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Patients with stable coronary artery disease were randomly assigned to fractional flow reserve–guided PCI or medical therapy. At 5 years, the composite of death, myocardial infarction, or urgent revascularization was significantly less frequent in the PCI group.

We report the 5-year results of the SYNTAX trial, which compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for the treatment of patients with left main coronary disease or three-vessel disease, to confirm findings at 1 and 3 years. The randomised, clinical SYNTAX trial with nested registries took place in 85 centres in the USA and Europe. A cardiac surgeon and interventional cardiologist at each centre assessed consecutive patients with de-novo three-vessel disease or left main coronary disease to determine suitability for study treatments. Eligible patients suitable for either treatment were randomly assigned (1:1) by an interactive voice response system to either PCI with a first-generation paclitaxel-eluting stent or to CABG. Patients suitable for only one treatment option were entered into either the PCI-only or CABG-only registries. We analysed a composite rate of major adverse cardiac and cerebrovascular events (MACCE) at 5-year follow-up by Kaplan-Meier analysis on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT00114972. 1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). More patients who were assigned to CABG withdrew consent than did those assigned to PCI (50 vs 11). After 5 years’ follow-up, Kaplan-Meier estimates of MACCE were 26·9% in the CABG group and 37·3% in the PCI group (p<0·0001). Estimates of myocardial infarction (3·8% in the CABG group vs 9·7% in the PCI group; p<0·0001) and repeat revascularisation (13·7%vs 25·9%; p<0·0001) were significantly increased with PCI versus CABG. All-cause death (11·4% in the CABG group vs 13·9% in the PCI group; p=0·10) and stroke (3·7%vs 2·4%; p=0·09) were not significantly different between groups. 28·6% of patients in the CABG group with low SYNTAX scores had MACCE versus 32·1% of patients in the PCI group (p=0·43) and 31·0% in the CABG group with left main coronary disease had MACCE versus 36·9% in the PCI group (p=0·12); however, in patients with intermediate or high SYNTAX scores, MACCE was significantly increased with PCI (intermediate score, 25·8% of the CABG group vs 36·0% of the PCI group; p=0·008; high score, 26·8%vs 44·0%; p<0·0001). CABG should remain the standard of care for patients with complex lesions (high or intermediate SYNTAX scores). For patients with less complex disease (low SYNTAX scores) or left main coronary disease (low or intermediate SYNTAX scores), PCI is an acceptable alternative. All patients with complex multivessel coronary artery disease should be reviewed and discussed by both a cardiac surgeon and interventional cardiologist to reach consensus on optimum treatment. Boston Scientific.

Fractional flow reserve (FFR) is a measure of the functional significance of a coronary stenosis. In this study, the use of FFR, as compared with angiography alone, in guiding the placement of coronary stents resulted in the use of fewer stents and better clinical outcomes. The use of fractional flow reserve, as compared with coronary angiography alone, in guiding the placement of coronary stents resulted in the use of fewer stents and better clinical outcomes. The presence of myocardial ischemia is an important risk factor for an adverse clinical outcome. 1 – 3 Revascularization of stenotic coronary lesions that induce ischemia can improve a patient's functional status and outcome. 3 – 5 For stenotic lesions that do not induce ischemia, however, the benefit of revascularization is less clear, and medical therapy alone is likely to be equally effective. 6 , 7 With the introduction of drug-eluting stents, the percentage of patients with multivessel coronary artery disease in whom percutaneous coronary intervention (PCI) is performed has increased. 8 , 9 Because drug-eluting stents are expensive and are associated with potential late complications, their appropriate . . .

In this large randomized trial (SYNTAX), patients with three-vessel or left main coronary artery disease were randomly assigned to undergo revascularization by means of either percutaneous coronary intervention (PCI) involving drug-eluting stents or coronary-artery bypass grafting (CABG). The need for repeat revascularization was lower, but the risk of stroke was higher, with CABG than with PCI. This tradeoff needs to be considered in making decisions about the treatment of patients with advanced coronary disease. Patients with severe coronary artery disease were randomly assigned to undergo revascularization by means of either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG). The need for repeat revascularization was lower, but the risk of stroke was higher, with CABG than with PCI. Coronary-artery bypass grafting (CABG) was introduced in 1968 and rapidly became the standard of care for symptomatic patients with coronary artery disease. 1 Advances in coronary surgery (e.g., off-pump CABG, smaller incisions, enhanced myocardial preservation, use of arterial conduits, and improved postoperative care) have reduced morbidity, mortality, and rates of graft occlusion. 2 – 6 Percutaneous coronary intervention (PCI) was introduced in 1977. 7 Experience with this approach, coupled with improved technology, has made it possible to treat increasingly complex lesions and patients with a history of clinically significant cardiac disease, risk factors for coronary artery disease, coexisting conditions, or anatomical risk factors. 8 , . . .

This clinical trial compared the effectiveness of an everolimus-eluting coronary stent with that of a paclitaxel-eluting stent in patients with coronary artery disease. Clinical outcomes at 1 year were superior with the everolimus-eluting stent in patients without diabetes, but not in patients with diabetes. These results are likely to influence clinical practice. This trial compared the effectiveness of an everolimus-eluting coronary stent with that of a paclitaxel-eluting stent in patients with coronary artery disease. Clinical outcomes at 1 year were superior with the everolimus-eluting stent in patients without diabetes, but not in patients with diabetes. Among patients undergoing percutaneous coronary intervention (PCI), the use of paclitaxel-eluting stents or sirolimus-eluting stents, as compared with use of bare-metal stents alone, reduces the rate of restenosis, as assessed clinically and angiographically. 1 , 2 Nevertheless, restenosis still occurs with drug-eluting stents, and the ongoing propensity for stent thrombosis necessitates the prolonged use of dual antiplatelet therapy. 1 – 5 Efforts have therefore focused on designing safer, more effective drug-eluting stents. An everolimus-eluting stent has been developed in which the drug is released from a thin (7.8-μm) fluorocopolymer coated onto a low-profile (81-μm strut thickness) cobalt–chromium stent. 6 Previously, the SPIRIT II and SPIRIT . . .

In a randomized trial in patients with moderate Dupuytren’s contracture, collagenase was not noninferior to limited fasciectomy with respect to the Patient Evaluation Measure score at 1 year after treatment.

In this trial involving 2492 patients, coronary revascularization guided by iFR, as compared with fractional flow reserve-guided revascularization, was within the prespecified margin for noninferiority with respect to major adverse cardiac events. For the past 20 years, physiological measurements obtained during invasive procedures have been used to guide coronary revascularization. Pioneering work supported the use of flow measurements to make safe decisions about revascularization, 1 , 2 but this approach was soon superseded by the use of fractional flow reserve (FFR), which measures pressure as a surrogate of flow to estimate the severity of stenosis. 3 – 5 FFR was successful largely because of its technical simplicity and because clinical trials showed that it was associated with improved clinical outcomes after percutaneous coronary intervention (PCI). 6 , 7 Consequently, FFR is now included in the appropriate-use criteria for . . .

In this randomized trial, proportional-assist ventilation with load-adjustable gain factors did not differ significantly from pressure-support ventilation with respect to the time to liberation from mechanical ventilation.

In this trial, 1830 patients undergoing PCI were assigned to receive a paclitaxel-eluting or an everolimus-eluting stent. At 1 year, rates of target-vessel failure, MI, stent thrombosis, and target-lesion and target-vessel revascularization were higher with paclitaxel. Diabetes mellitus is a highly prevalent medical condition globally and is frequently associated with symptomatic coronary artery disease necessitating percutaneous coronary intervention (PCI). 1 There is, however, controversy regarding the choice of a drug-eluting stent in patients with diabetes. Fundamental to this debate is the finding that there is attenuation of the mammalian target of rapamycin (mTOR) signaling pathway in patients with type 2 diabetes, which suggests that stents eluting rapamycin (now called sirolimus) or its analogues (everolimus or zotarolimus) — often termed “limus-eluting” stents — could be less effective in this cohort, potentially making paclitaxel-eluting stents an attractive option. 2 It . . .

Acute ST-segment elevation myocardial infarction is often treated with immediate coronary stenting of the infarct-related artery. The use of a paclitaxel-eluting stent, as compared with a bare-metal stent, reduced the risk of restenosis and was equally safe. Acute ST-segment elevation myocardial infarction is often treated with immediate coronary stenting of the infarct-related artery. The use of a paclitaxel-eluting stent, as compared with a bare-metal stent, reduced the risk of restenosis and was equally safe. By enlarging luminal dimensions and sealing dissection planes at the site of coronary-artery occlusion in patients with evolving ST-segment elevation myocardial infarction, bare-metal stents reduce the risk of early and late recurrent ischemia and reocclusion of the infarct-related artery, as compared with balloon angioplasty alone, decreasing the need for subsequent revascularization of the target lesion with repeat percutaneous coronary intervention (PCI) or coronary-artery bypass grafting. 1 , 2 Nonetheless, restenosis occurs in more than 20% of patients in whom bare-metal stents are implanted during primary PCI, and implantation of bare-metal stents, as compared with balloon angioplasty, has not reduced the rates of . . .