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Posts Tagged ‘bypass surgery’

Note:  I owe Dr. Vasquez a much more detailed article – which I am currently writing – but after our intellectually stimulating talk the other day, my mind headed off in it’s own direction..

Had a great sit down lunch and a fascinating talk with Dr. Vasquez.  As per usual – our discussion was lively, (a bit more lively than usual) which really got my gears turning.  Dr. Vasquez is a talented surgeon – but he could be even better with just a little ‘help’.  No – I am not trying to sell him a nurse practitioner – instead I am trying to sell Mexicali, and a comprehensive cardiac surgery program to the communities on both sides of the border..  Mexicali really could be the ‘land of opportunity’ for medical care – if motivated people and corporations got involved.

During lunch, Dr. Vasquez was explaining that there is no real ‘heart hospital’ or cardiac surgery program, per se in Mexicali – he just operates where ever his patients prefer.  In the past that has included Mexicali General, Issstecali (the public hospitals) as well as the tiny but more upscale private facilities such as Hospital Alamater, and Hospital de la Familia..

Not such a big deal if you are a plastic surgeon doing a nip/tuck here and there, or some outpatient procedures – okay even for general surgeons – hernia repairs and such – but less than ideal for a cardiac surgeon – who is less of a ‘lone wolf’ due to the nature and scale of cardiac surgery procedures..

Cardiac surgery differs from other specialties in its reliance on a cohesive, well-trained and experienced group – not one surgeon – but a whole team of people to look out for the patients; Before, During & After surgery..  That team approach [which includes perfusionists, cardiac anesthesiologists (more specialized than regular anesthesia), operating room personnel, cardiology interventionalists and specialty training cardiac surgery intensive care nurses]  is not easily transported from facility to facility.

just a couple members of the cardiac surgery team

That’s just the people involved; it doesn’t even touch on all the specialty equipment; such as the bypass pump itself, echocardiogram equipment, Impella/ IABP (intra-aortic balloon pump), ECMO or other equipment for the critically ill – or even just the infrastructure needed to support a heart team – like a pharmacy division that knows that ‘right now’ in the cardiac OR means five minutes ago, or a blood bank with an adequate stock of platelets, FFP and a wide range of other blood products..

We haven’t even gotten into such things such as a hydrid operating rooms and 24/7 caths labs – all the things you need for urgent/ emergent cases, endovascular interventions – things a city the size of Mexicali should really have..

But all of those things take money – and commitment, and I’m just not sure that the city of Mexicali is ready to commit to supporting Dr. Vasquez (and the 20 – something cases he’s done this year..) It also takes vision..

This is where a company/ corporation could come in and really change things – not just for Dr. Vasquez – and Mexicali – but for California..

It came to me again while I was in the operating room with Dr. Vasquez – watching him do what he does best – which is sometimes when I do what I do best.. (I have some of my best ideas in the operating room – where I tend to be a bit quieter.. More thinking, less talking)..

Dr. Vasquez, doing what he does best..

As I am watching Dr. Vasquez – I starting thinking about all the different cardiac surgery programs I’ve been to: visited, worked in – trained in.. About half of these programs were small – several were tiny, single surgeon programs a lot like his.. (You only need one great surgeon.. It’s all the other niceties that make or break a program..)

All of the American programs had the advantages of all the equipment / specialty trained staff that money could buy***

[I know what you are thinking – “well – but isn’t it all of these ‘niceties’ that make everything cost so darn much?”  No – actually it’s not – which is how the Cardioinfantils, and Santa Fe de Bogotas can still make a profit offering world-class services at Colombian prices…]

The cost of American programs are inflated due to the cost of defensive medicine practices (and lawyers), and the costs of medications/ equipment in the United States****

the possibilities are endless – when I spend quality time in the operating room (thinking!)

Well – there is plenty of money in Calexico, California** and not a hospital in sight – just a one room ‘urgent care center’.  The closest facility is in El Centro, California – and while it boasts a daVinci robot, and a (part-time?) heart surgeon (based out of La Mesa, California – 100 + miles away)– patients usually end up being transferred to San Diego for surgery.

Of course, in addition to all of the distance – there is also all of the expense..  So what’s a hard-working, blue-collar guy from Calexico with severe CAD going to do?  It seems the easiest and most logical thing – would be to walk/ drive/ head across the street to Mexicali.. (If only Kaiser Permanente or Blue Cross California would step up and spearhead this project – we could have the best of both worlds – for residents of both cities.. 

 A fully staffed, well-funded, well-designed, cohesive heart program in ONE medium- sized Mexicali facility – without the exorbitant costs of an American program (from defensive medicine practices, and outlandish American salaries.)  Not only that – but as a side benefit, there are NO drug shortages here..

How many ‘cross-border’ cases would it take to bring a profit to the investors?  I don’t know – but I’m sure once word got out – people would come from all over Southern California and Arizona – as well as Mexicali, other parts of Baja, and even places in Sonora like San Luis – which is closer to Mexicali than Hermasillo..  Then Dr. Vasquez could continue to do what he does so well – operate – but on a larger scale, without worrying about resources, or having to bring a suitcase full of equipment to the OR.

The Mexican – American International Cardiac Health Initiative?

But then – this article isn’t really about the ‘Mexican- American cross-border cardiac health initiative’

It is about a young, kind cardiac surgeon – with a vision of his own.

That vision brought Dr. Vasquez from his home in Guadalajara (the second largest city in Mexico) to one of my favorite places, Mexicali after graduating from the Universidad Autonomica in Guadalajara, and completing much of his training in Mexico (D.F.).  After finishing his training – Dr. Vasquez was more than ready to take on the world – and Mexicali as it’s first full-time cardiac surgeon.

Mexicali’s finest: Dr. Vasquez, (cardiac surgeon) Dr. Campa(anesthesia) and Dr. Ochoa (thoracic surgeon

Since arriving here almost two years ago – that’s exactly what he’s done.. Little by little, and case by case – he has begun building his practice; doing a wide range of cardiovascular procedures including coronary bypass surgery (CABG), valve replacement procedures, repair of the great vessels (aneurysm/ dissections), congenital repairs, and pulmonary thrombolectomies..

Dr. Vasquez, Mexicali’s cardiac surgeon

Dr. Cuauhtemoc Vasquez Jimenez, MD

Cardiac Surgeon

Calle B No. 248 entre Obregon y Reforma

Col. Centro, Mexicali, B. C.

Email: drcvasquez@hotmail.com

Tele: (686) 553 – 4714 (appointments)

Notes:

*The Imperial Valley paper reports that Calexico makes 3 million dollars a day off of Mexicali residents who cross the border to shop.

***In all the programs I visited  – there are a couple of things that we (in the United States do well..  Heart surgery is one of those things..)

**** Yes – they charge us more in Calexico for the same exact equipment made in India and sold everywhere else in the world..

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A full year after we reported it here (and several years after initially being reported in the literature), mainstream media has finally picked up the story about gastric bypass surgery for the definitive treatment of diabetes.   The story made all of the heavies; the Washington Post, the Wall Street Journal, and the Los Angeles Times.

Unfortunately, all of these outlets seem unaware of the existing literature in this area – these results while encouraging, are not surprising.  Similar results have been demonstrated in several other (but smaller) studies for the past ten years, which led to previous recommendations (last summer) for the adoption of gastric bypass surgery as a first-line treatment for diabetes in obese patients.

The publication of two new studies showing clear benefits for diabetics undergoing bariatric surgery has brought this news to the forefront.  In both of these studies, diabetic patients were able to stop taking oral glycemics and insulins after surgery within days..

As this front page story from the New York Times notes – these results do not apply to the more widely marketed ‘lap-band.’  This comes to no surprise to dedicated followers at Cartagena Surgery, who have been reading articles on this topic since our site’s inception in late 2010.

You heard it here first.  For more information on this topic, see our tab on Diabetes & Bariatrics under the ‘surgery’ header. We’ve included a small selection from our archives here.

Bariatric surgery headlines – August 2010

Gastric bypass surgery gets the international federation of diabetes approval.

Gastric bypass as treatment for diabetes

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As readers know, I recently gave a CME presentation on The Syntax Trial   and discussed the new Revascularization guidelines that were released last month.  I’ve posted the slides for anyone who wants to use them.  (It would be nice if you mentioned where you got them – but feel free to use them.)

Now – new criticisms of these revised guidelines are already emerging.  But before tackling these new criticisms, we should review the old controversies surrounding the previous guidelines.

In a interesting article (by one of my favorite summarists) Reed Miller over at The Heart.org reviews the issues behind the old (2009) guidelines..  It’s a good article that talks about many of the issues behind the 2012 revisions. I’ve re-posted the article below.

PCI appropriateness criteria draw criticism

(originally posted February 8th, 2012 at the Heart.org)

Kansas City, MO – The interminable controversy about appropriate use and overuse of PCI is being stirred up again [1].

Dr Steven P Marso (St Luke’s Mid-America Heart Institute, Kansas City, MO) and five other cardiologists have published a paper online February 8, 2012 in the Journal of the American College of Cardiology: Cardiovascular Interventions criticizing both the 2009 coronary revascularization appropriate-use criteria (AUC) and how those criteria have been applied to the study of contemporary practice patterns.

As reported by heartwire, the AUC were created by a technical committee representing six professional societies. Last summer, Marso’s colleague in Kansas City, Dr Paul Chan (St Luke’s Mid-America Heart Institute), led a study of PCI cases in the National Cardiovascular Data Registry (NCDR) that showed that only 50.4% of nonacute cases in the registry during the yearlong study period would be classified as appropriate under the AUC and that 11.6% of nonacute cases were classified as inappropriate.

“We are duty bound to evaluate appropriate use of PCI and other medical procedures,” Marso told heartwire. “The problem is that we are no closer to being able to identify overuse based upon these appropriate-use criteria than before they were created. The reason is that there are too many assumptions and too much variability that go into that 11.6% inappropriate rate.”

For example, Marso et al argue that the AUC put too much emphasis on stress testing without precise definitions to guide the interpretation of those tests. “The vast majority of AUC scenarios require knowledge of preprocedural stress-test findings . . . [but] the NCDR does not require interpreting physicians to determine this risk. Therefore, this data-collection burden falls onto the data abstractors, who are required to assign a risk category based on vague guidelines,” they say. “Essentially, they are required to interpret the interpretation.”

Chan told heartwire that the appropriateness criteria were never intended to be perfect, but they are the best effort to sort out which procedures are supported by evidence and which are not. They will evolve over several iterations, including the recent update, which provides more detail on patients with unstable angina. However, Chan does not expect any major changes from the 2009 version to be made soon.

Chan also pointed out that the purpose of the AUCs is to explain the existing evidence base, not pass judgment on each procedure, so nobody should interpret “inappropriate” in the AUCs to mean “fraudulent.”

“Ultimately, my main concern is that we don’t lose sight of the forest for the trees. Our profession of cardiology has taken an amazing leadership role in defining quality and appropriateness of care—in a way that no subspecialty has done to date. In so doing, we have moved the quality yardstick forward,” Chan said. “[But] we need to be humble as physicians to recognize that sometimes we may actually be doing procedures that have little evidence to support their use . . . and that not only are we not providing benefit but perhaps subjecting patients to unnecessary procedure risks and costs.”

Who decides which side is “right” and which side is “wrong?”

Marso et al are especially concerned with the AUC’s treatment of patients with one- or two-vessel disease, no proximal left anterior descending artery involvement or prior coronary artery bypass graft, class I or II symptoms, low-risk noninvasive findings, and on no or minimal medications. The AUC state that PCI in this scenario, labeled scenario 12b, is “inappropriate.” This scenario accounted for nearly 40% of the inappropriate nonacute procedures categorized by Chan et al as inappropriate, making it the most common type of procedure in this category.

Prior to the release of the 2009 AUCs, Chan et al surveyed 85 cardiologists—including 44 interventionalists and 41 noninterventional cardiologists—on the appropriateness of 68 coronary revascularization indications also addressed by the AUCs. That group classified scenario 12b as “uncertain.” Instead of assuming that the cardiologists in the survey need to be educated about the appropriateness of this procedure, Marso et al suggest it’s the technical panel that could learn something from the cardiologists in the survey. “These are 80 clinical cardiologists who answered questions about what they thought was appropriate, driven by medical decision-making, and they concluded that the technical panel just plain got it wrong,” Marso told heartwire.

In response to this specific point, Chan told heartwire, “The decision of the AUC technical panel to make this scenario inappropriate was based on the lack of available clinical evidence to support PCI in patients who have only mild to moderate symptoms with intermediate stress tests without a trial of medical therapy. This is, indeed, consistent with the COURAGE trial, wherein medical therapy was found to be comparable to PCI for patients with even greater symptoms and more severe ischemia.

“Although the COURAGE quality-of-life substudy did find that patients who underwent PCI, compared with medical therapy, had modestly improved angina relief during the first year, this benefit was likely concentrated in those COURAGE patients who had far greater symptoms than [Canadian Cardiovascular Society (CCS)] class I or II—eg, CCS class II or IV,” Chan said. “Dr Marso’s assertion that this indication should be uncertain, however, is not supported by any evidence to date.”

Who decides who gets to decide?

Marso et al also object to the composition of the technical panel, which included only four interventionalists out of 16 total members. The panel was put together according to the so-called Rand method to prevent conflicts of interest. Marso objects to the technical panel’s insinuation that “interventional cardiologists are inherently biased due a financial bias or an intellectual bias, that their ideas are preconceived, and that they are unwilling to evaluate data in an objective manner.” He points out that the FDA, which certainly has a vested interest in rooting out both financial and intellectual bias from its advisory panels, does not limit whole categories of experts from serving on these panels. Instead, it evaluates the background and potential conflicts of interest of each individual.

Dr John Spertus, the director of outcomes research at Saint Luke’s Mid America Heart Institute and senior author of the AUC writing group, does not agree that the AUC technical committee needs more interventionalists. “The benefits of revascularization should be very transparent. Clinicians caring for patients should all be on the same page with the same perspectives of revascularization of patients. That isn’t information that is uniquely known to the interventional community,” he said. “While they have extensive expertise and knowledge around the technical aspects of doing the procedure, whether it should be done or not is something that all clinicians caring for patients with coronary disease should know, appreciate, and be able to communicate to their patients.”

The missing voice: The patient

In an accompanying editorial [2], Dr James Blankenship (Geisinger Medical Center, Danville, PA) argues that the AUC “will never fully define the best treatment decision for a particular patient . . . because occasionally, patients will have exceptional circumstances that dictate treatment different from that recommended by AUC and guidelines; and different patients experience a given level of symptoms differently.

“Determinations of appropriateness by the AUC based on angina class fail to take patients’ perceptions and preferences into account. This is a fundamental flaw, because patients’ perceptions and preferences are a critical component of decision making,” Blankenship argues. However, he acknowledges that “factoring in patient preferences raises a host of new problems. Patients’ preferences are routinely based on incorrect perceptions and nonobjective factors; [they] routinely overestimate the benefits of PCI, underestimate its risks, and underestimate the efficacy of medical therapy [and] tend to discount the sometimes-superior benefits of one treatment (eg, CABG for very complex triple-vessel disease), because those benefits accrue later, and instead prefer the more immediate but lesser benefits of another treatment (eg, PCI) because they accrue sooner (temporal discounting).”

More data on the way

Chan said that a prospective study of 7000 to 8000 patients measuring the change in quality of life from baseline to six months among patients who have undergone PCI will soon be complete. Results of this study, intended to validate the ratings of the AUC, will probably be available this summer, he said.

“We anticipate that we will find that patients with inappropriate AUC ratings will have little to no improvement in quality of life at six months, appropriate AUC ratings will have substantial improvements in quality of life, and uncertain AUC ratings will have modest improvements in quality of life,” Chan said. “Once we have these results, we will be able to say with confidence whether indications such as 12b should be kept as inappropriate or changed to uncertain.”

Spertus said that the AUC will be updated when there are methodological or technical deficiencies in the current approach or if important new evidence on PCI is published. One of the goals of the AUC is to identify gaps in the scientific knowledge that need further study.

Marso reports no personal conflicts of interest during the previous 24 months.

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As I delve further into the Syntax trial, (in preparation for a presentation at work):

Mark Midei was charged with another 175 counts of unneccessary stenting this week..

The Syntax trial is a great example of the ‘big lie’ of the easy fix – and the publicity spin, as explained on this blog by (what appears to be ) one of the last honest cardiologists..  As I slosh through reams and reams of printed articles, as well as on-line stories, and links to journals on the Syntax trial and the results – it becomes readily apparent – that it is almost impossible to find an honest, and unbiased report of actual syntax results (particularly since cardiologists are doing most of the writing.)  Cardiac surgeons – listen up!!  You know the truth about outcomes with stents versus cabg (surgery) – you see it every single day.. But stop sitting there smugly, and self-assuredly, so certain that the truth will out..

The truth is out, but it’s so muddied as to be unrecognizable.  Start writing your own research papers and defend yourself (and your patients) from this watershed of biased reporting.. Stenting is EASY but it’s NOT effective, and bypass surgery remains the standard of practice and the best treatment for longevity.. No propaganda can change that – but surgeons can’t lie back and rest on their laurels..

Dr.  DeMaio escapes..

and the most infamous cardiologist in America.

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The newest study (meta-analysis) on the use of clopidogrel for ACS (acute coronary syndrome) gives dramatically different results that previously published studies, and years of clinical experience.  This study, (abstract lifted from cardiosource and re-posted below) attributes adverse events and increased mortality in the patients receiving clopidogrel to underlying cardiac status.  In this patient population – that could certainly be true.

However, when a meta-analysis comes up with results that our dramatically different from the previous studies it’s using for its composite – then it’s time to take a closer look at the data they used to compile their conclusions..

Without further access to the rest of the study (abstract published ahead of article publication), we will just have to wait..

But in the meantime, I’d still recommend judicious/ cautious clopidogrel use prior to the operating room.  Ten years of clinical reports and multiple studies showing increased bleeding/ bleeding complications/ MACE can’t be undone by one statistical analysis.. (At least until methodology is examined.)

Also the phrasing of the study is pretty precarious – I’ve italicized some of the results – where the authors skirt around the results to try and prove the hypothesis that they want.. Re-operation is increased in patients receiving clopidogrel BUT.. it’s increased in all patients receiving clopidogrel, not just ACS patients..  [That’s kind of a thready conclusion, in my humble opinion..]

Readers, what do you think?

Abstract:  Safety of Clopidogrel Being Continued Until the Time of Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome: A Meta-Analysis of 34 Studies

        Authors:   Nijjer SS, Watson G, Athanasiou T, Malik IS

        Citation:

        Safety of Clopidogrel Being Continued Until the Time of Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome: A Meta-Analysis of 34 Studies
        June 2, 2011
        Nijjer SS, Watson G, Athanasiou T, Malik IS.
Eur Heart J 2011;May 24:[Epub ahead of print].
 
Study Question:
      What is the risk of mortality, reoperation, perioperative myocardial infarction (MI), and stroke in the acute coronary syndrome (ACS) population undergoing coronary artery bypass grafting (CABG) while on clopidogrel?

        Methods:

Thirty-four studies with 22,584 patients undergoing CABG were assessed. Patients with recent clopidogrel exposure (CL) were compared with those without recent clopidogrel (NC). Uni- and multivariate meta-regression was performed for the main outcomes of mortality, reoperation, postoperative MI, and stroke using the logarithm of the odds ratio (OR) as the dependent variable. Interaction analysis was performed creating interaction terms between the variable ACS status and the following variables: year of study, the use of on-pump surgery, patient urgency status, and use of concomitant antiplatelet agents, including aspirin and glycoprotein IIb/IIIa antagonists.

        Results:

Although mortality is increased in CL versus NC (OR, 1.6; 95% confidence interval [CI], 1.30-1.96; p < 0.00001), it is influenced by the ACS status and case urgency in these mainly nonrandomized studies. In ACS patients, there is no significant difference in mortality (OR, 1.44; 95% CI, 0.97-2.1; p = 0.07) or in postoperative MI (OR, 0.57; 95% CI, 0.31-1.07; p = 0.08) and stroke rates (OR, 1.23; 95% CI, 0.66-2.29; p = 0.52). Combined major adverse cardiovascular events (MACE) (stroke, MI, and death) were not different in the two groups (OR, 1.10; 95% CI, 0.87-1.41; p = 0.43). Reoperation rates are elevated on clopidogrelbut have reduced over time, and were specifically not different in ACS patients (OR, 1.5; 95% CI, 0.88-2.54; p = 0.13).

        Conclusions:

The authors concluded that ACS patients requiring urgent CABG proceed with surgery without delay for a clopidogrel-free period.

        Perspective:

This meta-analysis suggests that continuing dual antiplatelet therapy until the day of CABG reduces the risk of recurrent ischemic events in ACS patients and reduces MI postoperatively. While mortality and reoperation rates are increased after recent clopidogrel exposure, event rates were still low and overall MACE rates did not appear to be significantly increased in the clopidogrel group. These data demonstrate the need for a randomized clinical trial assessing different discontinuation times prior to CABG to definitively answer the question. Meanwhile, the evidence appears to suggest that many ACS patients can undergo CABG safely with recent clopidogrel exposure in expert hands.

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Today’s headline is a bit like alphabet soup for readers, but don’t worry, we’ll sort it all out for all of you.

PCI – percutaneous intervention (stenting)

CABG – coronary artery bypass surgery “bypass surgery”

ACS – acute coronary syndrome – acute ischemia, if untreated leads to acute myocardial infarction (AMI) also known as a heart attack.

Now that we have that all sorted out, we will continue our discussion on the latest Medscape article by Megan Brooks – which is re-posted below.

Generally, when a person is found to have significant coronary artery disease (CAD) or blockages, the decision whether to stent, treat with medicines or surgery is made based on several criteria including the amount of blockages, the number of places with blockages and the location of blockages.

For many years, doctors (cardiologists and surgeons) followed a few general guidelines when determining whether a patient should have stents or surgery.  Surgery was generally indicated in the following cases (provided the patient could tolerate surgery):

1. Multi-vessel disease (blockages in more than one artery)

2. Left main disease (because anatomically the left main serves two arteries – making it multiple vessel disease).  Left main disease was also considered a specific entity because of the consequences – patients rarely survive an infarction caused by the left main, which is how it received it’s nickname, ‘the widowmaker’.

(There are some other guidelines, and quite a bit more goes into the decision-making process but we will just talk about these two for now.)

Left main disease is particularly deadly for this reason, because in many people, they are asymptomatic (without chest pain or other physical symptoms) until the left main artery becomes very, very narrowed.  This disease pattern (or pattern of blockages also runs in families, and is sometimes seen in younger people (forties). Due to the importance of this vessel for survival, and due to the known durability of bypass surgery – this patients were usually sent automatically for a surgical referral.  These are also the patients that sometimes skipped right ahead to surgery – particularly if they came into the hospital with chest pain/ and had chest pain in the cath lab. (The ACS portion of the title)

But as stenting grew in popularity, not just with cardiologists but with patients (medicine is market-driven, just like cars or anything else) cardiologists began placing more and more stents in more and more people for disease that had traditionally been treated with surgery.  (Every time you seen an article about decrease in bypass surgery rates – think more stents – people don’t have less disease, they are just having less surgery to treat it.)

People began receiving four, five even six stents at a time, in multiple vessels.. Then cardiologists started stenting the left main..  All of this was done under the guise of “it’s what the patients want” which is a pretty important point to consider.  Now, in the five plus years I’ve been doing this, I’ve never, ever had a patient in the cath lab, or in the office come to me, or the surgeons I’ve worked for and say, “Hey – I’d like to have heart surgery.”  But we managed to stay pretty busy all the same – because it’s not about if the patient wants surgery – that’s using semantics..

But if I were to ask those same patients, “Do you want a proven therapy for your disease with good 20 year outcomes?”  then we get a very different answer, and surgery becomes a necessary evil – to get to that twenty years – to the children’s graduation, fiftieth anniversary and all of those other milestones of life.

Now researchers are looking at the data behind PCI for left main and comparing it to CABG.  That always tends to be fraught with danger because it seems that so many times, these trials are bought and paid for by drug companies – the ones that make the devices, and the drugs used in the cath lab..  So often when looking at the methodology for studies comparing surgery to stents – the researchers are actually comparing apples to oranges.

The other big error that a lot of these studies do – is ignore the long-term data.  They usually stop looking after six months or a year.  We know that stents can usually last a year if patients take their medication (clopidogrel, statins, aspirin, etc.) and we also know that surgery is proven to last twenty years or more.. But, invariably, the researchers stop the trials, and stop looking so we don’t see how all those patients with left main stents, or five stents fared even five years later.  Did they need more stents?  Did they have a heart attack?  Did they die? 

This image from the Texas Heart Institute to illustrate our discussion:

Coronary anatomy

I’ve added my own comments in [brackets and italics].

PCI for left main CAD and ACS linked to more adverse events

By Megan Brooks

NEW YORK (Reuters Health) May 16 – In patients with left main coronary artery disease (CAD) and acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) carry similar risks of death and re-infarction, new research from Italy shows.

However, PCI carries a significantly higher risk of major adverse cardiac events, driven by more frequent repeat revascularizations, the researchers found. [this means the patient had to come back and get another stent – or ended up having surgery later].

“Similarly to non-ACS presentations, PCI patients experience a higher risk of re-intervention, perhaps inflated by a more liberal use of follow-up angiography compared to CABG,” said co-author Dr. Davide Capodanno from Ferrarotto Hospital in Catania, in e-mail to Reuters Health.

The best way to manage patients with left main CAD and ACS remains uncertain, he and his colleagues said in a May 5 online paper in the American Journal of Cardiology.

Using registry data, the researchers analyzed one-year outcomes of patients with left main CAD and ACS who were treated with PCI and drug-eluting stents (n = 222) or CABG (n = 361), since 2002.  [another one year study].

They found that the rate of major adverse cardiac events was significantly higher in the PCI group than the CABG group (14.4% vs 5.3%; P < 0.001).  [Note that this is almost three times higher – or 1 in 6].

The difference was driven by a higher rate of target lesion revascularization with PCI (8.1% vs 1.7%; P = 0.001). This difference persisted after statistical adjustment for major adverse cardiac events (adjusted hazard ratio 2.7) and target lesion revascularization (adjusted hazard ratio 8.0).

Follow-up angiography was significantly associated with higher odds of major adverse cardiac events and target lesion revascularization at one year (P < 0.001 for both). There were no statistically significant differences in rates of death (6.3% for PCI vs 3.6% for CABG) or myocardial infarction (1.8% vs 0.6%). [not statistically significant but  PCI carries double the rate of CABG patients].

The diagnosis – either ST-segment elevation myocardial infarction (STEMI), or unstable angina/non-STEMI – was not correlated with treatment, a finding the authors say is noteworthy.

It seems from our data that the clinical scenario in which a left main stenosis is detected does not significantly interact with the type of revascularization offered to the patient,” Dr. Capodanno told Reuters Health.

“Decision making might not necessarily rely on whether the patients present with an ACS or not,” he said. “This is consistent with the notion that score algorithms — such as the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score – have been proven to work well in stable angina patients as well as in those with an ACS,” he noted. [actually multiple studies showed the ‘Syntax score’ was a poorly validated tool, and essentially useless, which is why it was revised multiple times.]

The findings could mean that guidelines for using scores to aid decision-making in left main disease “may also theoretically apply to ACS patients,” he said. “However, the impact of other clinical variables could be not negligible. Therefore, careful patient selection on a case-by-case basis is necessary.”

The observational nature of a registry study is the most important limitation of the current analysis, he and his colleagues note in their report, adding that “only randomization can provide an unbiased estimation of effects of a treatment.”

In addition, because the “presumptive benefit of CABG is likely to increase over time, longer follow-up would add meaningfully to the present report.”

Additional references:

In an unrelated report – on the use of NSAIDS following myocardial infarction. : NSAIDs (acetaminophen, ibuprofen, as well as COX-2 inhibitors) unsafe after heart attack. I don’t usually write posts on pharmacology (with the exception of clopidogrel) because I usually leave that to my co-writer, Dr. Albert Klein (PharmD), a clinical pharmacist.  But in this instance, I think it is an important reminder to readers – that even over-the-counter medications can prove harmful.

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Dr. Francisco Holguin, and his charming wife, Ximena Reyes

Spent a charming afternoon with Dr. Francisco Holguin Rueda and his wife, Ximena Reyes (RN) on a sunny afternoon here in Bogota.   Now that I had a chance to sit down with Dr. Holguin, we talked about Medical City, what it was, and what he expected it to bring to the Cartagena area.  We are planning another sit down later next week – to talk more in-depth, so I can bring it to all of your here.

Medical City is Dr. Holguin’s latest creation – to bring large-scale, centralized medical care to Cartagena that is designed to attract, and serve the needs of medical tourists from around the globe.  Cartagena’s convenient and strategic location makes it an ideal destination for medical tourists from North , Central and South America, and well as the entire Caribbean.. By creating a medical center, just outside Cartagena (10 km) from the airport, in an upscale neighborhood, that is already home to many Americans and other ex-pats – patients can receive a wide range of medical and surgical services all in one place, without having to navigate Cartagena city traffic, or transverse the city from one specialist to another.

All the major surgical specialties will be represented with specialized centers; cardiac surgery, orthopedic surgery, plastic surgery, and of course, Dr. Holguin’s specialty, Bariatric surgery.  I am looking forward to our next meeting, so I can bring you more information.  Check back next week.

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