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Among patients with diabetes and stable heart disease, those with troponin T levels of 14 ng per liter or more had a 5-year rate of cardiovascular death, MI, or stroke of 27%, versus 13% in those with lower levels, but received no benefit from prompt revascularization. Cardiac troponin concentration is the preferred marker of myocardial necrosis. 1 Elevated concentrations of cardiac troponin have a strong association with an adverse prognosis in patients with acute coronary syndromes and are used to identify patients who are likely to benefit from an early invasive management strategy. 2 – 4 High-sensitivity assays that allow the measurement of very low cardiac troponin levels in patients with stable heart disease are now available for clinical and research use. These low, previously undetectable troponin concentrations have shown strong associations with myocardial infarction, stroke, and death in a variety of primary and secondary prevention populations, including in . . .

Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor-guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.

To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG. From January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used. In multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65). RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

To evaluate the cardiovascular (CV) prognostic value of adipokines in a large prospective cohort of patients participating in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. The effects of the adipokine levels at baseline and change from baseline on the composite outcome (CV death, myocardial infarction, and stroke) were analyzed using unadjusted and fully adjusted Cox models in 2330 patients with type 2 diabetes and coronary artery disease who had participated in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial (from January 1, 2001, through December 1, 2008). In a fully adjusted model, baseline leptin and change from baseline leptin were protective for CV events, whereas baseline adiponectin, baseline tumor necrosis factor α (TNF-α), change from baseline TNF-α, baseline C-reactive protein (CRP), and change from baseline CRP were harmful. The effect of baseline leptin on CV events depended on the body mass index (BMI), such that the hazard ratios (HRs) varied between 0.6 and 1.4 across the BMI quintiles (interaction P=.03). The same was true for baseline adiponectin (HR varied from 0.7 to 1.7; interaction P=.01), change from baseline monocyte chemoattractant protein-1 (HR varied from 0.8 to 1.8; interaction P=.03), change from baseline TNF-α (HR varied from 0.9 to 1.4; interaction P=.02), and change from baseline IL-6 (HR varied from 0.7 to 1.8; interaction P=.005). Adipokines are independent predictors of CV events in patients with type 2 diabetes and coronary artery disease. The association between the specific adipokines and CV outcome varies depending on BMI. This reflects the complex pathophysiology of CV disease in obesity and may help explain the “obesity paradox.” clinicaltrials.gov Identifier: NCT00006305.

Because octogenarian patients have not been adequately represented in randomized trials comparing CABG and PCI, the most appropriate method of revascularization for this group of patients has not been determined. In this paper the authors performed a systematic review and a meta-analysis of 66 studies of coronary revascularization in patients aged over 80 years. Their data shows that revascularization can be performed in octogenarians with acceptable short-term and long-term outcomes. Furthermore, it is unclear whether octogenarians derive greater survival benefit from CABG or from PCI because preprocedural risk profiles differ between intervention types. Background Elderly patients are the fastest growing population in the US healthcare system and more patients aged 80 years and older require CABG or percutaneous coronary intervention (PCI) for coronary revascularization than ever before. Because octogenarian patients have not been adequately represented in randomized trials comparing CABG and PCI, the most appropriate method of revascularization for this group of patients has not been determined. Methods We performed a systematic review and a meta-analysis of 66 studies of coronary revascularization in patients aged over 80 years. The primary endpoints included 30 day mortality and long-term survival. Subgroup analyses stratified by revascularization type (PCI versus CABG) were also performed. Results Pooled estimate of 30 day mortality was 6.3% (95% CI 5.3%–7.5%), and for survival at 1, 3 and 5 years, 86% (84%–88%), 78% (74%–81%) and 67% (61%–72%), respectively. A greater number of men ( P <0.001) and patients with multivessel disease ( P = 0.004) were treated with CABG than with PCI. Pooled estimates, based on type of revascularization, of 30 day mortality and 1 year survival were similar (7.3% [6.3%–8.2%] for CABG vs 5.4% [4.4%–6.4%] for PCI and 86% [83%–88%] for CABG vs 87% [84%–91%] for PCI, respectively). Conclusions Available data indicate that revascularization can be performed in octogenarians with acceptable short-term and long-term outcomes; most of the evidence is, however, low level. Furthermore, it is unclear whether octogenarians derive greater survival benefit from CABG or from PCI because preprocedural risk profiles differ between intervention types. Periprocedural and long-term outcomes are, however, equivalent, and randomized, controlled trials of high-risk octogenarians are needed. Key Points We performed a systematic review and meta-analysis to evaluate the clinical outcome of patients aged 80 years and older undergoing coronary revascularization Pooled estimates of 30 day mortality and 1 year survival were 6.3% and 86%, respectively Clinical outcomes were similar for patients undergoing PCI and CABG despite higher preprocedural risk among patients undergoing CABG Based on the similar outcomes observed between intervention type as well as future demand for resources and clinical guidelines for an aging population, randomized, controlled trials of revascularization in high-risk octogenarians is both ethical and necessary

In this trial involving patients with type 2 diabetes and stable ischemic cardiovascular disease, prompt revascularization was compared with medical therapy, and insulin sensitization was compared with insulin provision, with patients stratified according to whether they underwent percutaneous coronary intervention or coronary-artery bypass grafting. Revascularization did not significantly reduce the rate of death from any cause or the rate of major cardiovascular events overall. Insulin sensitization and insulin provision also had similar cardiovascular outcomes. In patients with type 2 diabetes and stable ischemic cardiovascular disease, revascularization did not significantly reduce the rate of death from any cause or the rate of major cardiovascular events overall, as compared to medical therapy. Insulin sensitization and insulin provision also had similar cardiovascular outcomes. Patients with type 2 diabetes mellitus have a higher risk of cardiovascular events and death than those without diabetes. 1 – 4 Few large, randomized trials have addressed the question of the optimal treatment for patients with diabetes and angiographically defined stable ischemic heart disease. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was designed to test treatment strategies for patients with coronary artery disease and diabetes. Our goal was to address the effects of therapy on the rate of myocardial ischemia, a major cause of death in patients with diabetes, and of insulin resistance, the fundamental mechanism underlying diabetes . . .

Mitral regurgitation is a common heart-valve disorder that is often difficult to manage. Symptoms may be absent for years, 1 despite severe regurgitation. Surgical correction of mitral regurgitation can relieve symptoms, 2 but when it is performed in symptomatic patients, it frequently leaves residual postoperative left ventricular dysfunction, which carries a poor prognosis. 3 , 4 This serious complication, in conjunction with the feasibility of valve repair, 5 has led to the suggestion that surgical correction be performed early in the course of mitral regurgitation. 3 – 6 The value of this approach is unclear, however, because of the lack of data on the course of medically . . .

2.Which one of this patient's risk factors would most strongly increase his risk of a perioperative cardiovascular event? a. Previous malignancy b. First-degree AV block c. Creatinine level of 1.2 mg/dL d. Diabetes mellitus treated with insulin e. Hemoglobin level of 10.3 g/dL A commonly used and well-validated perioperative cardiac risk model is the Revised Cardiac Risk Index outlined by Lee et al.2 In an analysis of 2893 consecutive patients undergoing noncardiac surgery, 6 independent risk factors were identified. The patient continued to deny any chest pain, palpitations, shortness of breath, orthopnea or other signs of ischemic cardiac disease or congestive heart failure. 3.Given the previously noted findings, which one of the following would you use to treat the newly found left apical thrombus? a. No acute treatment, follow up in 3 months b. Surgical thrombectomy c. Intravenous heparin bridging to warfarin d. Intravenous thrombolysis e. Low-dose aspirin and clopidogrel The main risk associated with an intracardiac thrombus is a cardioembolic event, primarily stroke. [...]the incidence of left ventricular thrombus has been reported to be as high as 1.3% of patients with stress-induced cardiomyopathy.12 The primary goal of treatment is prevention of cardioembolic phenomena, in particular, stroke. There are currently limited data regarding using direct oral anticoagulants in this scenario, and this may be a future area of research. [...]apical ballooning syndrome should be high on one's differential diagnosis, especially in the setting of an acute stressor.

To characterize in-hospital and long-term outcomes after percutaneous coronary interventions (PCIs) in patients with diabetes mellitus (DM). Patients who underwent PCIs were grouped by era: group 1, October 9, 1979, to December 31, 1989 (408 with DM and 2684 without DM); group 2, January 1, 1990, to December 31, 1996 (1170 and 4664); group 3, January 1, 1997, to December 31, 2003 (2032 and 6584); and group 4, January 1, 2004, to December 31, 2008 (1412 and 4141). The main outcome measures were in-hospital mortality, major adverse cardiovascular events, long-term mortality, composites of mortality with revascularization, and ischemic events. Patients with DM had significant declines in in-hospital adverse outcomes over time. These declines were similar to those observed in patients without DM. After adjusting for baseline risk, there was no significant change in the association between DM and in-hospital death or in-hospital major adverse cardiovascular events over time. The use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and thienopyridines all increased over time. The effect of DM on long-term survival and survival free of revascularization did not change significantly from group 2 to group 4. However, the effect of DM on survival free of myocardial infarction and stroke was reduced significantly, from a hazard ratio (95% CI) of 1.71 (1.51-1.92) in group 2 to 1.39 (1.20-1.60) in group 4 (P=.04). Over 30 years, the improving outcomes in patients with diabetes who underwent PCIs have been similar to improvements in patients without DM. However, the risk-adjusted association of DM with long-term death, myocardial infarction, and stroke has decreased in the current era (group 4) compared with the bailout stent era (group 2).

Pre-existent cardiovascular disease is a risk factor for weak anti-viral immunity, but underlying mechanisms remain undefined. Here, we report that patients with coronary artery disease (CAD) have macrophages (Mϕ) that actively suppress the induction of helper T cells reactive to two viral antigens: the SARS-CoV2 Spike protein and the Epstein-Barr virus (EBV) glycoprotein 350. CAD Mϕ overexpressed the methyltransferase METTL3, promoting the accumulation of N⁶-methyladenosine (m6A) in Poliovirus receptor (CD155) mRNA. m6A modifications of positions 1635 and 3103 in the 3'UTR of CD155 mRNA stabilized the transcript and enhanced CD155 surface expression. As a result, the patients' Mϕ abundantly expressed the immunoinhibitory ligand CD155 and delivered negative signals to CD4 T cells expressing CD96 and/or TIGIT receptors. Compromised antigen-presenting function of METTL3 CD155 Mϕ diminished anti-viral T cell responses in vitro and in vivo. LDL and its oxidized form induced the immunosuppressive Mϕ phenotype. Undifferentiated CAD monocytes had hypermethylated CD155 mRNA, implicating post-transcriptional RNA modifications in the bone-marrow in shaping anti-viral immunity in CAD.