Explore the vast range of titles available.

Patients undergoing nonemergency PCI were assigned to a hospital with or a hospital without on-site cardiac surgery. There was no significant difference in efficacy or safety outcomes between groups. For nonemergency PCI, cardiac surgery capability may not be necessary. Since coronary balloon angioplasty was introduced into clinical practice in 1977, marked advances in technology, technique, adjunctive pharmacotherapy, and operator experience have resulted in higher rates of procedural success and lower rates of complications. 1 , 2 Emergency coronary-artery bypass grafting (CABG), which was initially required in 6 to 10% of procedures, 1 , 3 has become a rare event, with an incidence of 0.1 to 0.4% in contemporary studies. 4 – 6 Moreover, as data supporting the use of primary PCI for patients with ST-segment elevation myocardial infarction (STEMI) have emerged, the need for timely access to the procedure has justified the expansion of emergency . . .

In the treatment of de-novo coronary small vessel disease, drug-coated balloons (DCBs) are non-inferior to drug-eluting stents (DESs) regarding clinical outcome up to 12 months, but data beyond 1 year is sparse. We aimed to test the long-term efficacy and safety of DCBs regarding clinical endpoints in an all-comer population undergoing percutaneous coronary intervention. In this prespecified long-term follow-up of a multicentre, randomised, open-label, non-inferiority trial, patients from 14 clinical sites in Germany, Switzerland, and Austria with de-novo lesions in coronary vessels <3 mm and an indication for percutaneous coronary intervention were randomly assigned 1:1 to DCB or second-generation DES and followed over 3 years for major adverse cardiac events (ie, cardiac death, non-fatal myocardial infarction, and target-vessel revascularisation [TVR]), all-cause death, probable or definite stent thrombosis, and major bleeding (Bleeding Academic Research Consortium bleeding type 3–5). Analyses were performed on the full analysis set according to the modified intention-to-treat principle. Dual antiplatelet therapy was recommended for 1 month after DCB and 6 months after DES with stable symptoms, but 12 months with acute coronary syndromes. The study is registered with ClinicalTrials.gov, NCT01574534 and is ongoing. Between April 10, 2012, and Feb 1, 2017, of 883 patients assessed, 758 (86%) patients were randomly assigned to the DCB group (n=382) or the DES group (n=376). The Kaplan-Meier estimate of the rate of major adverse cardiac events was 15% in both the DCB and DES groups (hazard ratio [HR] 0·99, 95% CI 0·68–1·45; p=0·95). The two groups were also very similar concerning the single components of adverse cardiac events: cardiac death (Kaplan-Meier estimate 5% vs 4%, HR 1·29, 95% CI 0·63–2·66; p=0·49), non-fatal myocardial infarction (both Kaplan-Meier estimate 6%, HR 0·82, 95% CI 0·45–1·51; p=0·52), and TVR (both Kaplan-Meier estimate 9%, HR 0·95, 95% CI 0·58–1·56; p=0·83). Rates of all-cause death were very similar in DCB versus DES patients (both Kaplan-Meier estimate 8%, HR 1·05, 95% CI 0·62–1·77; p=0·87). Rates of probable or definite stent thrombosis (Kaplan-Meier estimate 1% vs 2%; HR 0·33, 95% CI 0·07–1·64; p=0·18) and major bleeding (Kaplan-Meier estimate 2% vs 4%, HR 0·43, 95% CI 0·17–1·13; p=0·088) were numerically lower in DCB versus DES, however without reaching significance. There is maintained efficacy and safety of DCB versus DES in the treatment of de-novo coronary small vessel disease up to 3 years. Swiss National Science Foundation, Basel Cardiovascular Research Foundation, and B Braun Medical.

An analysis of national cardiovascular data showed that median door-to-balloon times for primary PCI declined from 83 minutes in 2005 to 67 minutes in 2009, whereas in-hospital mortality remained unchanged during this period. Primary percutaneous coronary intervention (PCI) is currently the preferred treatment for acute ST-segment elevation myocardial infarction. Previous observational studies have shown a strong association between prompt performance of primary PCI, as assessed in terms of the door-to-balloon time (the interval from the patient's arrival at the hospital to inflation of the balloon to restore flow), and reduced mortality. 1 – 3 On the basis of these data, current joint clinical practice guidelines of the American College of Cardiology and the American Heart Association (ACC–AHA) endorse a door-to-balloon time of 90 minutes or less as the goal, giving it a Class I (highest . . .

Background Physician adherence to guidelines is often poor, but the reasons have not been completely studied. We investigated whether physician adherence to guidelines for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) varied by source, development methods, or the extent of their evidence-base. Methods and Results We assessed adherence to guidelines developed by the American College of Cardiology/American Heart Association (ACC/AHA) for PTCA (1988 and 1993) and for CABG (1990) and guidelines developed by RAND for PTCA and CABG in 1990. We randomly sampled patients on Medicare who were undergoing coronary angiography in 5 states in 1991 and 1992, extracting clinical and laboratory data from medical records and using computer programs to classify the appropriateness of each procedure. A total of 543 PTCA and 676 CABG procedures were studied. By use of the 1988 ACC/AHA guidelines, 30% of PTCAs were rated class III (inappropriate), whereas 24% were class III by use of the 1993 guidelines. Only 1.5% of CABG procedures were class III with ACC/AHA guidelines. By use of RAND guidelines, 12% of PTCA and 9% of CABG procedures were classified as inappropriate. Conclusions Adherence to guidelines is higher when the recommendations are supported by evidence from randomized clinical trials (CABG). The credibility of the source and familiarity with the guidelines do not ensure compliance. When evidence is lacking, as with PTCA at the time of this study, guideline recommendations may lag behind appropriate changes in clinical practice. More frequent revisions coupled with on-line access have the potential to make guidelines more useful. (Am Heart J 2003;145:19-26.)

The Randomised Intervention Treatment of Angina (RITA) trial is comparing the long-term effects of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with one, two, or three diseased coronary arteries in whom equivalent revascularisation was deemed achievable by either procedure. This first report is for a mean 2·5 years' follow-up on the 1011 patients randomised. 59% had grade 3 or 4 angina, 59% had experienced angina at rest, and 55% had two or more diseased coronary arteries. The intended procedure was done in 98% of patients. In 97% of CABG patients all intended vessels were grafted. Dilatation of all treatment vessels was attempted in 87% of PTCA patients with an angiographic success rate per vessel of 87% (90% excluding occluded vessels). There have been 34 deaths (18 CABG, 16 PTCA) and the pre-defined combined primary event of death or definite myocardial infarction shows no evidence of a treatment difference (43 CABG, 50 PTCA; relative risk 0·88 [95% confidence interval 0·59-1·29]). 4% of PTCA patients required emergency CABG before discharge and a further 15% had CABG during follow-up. Within 2 years of randomisation 38% and 11% of the PTCA and CABG groups, respectively, required revascularisation procedure(s) or had a primary event (p <0·001) and repeat coronary arteriography during follow-up was four times more common in PTCA than in CABG patients (31% vs 7%, p<0·001). The prevalence of angina during follow-up was higher in the PTCA group (eg, 32% vs 11% at 6 months) but this difference became less marked after 2 years (31% vs 22%). Anti-anginal drugs were prescribed more frequently for PTCA patients. At 1 month CABG patients were less physically active, with greater coronary related unemployment and lower mean exercise times than the PTCA patients. Thereafter employment status, breathlessness, and physical activity improved, with no significant differences between the two treatment groups. At 1 year mean exercise times had increased by 3 min for both groups. These interim findings indicate that recovery after CABG, the more invasive procedure, takes longer than after PTCA. However, CABG leads to less risk of angina and fewer additional diagnostic and therapeutic interventions in the first 2 years than PTCA. So far, there is no significant difference in risk of death or myocardial infarction, and follow-up continues to at least five years.

To minimize door-to-balloon times, Ottawa developed a program in which patients with ST-elevation myocardial infarction were taken directly from the field to a cardiac care center for primary coronary angioplasty. The median door-to-balloon time (69 minutes) was approximately half that of patients who were transferred from emergency departments (123 minutes). Respective in-hospital mortality rates were 3.0% and 5.7% (P=0.30). Ottawa developed a program in which patients with ST-elevation myocardial infarction were taken directly from the field to a cardiac care center for primary coronary angioplasty. The median door-to-balloon time (69 minutes) was approximately half that of patients who were transferred from emergency departments (123 minutes). Survival of patients presenting with ST-segment elevation myocardial infarction is enhanced by rapid, complete, and sustained reperfusion of the infarct-related artery. 1 – 3 Delays in either door-to-needle 1 or door-to-balloon 4 – 7 times are associated with increased mortality. In patients who are treated with primary percutaneous coronary intervention (PCI), each 30 minutes of delay increases the relative risk of 1-year mortality by 7.5%. 6 It has been recommended that efforts be made to shorten door-to-balloon times for all patients because time-to-balloon strongly correlates with mortality regardless of the baseline risk of mortality. 7 PCI ensures more complete and sustained restoration of flow to the infarct-related . . .

Hospitals have a variety of strategies to reduce the time from arrival at the hospital to intracoronary balloon inflation (door-to-balloon time) for patients who have acute myocardial infarction with ST-segment elevation. In a study of 365 hospitals, 28 institutional strategies were identified with the use of a field-tested questionnaire. These strategies were correlated with door-to-balloon times for individual patients as reported to the Centers for Medicare and Medicaid Services. Six strategies were associated with a significant reduction in the door-to-balloon time. The use of these strategies may improve outcomes for patients. In a study of 365 hospitals, six strategies were associated with a significant reduction in the door-to-balloon time. The use of these strategies may improve outcomes for patients. Prompt treatment increases the likelihood of survival for patients who have myocardial infarction with ST-segment elevation. 1 – 3 Hospitals can therefore influence the outcomes for such patients by developing and implementing systems and processes that minimize the interval between arrival at the hospital and the administration of reperfusion therapy. Since percutaneous coronary intervention (PCI) has become the preferred approach for treating myocardial infarction with ST-segment elevation, 4 hospitals are seeking ways to reduce the door-to-balloon time, defined as the time between arrival at the hospital and the first balloon inflation during PCI. The importance of the door-to-balloon time is highlighted by its . . .

Although stents reduce the restenosis rate, stent restenosis continues to be a major problem and the optimal treatment of stent restenosis is still controversial. In this study, we aimed to investigate the angiographic recurrent stent restenosis rate at 6-12 months after successful cutting balloon angioplasty (CBA) for the bare metal stent restenosis. Thirty patients (mean age: 57.9 ± 11.6, 22 males) undergoing successful CBA for the treatment of in-stent restenosis at our hospital were prospectively included in this study. Control coronary angiography was performed at 6-12 months after CBA. Lesion length, minimal lumen diameter (MLD), and reference vessel diameter were analyzed by computerized digital angiographic analysis. Recurrent restenosis was defined as the lesions obstructing the lumen more than 50%. We described the lesions shorter than 10 mm as to be focal and those longer than 10 mm as to be diffuse. We used Student t, Chi-square, and Mann-Whitney U tests for statistical analysis. Two patients had two distinct lesions; therefore, 32 lesions were assessed. There were 9 (28.1%) recurrent restenosis on the control coronary angiography. Recurrent restenosis developed in 3/21 (14.3%) of focal type lesions and 6/11(54.5%) of diffuse type lesions (p=0.035). Pre-procedural MLD was lower in the restenotic group compared to non-restenotic group (0.41 ± 0.29 vs. 0.64 ± 0.17 mm, p=0.048) while percent of stenosis was higher in the restenotic group (76.8 ± 12 vs. 69.6 ± 5.37%, p=0.029). In the selected patients, CBA is an effective and a safe method for the treatment of bare metal stent restenosis. CBA might be considered as a first-line treatment method in patients with focal type lesions.

Insulin-dependent diabetic patients found to have substantial coronary artery disease at the time of assessment for renal transplantation have 2-year survival of less than 50%. Because most of these patients have no angina symptoms their management is controversial. We tried to find out whether coronary artery revascularisation in such patients might decrease the combined incidence of unstable angina, myocardial infarction, and cardiac death. 151 consecutive insulin-dependent diabetic candidates for renal transplantation underwent coronary angiography. 31 had stenoses greater than 75% in one or more coronary arteries, atypical chest pain or no chest pain, and a left ventricular ejection fraction greater than 0·35. Of these, 26 agreed to be randomly assigned medical treatment (a calcium-channel-blocking drug plus aspirin) or revascularisation (angioplasty or coronary bypass surgery). 10 of 13 medically managed and 2 of 13 revascularised patients had a cardiovascular endpoint within a median of 8·4 months of coronary angiography (p<0·01). 4 medically managed patients died of myocardial infarction during follow-up. Thus, revascularisation decreased the frequency of cardiac events in insulin-dependent diabetic patients with chronic renal failure and symptomless coronary artery stenoses. These findings suggest that diabetic renal transplant candidates should be screened for silent coronary artery disease, because revascularisation may decrease cardiac morbidity and mortality in this population.

The focus on door-to-balloon time has expedited arrival in the cardiac catheterization laboratory for patients with ST-segment elevation myocardial infarction. Now the main opportunity for improving outcomes lies in the prehospital system of care, where challenges remain. ST-segment elevation myocardial infarction (STEMI) usually results from acute thrombotic occlusion of a coronary artery and is a leading cause of death. Although myocardial cell injury can occur after 20 to 30 minutes of ischemia, it takes several hours for transmural myocardial necrosis to develop. The goal of reperfusion therapy with fibrinolytic drugs or primary percutaneous coronary intervention (PCI) is to restore blood flow to ischemic, but still viable, myocardium and reduce infarct size. Reducing the time to treatment and maximizing myocardial salvage — in keeping with the mantra that “time is muscle” — present a logistic challenge. Early randomized . . .