has been widely used. As we all know that saphenous vein graft occluded more than 50 per cent after 10 years. Most arterial conduits come from internal mammary artery, radial artery than been used for decades. Another arterial conduit, the right gastroepiploic artery (GEA), is now more popular among cardiac surgeons. This artery can be used along with other arterial conduit for "all arterial coronary bypass surgery" with better long-term patency. We reviewed the recent reports on GEA and to add on our experience on this subject.

Off-pump coronary bypass surgery and all arterial conduits: learning experience at Bangkok Heart Institute.

Off-pump coronary artery bypass technique or bypass graft surgery without the use of a heart-lung machine has been introduced in the last six years, and now comprises approximately 25 per cent of all coronary artery bypass surgery being done in the world. One of the goals of beating heart surgery is to eliminate the complications associated with the use of cardiopulmonary bypass. The use of all arterial conduits for coronary artery bypass graft has become more acceptable after experiences gained and reports of better long-term results. From January 2001 to December 21 2002 the authors performed 251 off-pump procedures. One hundred and nine of these cases were done utilizing all arterial conduits. The data was stratified using the US National Society of Thoracic Surgeons Cardiac Surgery Database pre-operative risk module and divided into 3 groups as suggested: Low risk group with a predicted mortality of 0-1 per cent (2 patients); Medium risk group with a predicted mortality of 2-9 per cent (87 patients), and High risk group with a predicted mortality of 10+ per cent (10 patients). The predicted mortality of the entire group was 4.5 per cent. There were 90 males and 19 females with a mean age of 60.2 +/- 10.7 years, with 15.6 per cent of them older than 70 years. Pre-operative co-morbidities included 1/4 of the patients who had ejection fraction (EF) of equal to or less than 0.4, 4.5 per cent had unstable angina, 1.6 per cent had urgent/emergent status, 26.6 per cent underwent re-operative procedure, 1 per cent had pre-operative serum creatinine more than 2 mg per cent, 4.8 per cent had a history of stroke, 20.2 per cent had a history of congestive heart failure, 45.2 per cent had a history of previous myocardial infarction, 10.7 per cent had a history of chronic obstructive pulmonary disease, 46.9 per cent had a history of diabetes, 62 per cent had hypertension, and 20 patients (18.3%) required intra aortic balloon pump. Intra-operative parameters revealed 3.7 +/- 1.3 grafts/patient. The left internal mammary artery (LIMA) was used to the left anterior descending (LAD) in 6.4 per cent, or sequential with the diagonals 93.6 per cent. The 30 days mortality was 3.6 per cent (4 cases). Further analysis revealed that pre-operatively, none of these 4 cases was in the low predicted (predicted mortality of 0-1%) risk group, 2 of them were in the medium (predicted mortality of 2-9%) and the other 2 were in the high predicted risk (predicted mortality of 10+%) group. The skin-to-skin time was 4.1 hours and there were two conversions to on-pump in this group. Post-operatively, the intubation time was 4.7 hours. There was no peri-operative myocardial infarction, one patient required dialysis, and no patient experienced stroke. There was no sternal wound or arm wound infection, 9.5 per cent experienced temporal sensation impairment at the site of the radial artery harvesting at one month. Re-operation for bleeding occurred in 3 cases, and thirteen patients (14.3%) developed new atrial fibrillation. The authors are no longer making a one-foot long incision and spread ten inches wide like in the old days'. With the less invasive approach lessened in the recent past, the authors have found the less invasive the incision the less the pain after surgery. Totally eliminating the leg incision has allowed the patient to get up and mobilize on the same afternoon, if the procedure was done in the morning. All of these approaches combined with the off-pump technique, as far as the authors are concerned, will provide those who need coronary arterial bypass graft the best operative procedure.