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1.
Eur Heart J ; 43(48): 5020-5032, 2022 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-36124729

RESUMO

AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.


Assuntos
Infarto Miocárdico de Parede Anterior , Comunicação Interventricular , Infarto do Miocárdio , Humanos , Choque Cardiogênico/etiologia , Assistência ao Convalescente , Resultado do Tratamento , Alta do Paciente , Comunicação Interventricular/cirurgia , Sistema de Registros , Reino Unido/epidemiologia , Estudos Retrospectivos
2.
J Am Heart Assoc ; 8(8): e011279, 2019 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-30943827

RESUMO

Background The Heart Team ( HT ) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease ( CAD ). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion. Methods and Results This observational study was conducted at St Thomas' Hospital (London, UK). Case mixture included unprotected left main, 2-vessel (including proximal left anterior descending artery) CAD , 3-vessel CAD , or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy ( OMT ) alone, OMT +percutaneous coronary intervention ( PCI ), or OMT +coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23-39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3-vessel CAD . Three-year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT + PCI cohort, and 90.2% in the OMT +coronary artery bypass grafting cohort (92 of 102). Conclusions In our experience, the HT approach involved a careful selection process resulting in appropriate patient-specific decision making and good long-term outcomes in patients with complex CAD .


Assuntos
Cardiologia , Fármacos Cardiovasculares/uso terapêutico , Tomada de Decisão Clínica/métodos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Equipe de Assistência ao Paciente , Intervenção Coronária Percutânea , Cirurgia Torácica , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comportamento Cooperativo , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Choque Cardiogênico/epidemiologia , Taxa de Sobrevida , Reino Unido , Disfunção Ventricular Esquerda/epidemiologia
3.
Int J Cardiol ; 206: 37-41, 2016 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-26774827

RESUMO

BACKGROUND: A multidisciplinary team (MDT) approach for decision-making in patients with complex coronary artery disease (CAD) is now a class IC recommendation in the European and American guidelines for myocardial revascularisation. The aim of this study was to evaluate the implementation and consistency of Heart Team HT decision-making in complex coronary revascularisation. METHODS: We prospectively evaluated the data of 399 patients derived from 51 consecutive MDT meetings held in a tertiary cardiac centre. A subset of cases was randomly selected and re-presented with the same clinical data to a panel blinded to the initial outcome, at least 6 months after the initial discussion, in order to evaluate the reproducibility of decision-making. RESULTS: The most common decisions included continued medical management (30%), coronary artery bypass grafting (CABG) (26%) and percutaneous coronary intervention (PCI) (17%). Other decisions, such as further assessment of symptoms or evaluation with further invasive or non-invasive tests were made in 25% of the cases. Decisions were implemented in 93% of the cases. On re-discussion of the same data (n=40) within a median period of 9 months 80% of the initial HT recommendations were successfully reproduced. CONCLUSIONS: The Heart Team is a robust process in the management of patient with complex CAD and decisions are largely reproducible. Although outcomes are successfully implemented in the majority of the cases, it is important that all clinical information is available during discussion and patient preference is taken into account.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/terapia , Tomada de Decisões , Equipe de Assistência ao Paciente , Intervenção Coronária Percutânea/métodos , Idoso , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Revascularização Miocárdica/métodos , Revascularização Miocárdica/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Padrões de Prática Médica , Estudos Prospectivos , Reprodutibilidade dos Testes
4.
J Invasive Cardiol ; 26(5): E50-1, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24791724

RESUMO

Cardiogenic shock (CS) during elective percutaneous coronary intervention (PCI) is a rare but potentially lethal clinical condition. Pharmacological inotropic support and mechanical circulatory assistance with intra-aortic balloon pump (IABP) counterpulsation remains the gold-standard treatment. We report the case of a patient who developed refractory CS during elective PCI and was successfully managed with concomitant use of IABP and the Impella 2.5 L support device.


Assuntos
Coração Auxiliar , Hemodinâmica/fisiologia , Balão Intra-Aórtico , Choque Cardiogênico/terapia , Cardiotônicos , Terapia Combinada , Doença da Artéria Coronariana/terapia , Feminino , Hemofiltração , Humanos , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento
6.
Circulation ; 111(12): 1530-6, 2005 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-15795363

RESUMO

BACKGROUND: Circulating concentrations of the sensitive inflammatory marker C-reactive protein (CRP) predict future cardiovascular events, and CRP is elevated during sepsis and inflammation, when vascular reactivity may be modulated. We therefore investigated the direct effect of CRP on vascular reactivity. METHODS AND RESULTS: The effects of isolated, pure human CRP on vasoreactivity and protein expression were studied in vascular rings and cells in vitro, and effects on blood pressure were studied in rats in vivo. The temporal relationship between changes in CRP concentration and brachial flow-mediated dilation was also studied in humans after vaccination with Salmonella typhi capsular polysaccharide, a model of inflammatory endothelial dysfunction. In contrast to some previous reports, highly purified and well-characterized human CRP specifically induced hyporeactivity to phenylephrine in rings of human internal mammary artery and rat aorta that was mediated through physiological antagonism by nitric oxide (NO). CRP did not alter endothelial NO synthase protein expression but increased protein expression of GTP cyclohydrolase-1, the rate-limiting enzyme in the synthesis of tetrahydrobiopterin, the NO synthase cofactor. In the vaccine model of inflammatory endothelial dysfunction in humans, increased CRP concentration coincided with the resolution rather than the development of endothelial dysfunction, consistent with the vitro findings; however, administration of human CRP to rats had no effect on blood pressure. CONCLUSIONS: Pure human CRP has specific, direct effects on vascular function in vitro via increased NO production; however, further clarification of the effect, if any, of CRP on vascular reactivity in humans in vivo will require clinical studies using specific inhibitors of CRP.


Assuntos
Proteína C-Reativa/farmacologia , Endotélio Vascular/efeitos dos fármacos , Inflamação/patologia , Óxido Nítrico/biossíntese , Vasodilatação/efeitos dos fármacos , Animais , Artérias , Pressão Sanguínea/efeitos dos fármacos , GTP Cicloidrolase/efeitos dos fármacos , GTP Cicloidrolase/genética , Humanos , Inflamação/induzido quimicamente , Lipopolissacarídeos/administração & dosagem , Ratos , Regulação para Cima/efeitos dos fármacos
7.
Cardiovasc Res ; 64(1): 172-8, 2004 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-15364625

RESUMO

OBJECTIVES: Our aim was to investigate mechanisms of inflammation-induced endothelial dysfunction in humans. METHODS: Endothelial function in twenty-one healthy human volunteers was measured using forearm venous plethysmography before and 8 h after administration of typhoid vaccination to generate an inflammatory response. Basal and stimulated endothelial nitric oxide (NO) bioavailability was assessed by measurement of the responses to intra-arterial N(G)-monomethyl-l-arginine (l-NMMA) and bradykinin, respectively. The effects of supplementation with l-arginine or ascorbic acid were assessed to probe the effects of substrate deficiency and oxidative stress, respectively. Systemic effects were determined by measuring cytokine response, total anti-oxidant status (TAOS) and urinary protein excretion. RESULTS: Vaccination induced a cytokine response, a fall in total anti-oxidant status and increased urinary albumin excretion (UAE). There was a reduction in the response to bradykinin (BK, P<0.005) and l-NMMA (P<0.0001) with no effect on the response to glyceryl trinitrate (GTN) and norepinephrine (NE). Following vaccination blood flow response to BK (but not GTN) was partially returned to pre-vaccine levels by infusion of ascorbic acid (P=0.01). Supplementation with l-arginine had no effect. CONCLUSION: Inflammation causes widespread endothelial dysfunction, reduces vascular NO bioavailability and increases oxidative stress. These actions are partially reversible with local anti-oxidants. These findings suggest a role for reactive oxygen species in inflammation-induced endothelial dysfunction.


Assuntos
Endotélio Vascular/imunologia , Óxido Nítrico/metabolismo , Estresse Oxidativo , Adulto , Albuminúria/imunologia , Análise de Variância , Arginina/farmacologia , Ácido Ascórbico/farmacologia , Disponibilidade Biológica , Bradicinina/farmacologia , Relação Dose-Resposta a Droga , Endotélio Vascular/metabolismo , Feminino , Antebraço/irrigação sanguínea , Humanos , Masculino , Nitroglicerina/farmacologia , Norepinefrina/farmacologia , Pletismografia , Fluxo Sanguíneo Regional , Estatísticas não Paramétricas , Vacinas Tíficas-Paratíficas/administração & dosagem , Vasoconstritores/farmacologia , Vasodilatadores/farmacologia , ômega-N-Metilarginina/farmacologia
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