Myocardial revascularization: Difference between revisions

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Revascularization procedures include:
Revascularization procedures include:
* [[Coronary artery bypass grafting]] (CABG) which is a "surgical therapy of ischemic [[Coronary heart disease|coronary artery disease]] achieved by grafting a section of [[saphenous vein]], [[internal mammary artery]], or other substitute between the [[aorta]] and the obstructed coronary artery distal to the obstructive lesion."<ref>{{MeSH|Coronary Artery Bypass}}</ref>
* [[Coronary artery bypass]] grafting(CABG) which is a "surgical therapy of ischemic [[Coronary heart disease|coronary artery disease]] achieved by grafting a section of [[saphenous vein]], [[internal mammary artery]], or other substitute between the [[aorta]] and the obstructed [[coronary artery]] distal to the obstructive lesion."<ref>{{MeSH|Coronary Artery Bypass}}</ref>
* [[Percutaneous transluminal coronary angioplasty]] (PCTA) ([[angioplasty]] of a coronary artery) is  "dilatation of an occluded coronary artery (or arteries) by means of a balloon catheter to restore myocardial blood supply."<ref>{{MeSH|Percutaneous transluminal coronary angioplasty}}</ref>
* [[Percutaneous transluminal coronary angioplasty]] (PCTA) ([[angioplasty]] of a coronary artery) is  "dilatation of an occluded [[coronary artery]] (or arteries) by means of a balloon catheter to restore myocardial blood supply."<ref>{{MeSH|Percutaneous transluminal coronary angioplasty}}</ref>
* [[Coronary atherectomy]] which is a "percutaneous transluminal procedure for removing atheromatous plaque from the coronary arteries. Both directional (for removing focal atheromas) and rotational (for removing concentric atheromatous plaque) atherectomy devices have been used."<ref>{{MeSH|Coronary Atherectomy}}</ref>
* [[Coronary atherectomy]] which is a "percutaneous transluminal procedure for removing atheromatous plaque from the [[coronary artery|coronary arteries]]. Both directional (for removing focal atheromas) and rotational (for removing concentric atheromatous plaque) atherectomy devices have been used."<ref>{{MeSH|Coronary Atherectomy}}</ref>


In general, surgery is more effective.<ref name="pmid-17938385">{{cite journal |author=Bravata DM, Gienger AL, McDonald KM, ''et al'' |title=Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery |journal=Ann Intern Med |volume= |issue= |pages= |year=2007 |pmid=17938385 |doi=}}</ref>
[[Clinical practice guideline]]s address management and selection of patients.<ref name="pmid22064601">{{cite journal| author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B et al.| title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. | journal=Circulation | year= 2011 | volume=  | issue=  | pages=  | pmid=22064601 | doi=10.1161/CIR.0b013e31823ba622 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22064601  }} </ref>
 
Elective [[percutaneous transluminal coronary angioplasty]] is not clearly better to optimal medical therapy.<ref name="pmid17387127">{{cite journal| author=Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al.| title=Optimal medical therapy with or without PCI for stable coronary disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 15 | pages= 1503-16 | pmid=17387127 | doi=10.1056/NEJMoa070829 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17387127  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608377 Review in: ACP J Club. 2007 Jul-Aug;147(1):12]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17612033 Review in: J Fam Pract. 2007 Jul;56(7):529]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17885155 Review in: Evid Based Med. 2007 Aug;12(4):107] </ref>
 
Coronary artery bypass is more effective for myocardial revascularization of [[coronary heart disease]] than [[percutaneous transluminal coronary angioplasty]]<ref name="pmid-17938385">{{cite journal |author=Bravata DM, Gienger AL, McDonald KM, ''et al'' |title=Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery |journal=Ann Intern Med |volume= |issue= |pages= |year=2007 |pmid=17938385 |doi=}}</ref>, especially for patients with diabetes who have stenosis of two[[coronary artery|coronary arteries]].<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref><ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref><ref name="pmid8657237">{{cite journal |author= |title=Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators |journal=N. Engl. J. Med. |volume=335 |issue=4 |pages=217–25 |year=1996 |month=July |pmid=8657237 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=8657237&promo=ONFLNS19 |issn=}}</ref> Coronary artery bypass is also more effective than [[percutaneous transluminal coronary angioplasty]] with drug-eluting stents; however, bypass may increase the rate of stroke.<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref><ref name="pmid19228612">{{cite journal |author=Serruys PW, Morice MC, Kappetein AP, ''et al'' |title=Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease |journal=N. Engl. J. Med. |volume=360 |issue=10 |pages=961–72 |year=2009 |month=March |pmid=19228612 |doi=10.1056/NEJMoa0804626 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19228612&promo=ONFLNS19 |issn=}}</ref>
 
Clinical practice guidelines suggest that the [http://www.syntaxscore.com/ SYNTAX score] may help determine choice of procedure for myocardial revascularization.<ref name="pmid17437730">{{cite journal |author=Valgimigli M, Serruys PW, Tsuchida K, ''et al'' |title=Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention |journal=Am. J. Cardiol. |volume=99 |issue=8 |pages=1072–81 |year=2007 |month=April |pmid=17437730 |doi=10.1016/j.amjcard.2006.11.062 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(07)00072-0 |issn=}}</ref>
*"Calculation of the Society of Thoracic Surgeons (STS) and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD."<ref name="pmid22064601"/>
* However, the more recent FREEDOM trial found the SYNTAX score did not predict benefit.<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref>
 
==Appropriateness of decisions for PTCA==
Less than half of patients with stable angina who receive PTCA are receiving optimal medical therapy.<ref name="pmid21558519">{{cite journal| author=Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA| title=Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention. | journal=JAMA | year= 2011 | volume= 305 | issue= 18 | pages= 1882-9 | pmid=21558519 | doi=10.1001/jama.2011.601 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558519  }} </ref>
 
Of patients without indications for myocardial revascularization, cardiologists will recommended [[percutaneous transluminal coronary angioplasty]]  for 21% of patients.<ref name="pmid20048207">{{cite journal|  author=Hannan EL, Racz MJ, Gold J, Cozzens K, Stamato NJ, Powell T et  al.| title=Adherence of catheterization laboratory cardiologists to  American College of Cardiology/American Heart Association guidelines for  percutaneous coronary interventions and coronary artery bypass graft  surgery: what happens in actual practice? | journal=Circulation | year=  2010 | volume= 121 | issue= 2 | pages= 267-75 | pmid=20048207 |  doi=10.1161/CIRCULATIONAHA.109.887539 | pmc= |  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20048207  }} </ref> A second study found that 12% of elective [[percutaneous transluminal coronary angioplasty|percutaneous transluminal coronary angioplasties]] were done for inappropriate reasons.<ref name="pmid21730241">{{cite journal| author=Chan PS, Patel MR, Klein LW, Krone RJ, Dehmer GJ, Kennedy K et al.| title=Appropriateness of percutaneous coronary intervention. | journal=JAMA | year= 2011 | volume= 306 | issue= 1 | pages= 53-61 | pmid=21730241 | doi=10.1001/jama.2011.916 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21730241  }} </ref>
 
Regarding drug eluting stents, about 50% of patients received them for off-label purposes.<ref name="pmid17488965">{{cite journal| author=Win HK, Caldera AE, Maresh K, Lopez J, Rihal CS, Parikh MA et al.| title=Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents. | journal=JAMA | year= 2007 | volume= 297 | issue= 18 | pages= 2001-9 | pmid=17488965 | doi=10.1001/jama.297.18.2001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17488965  }} </ref><ref name="pmid17488964">{{cite journal| author=Beohar N, Davidson CJ, Kip KE, Goodreau L, Vlachos HA, Meyers SN et al.| title=Outcomes and complications associated with off-label and untested use of drug-eluting stents. | journal=JAMA | year= 2007 | volume= 297 | issue= 18 | pages= 1992-2000 | pmid=17488964 | doi=10.1001/jama.297.18.1992 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17488964  }} </ref> Patients receiving stents for off-label indications have more adverse outcomes.<ref name="pmid17488965"/><ref name="pmid17488964"/>


==References==
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Latest revision as of 08:05, 13 October 2024

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In medicine, myocardial revascularization is "the restoration of blood supply to the myocardium."[1]

Revascularization procedures include:

Clinical practice guidelines address management and selection of patients.[5]

Elective percutaneous transluminal coronary angioplasty is not clearly better to optimal medical therapy.[6]

Coronary artery bypass is more effective for myocardial revascularization of coronary heart disease than percutaneous transluminal coronary angioplasty[7], especially for patients with diabetes who have stenosis of twocoronary arteries.[8][8][9] Coronary artery bypass is also more effective than percutaneous transluminal coronary angioplasty with drug-eluting stents; however, bypass may increase the rate of stroke.[8][10]

Clinical practice guidelines suggest that the SYNTAX score may help determine choice of procedure for myocardial revascularization.[11]

  • "Calculation of the Society of Thoracic Surgeons (STS) and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD."[5]
  • However, the more recent FREEDOM trial found the SYNTAX score did not predict benefit.[8]

Appropriateness of decisions for PTCA

Less than half of patients with stable angina who receive PTCA are receiving optimal medical therapy.[12]

Of patients without indications for myocardial revascularization, cardiologists will recommended percutaneous transluminal coronary angioplasty for 21% of patients.[13] A second study found that 12% of elective percutaneous transluminal coronary angioplasties were done for inappropriate reasons.[14]

Regarding drug eluting stents, about 50% of patients received them for off-label purposes.[15][16] Patients receiving stents for off-label indications have more adverse outcomes.[15][16]

References

  1. ↑ Anonymous (2024), Myocardial revascularization (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Anonymous (2024), Coronary Artery Bypass (English). Medical Subject Headings. U.S. National Library of Medicine.
  3. ↑ Anonymous (2024), Percutaneous transluminal coronary angioplasty (English). Medical Subject Headings. U.S. National Library of Medicine.
  4. ↑ Anonymous (2024), Coronary Atherectomy (English). Medical Subject Headings. U.S. National Library of Medicine.
  5. ↑ 5.0 5.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B et al. (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.". Circulation. DOI:10.1161/CIR.0b013e31823ba622. PMID 22064601. Research Blogging.
  6. ↑ Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al. (2007). "Optimal medical therapy with or without PCI for stable coronary disease.". N Engl J Med 356 (15): 1503-16. DOI:10.1056/NEJMoa070829. PMID 17387127. Research Blogging. Review in: ACP J Club. 2007 Jul-Aug;147(1):12 Review in: J Fam Pract. 2007 Jul;56(7):529 Review in: Evid Based Med. 2007 Aug;12(4):107
  7. ↑ Bravata DM, Gienger AL, McDonald KM, et al (2007). "Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery". Ann Intern Med. PMID 17938385. [e]
  8. ↑ 8.0 8.1 8.2 8.3 Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes.". N Engl J Med. DOI:10.1056/NEJMoa1211585. PMID 23121323. Research Blogging.
  9. ↑ (July 1996) "Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators". N. Engl. J. Med. 335 (4): 217–25. PMID 8657237. [e]
  10. ↑ Serruys PW, Morice MC, Kappetein AP, et al (March 2009). "Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease". N. Engl. J. Med. 360 (10): 961–72. DOI:10.1056/NEJMoa0804626. PMID 19228612. Research Blogging.
  11. ↑ Valgimigli M, Serruys PW, Tsuchida K, et al (April 2007). "Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention". Am. J. Cardiol. 99 (8): 1072–81. DOI:10.1016/j.amjcard.2006.11.062. PMID 17437730. Research Blogging.
  12. ↑ Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA (2011). "Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention.". JAMA 305 (18): 1882-9. DOI:10.1001/jama.2011.601. PMID 21558519. Research Blogging.
  13. ↑ Hannan EL, Racz MJ, Gold J, Cozzens K, Stamato NJ, Powell T et al. (2010). "Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice?". Circulation 121 (2): 267-75. DOI:10.1161/CIRCULATIONAHA.109.887539. PMID 20048207. Research Blogging.
  14. ↑ Chan PS, Patel MR, Klein LW, Krone RJ, Dehmer GJ, Kennedy K et al. (2011). "Appropriateness of percutaneous coronary intervention.". JAMA 306 (1): 53-61. DOI:10.1001/jama.2011.916. PMID 21730241. Research Blogging.
  15. ↑ 15.0 15.1 Win HK, Caldera AE, Maresh K, Lopez J, Rihal CS, Parikh MA et al. (2007). "Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents.". JAMA 297 (18): 2001-9. DOI:10.1001/jama.297.18.2001. PMID 17488965. Research Blogging.
  16. ↑ 16.0 16.1 Beohar N, Davidson CJ, Kip KE, Goodreau L, Vlachos HA, Meyers SN et al. (2007). "Outcomes and complications associated with off-label and untested use of drug-eluting stents.". JAMA 297 (18): 1992-2000. DOI:10.1001/jama.297.18.1992. PMID 17488964. Research Blogging.

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