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Tenecteplase for thrombolysis in a 4.5-to-24-hour window did not improve disability outcomes at 90 days in patients with ischemic stroke who had been chosen on the basis of imaging. Most patients had endovascular thrombectomy.

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines—based on available evidence from mostly observational studies—suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0–3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI −4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

In patients with acute stroke and a large infarct of unrestricted size, use of thrombectomy and medical care within 7 hours after symptom onset led to better functional outcomes and lower mortality than medical care alone.

In a randomized trial, 3102 patients undergoing CABG were assigned to receive bilateral or single internal-thoracic-artery grafts. There was no significant between-group difference in all-cause mortality at 10 years.

BackgroundIntravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been shown to improve outcomes in complex coronary artery disease compared with angiography-guided PCI. However, long-term comparisons between IVUS-guided PCI and coronary artery bypass grafting (CABG) for multivessel disease (MVD) remain limited.MethodsThis post hoc analysis of the Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment Extended Follow-up study included 880 patients with MVD, excluding 15 patients who received medical therapy. Patients were categorised into IVUS-guided PCI (n=333), angiography-guided PCI (n=131) and CABG (n=401). The primary endpoint was the composite of death, myocardial infarction (MI) or target-vessel revascularisation over a median follow-up of 11.8 years.ResultsThe IVUS-guided PCI group showed no difference in the primary endpoint compared with CABG (adjusted HR 1.013; 95% CI 0.747 to 1.374; p=0.93). In contrast, angiography-guided PCI was associated with a higher risk of clinical events (adjusted HR 2.231; 95% CI 1.582 to 3.145; p<0.001). The safety endpoint (composite of death, MI and stroke) did not differ between IVUS-guided PCI and CABG (adjusted HR 0.845; 95% CI 0.605 to 1.181; p=0.324), while angiography-guided PCI was associated with a higher risk (adjusted HR 2.016; 95% CI 1.405 to 2.895; p<0.001). Both PCI groups had higher rates of repeat revascularisation compared with CABG.ConclusionsIVUS-guided PCI demonstrated comparable long-term outcomes to CABG in terms of mortality and safety endpoints, supporting its use in the treatment of MVD. These findings highlight the potential benefits of IVUS guidance in complex PCI procedures.Trial registration numbers NCT05125367 and NCT00997828.

A total of 2203 patients at 18 medical centers were randomly assigned to undergo on-pump or off-pump CABG. Mortality at 5 years was significantly lower with on-pump CABG than with off-pump CABG. No secondary outcomes indicated a benefit of off-pump surgery.

In a randomized trial involving patients with a low LVEF and viable myocardium who received optimal medical therapy, PCI did not lead to a lower incidence of death or hospitalization for heart failure.

In a randomized trial, over 1900 patients with left main coronary artery disease were assigned to percutaneous coronary intervention or coronary-artery bypass grafting. At 3 years, PCI was noninferior to CABG with respect to the rate of death, stroke, or myocardial infarction. Left main coronary artery disease is associated with high morbidity and mortality owing to the large amount of myocardium at risk. European and U.S. guidelines recommend that most patients with left main coronary artery disease undergo coronary-artery bypass grafting (CABG). 1 , 2 Randomized trials have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents might be an acceptable alternative for selected patients with left main coronary disease. 3 – 5 Specifically, in the subgroup of patients with left main coronary disease in the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, the rate of a composite of death, stroke, myocardial infarction, . . .

After 5 years of follow-up in this trial, the rates of the composite outcome of death, stroke, myocardial infarction, renal failure, or repeat revascularization were similar with off-pump and on-pump CABG. There was also no significant difference in cost or in quality of life. Coronary-artery bypass grafting (CABG) reduces the risk of death in patients with extensive coronary artery disease. 1 CABG is usually performed with the use of a cardiopulmonary bypass (on-pump CABG). With this approach, perioperative mortality is approximately 2%, with an additional 5 to 9% of patients having myocardial infarction, stroke, or renal failure requiring dialysis. The technique of performing CABG on a beating heart (off-pump CABG) was developed to decrease the risk of perioperative complications and to improve long-term outcomes; some complications, both perioperative and long term, may be related to the use of cardiopulmonary bypass and to cross-clamping of the . . .

In this trial, over 3000 patients undergoing CABG were assigned to single or bilateral internal-thoracic-artery grafts. At 5 years, there was no difference in mortality or cardiovascular events. More sternal wound infections occurred with bilateral grafts. Coronary-artery bypass grafting (CABG) is one of the most commonly performed operations worldwide and has been established as an effective treatment for symptomatic multivessel coronary artery disease. 1 , 2 The standard surgical approach is anastomosis of the left internal thoracic (mammary) artery to the left anterior descending coronary artery and the use of saphenous-vein or radial-artery grafts to bypass other coronary arteries. 3 , 4 The single internal-thoracic-artery graft has a 10-year rate of angiographic patency exceeding 90%, as compared with 50% for vein grafts. 5 – 10 The excellent long-term outcomes of single internal-thoracic-artery grafts 11 , 12 have stimulated the use of a bilateral internal-thoracic-artery . . .