Remodelado inverso ecocardiográfico y eléctrico en terapia de resincronización cardiaca / Echocardiographic and electrical reverse remodeling in cardiac resynchronization therapy

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Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis.

INTRODUCTION AND OBJECTIVES: Since the introduction of drug-eluting stents, the optimum revascularization strategy in diabetic patients with multivessel coronary disease has remained controversial. METHODS: This study used multivariate logistic regression analysis and propensity score matching to compare results in 270 consecutive diabetic patients (2000-2004) with multivessel disease (> or =2 vessels with a >70% de novo stenosis involving the proximal left anterior descending coronary artery) who underwent either coronary artery bypass grafting (CABG; n=142) or implantation of a drug-eluting stent (DES; i.e. rapamycin or paclitaxel; n=128). The following clinical outcomes (i.e. major adverse cardiac or cerebrovascular events [MACCEs]) were assessed: death, nonfatal myocardial infarction (MI), stroke and repeat revascularization at 2 years. RESULTS: Patients who received DESs were older (67.5+/-7 years vs. 65.3+/-8 years; P=.05) and more often had a previous MI (49.2% vs. 28.2%; P< .01), but no more often had a depressed left ventricular ejection fraction < or =45% (32.4% vs. 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9+/-7 vs. 18.5+/-6; P< .001) and the quality of revascularization was better (i.e. anatomically complete revascularization: 52.8% vs. 28.1%; P< .01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] = 0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR = 1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs. 12.1%; adjusted OR = 0.42; 95% CI, 0.16-1.14; P=.09). CONCLUSIONS: In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke.

Comparación de los resultados clínicos a medio plazo de los stents farmacoactivos frente a la cirugía de revascularización coronaria en una población no seleccionada de pacientes diabéticos con afección multivaso. Análisis mediante propensity score / Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis

Introducción y objetivos. La estrategia de revascularización en el paciente diabético con enfermedad multivaso en la era actual de los stents farmacoactivos es controvertida. Métodos. Comparamos a 270 pacientes diabéticos consecutivos (2000-2004) con enfermedad multivaso (al menos 2 vasos con estenosis > 70% de novo y afección de la descendente anterior proximal) a los que se practicó cirugía de revascularización coronaria (n = 142) o se implantó stents farmacoactivos (rapamicina/paclitaxel) (n = 128) mediante análisis de regresión logística multivariable con propensity score. Analizamos los resultados clínicos (eventos cardiacos y cerebrovasculares mayores): muerte, infarto no fatal, ictus y necesidad de revascularización a 24 meses. Resultados. Los pacientes que recibieron stents farmacoactivos tuvieron mayor edad (67,5 ± 7 frente a 65,3 ± 8 años; p = 0,05) y más infarto previo (el 49,2 frente al 28,2%; p < 0,01), aunque no hubo diferencias en la presencia de disfunción ventricular significativa (≤ 45%): el 32,4 frente al 28,1%. En los pacientes quirúrgicos, la anatomía coronaria fue más compleja: score SYNTAX (25,9 ± 7 frente a 18,5 ± 6; p < 0,001) y la calidad de la revascularización fue superior (revascularización anatómica completa, el 52,8 frente al 28,1%; p < 0,01). La incidencia total del evento combinado fue del 18,7% en el grupo quirúrgico y el 21,8% en el grupo percutáneo (odds ratio [OR] ajustada = 0,93; intervalo de confianza [IC] del 95%, 0,47-1,86). El evento combinado de muerte, infarto e ictus fue del 15,8% en el grupo quirúrgico, frente al 12,9% en el grupo de stent farmacoactivo (OR ajustada = 1,19; IC del 95%, 0,72-1,88). Los pacientes quirúrgicos tuvieron menor necesidad de revascularización (el 4,3 frente al 12,1%; OR ajustada = 0,42; IC del 95%, 0,16-1,14; p = 0,09). Conclusiones. En una población no seleccionada de diabéticos multivaso, la ventaja de la cirugía de revascularización coronaria se centró en reducir las revascularizaciones. No encontramos diferencias en muerte, infarto o ictus (AU)

Introduction and Objectives. Since the introduction of drug-eluting stents, the optimum revascularization strategy in diabetic patients with multivessel coronary disease has remained controversial. Methods. This study used multivariate logistic regression analysis and propensity score matching to compare results in 270 consecutive diabetic patients (2000-2004) with multivessel disease (≥2 vessels with a >70% de novo stenosis involving the proximal left anterior descending coronary artery) who underwent either coronary artery bypass grafting (CABG; n=142) or implantation of a drug eluting stent (DES; ie, rapamycin or paclitaxel; n=128). The following clinical outcomes (ie, major adverse cardiac or cerebrovascular events [MACCEs]) were assessed: death, nonfatal myocardial infarction (MI), stroke, and repeat revascularization at 2 years. Results. Patients who received DESs were older (67.5 [7] years vs 65.3 [8] years; P=.05) and more often had a previous MI (49.2% vs 28.2%; P < .01), but no more often had a depressed left ventricular ejection fraction ≤45% (32.4% vs 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9 [7] vs 18.5 [6]; P < .001) and the quality of revascularization was better (ie, anatomically complete revascularization: 52.8% vs 28.1%; P < .01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] =0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR =1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs 12.1%; adjusted OR=0.42; 95% CI, 0.16-1.14; P=.09). Conclusions. In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke. and more often had a previous MI (49.2% vs. 28.2%; P < .01), but no more often had a depressed left ventricular ejection fraction ≤45% (32.4% vs. 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9±7 vs. 18.5±6; P < .001) and the quality of revascularization was better (i.e. anatomically complete revascularization: 52.8% vs. 28.1%; P < .01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] = 0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR = 1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs. 12.1%; adjusted OR = 0.42; 95% CI, 0.16-1.14; P=.09). Conclusions. In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke (AU)