ABSTRACT
BACKGROUND: The optimal management strategy for significant unprotected ostial left anterior descending artery (LAD) disease remains undefined. Merits of the two most common percutaneous approaches are considered in this quantitative synthesis. METHOD: A meta-analysis was performed to compare ostial stenting (OS) and crossover stenting (CS) in the treatment of unprotected ostial LAD stenosis. The primary outcome is the disparity in target lesion revascularisation (TLR). The Mantel-Haenszel method was employed with random effect model, chosen a priori to account for heterogeneity among the included studies. RESULTS: Seven studies comprising 1,181 patients were included in the analyses. Of these, 482 (40.8%) patients underwent CS. Overall, there was a statistically significant trend in favour of CS (odds ratio 0.51, 95% confidence interval 0.30-0.86, p=0.01) with respect to the rate of TLR at follow-up. This remained true when TLR involving the left circumflex artery (LCx) was considered, even when there was a greater need for unintended intervention to the LCx during the index procedure (odds ratio 6.68, 95% confidence interval: 1.69-26.49, p=0.007). Final kissing balloon inflation may reduce the need for acute LCx intervention. Imaging guidance appeared to improve clinical outcomes irrespective of approach chosen. CONCLUSIONS: In the percutaneous management of unprotected ostial LAD disease, CS into the left main coronary artery (LMCA) appeared to reduce future TLR. Integration of intracoronary imaging was pivotal to procedural success. The higher incidence of unintended LCx intervention in the CS arm may be mitigated by routine final kissing balloon inflation, although the long-term implication of this remains unclear. In the absence of randomised trials, clinicians' discretion remains critical.
ABSTRACT
Using a network meta-analysis, this study compared fractional flow reserve (FFR) guided with angiography-guided revascularization of non-culprit lesions in ST elevation myocardial infarction (STEMI). We also assessed if early complete revascularization is superior to delayed revascularization. We conducted a network meta-analysis using Net Meta XL of trials of STEMI patients with multivessel disease and compared revascularization strategies. The primary outcomes of interest were rate of revascularization, myocardial infarction, and all-cause mortality. Ten studies were included in our analysis comprising 7981 patients with 4484 patients undergoing complete revascularization and 3497 patients with culprit-only revascularization. There was no significant reduction in all-cause death, myocardial infarction, or revascularization using FFR guidance. There was significant reduction in repeat revascularization with complete revascularization irrespective of timing of percutaneous coronary intervention (PCI) compared with the culprit-only group. There was an overall trend favoring earlier revascularization. For patients with multivessel disease presenting with ST-elevation MI, complete revascularization significantly reduces repeat revascularization compared with culprit-only treatment. FFR guidance is non-superior to angiography-guided revascularization. Furthermore, there was significant reduction in repeat revascularization irrespective of timing of PCI to non-culprit vessels.
ABSTRACT
Background: Advances in percutaneous coronary intervention (PCI) has made the possibility of facilitating same day discharge (SDD) of patients undergoing intervention. We sought to investigate the feasibility, safety and economic impact of such a service. Methods: We retrospectively collected data on all patients undergoing outpatient PCI at our institution over a 12-month period. We included in-hospital and 30-day major adverse cardiac events (MACE), vascular complications, acute kidney injury and any re-hospitalisations. We analysed the cost effectiveness of SDD compared to overnight admission post PCI and staged PCI following diagnostic angiography. Results: A total of 147 patients undergoing PCI with 129 patients deemed suitable for SDD (88%). Mean age was 65.7 years. Most patients had type C lesions (60.3%); including 4 chronic total occlusions (CTOs). At 30-day follow-up there were no MACE events (0%). There were 10 (7.8%) re-hospitalisations of which majority (70%) were non cardiac presentations. We also included cost analysis for an elective PCI with SDD, which equated to $2090 per patient (total of $269 610 for cohort). Elective PCI with an overnight admission was $4440 per patient (total of $572 760 for cohort), an additional $2350 per patient (total $303 150). Total cost of an angiogram followed by a staged PCI with an overnight stay was $4700 per patient (total $606 300). Conclusion: SDD is safe and feasible in the majority of patients that have elective coronary angiography that require PCI. SDD leads to a significant reduction in total cost and hospital stay of patients undergoing elective PCI.
ABSTRACT
INTRODUCTION: There is limited information about the end-of-life care provided to patients with end-stage chronic obstructive pulmonary disease (COPD) in comparison to patients with lung cancer. AIM AND METHODS: We compared the end-of-life care provided to patients with COPD versus patients with lung cancer who died in hospital over a 12-month period in our institution. RESULTS: During the study period, 89 patients died due to COPD (n = 34) or lung cancer (n = 55). Compared to patients with lung cancer, patients with COPD received less palliative care services (50% vs 9%, P < .001) and underwent more diagnostic tests and received more life-prolonging measures. CONCLUSION: Toward the end of their life, patients with COPD received fewer symptom-alleviating treatments and palliative care services.
