1、實證醫學文獻討論A case of chest tightnessCase summaryProfile:An 80 y/o maleChief complaint:exertional chest tightness for 1 monthPast medical and surgical history:1.Patient denied of any significant past medical history,no HTN,DM,dyslipidemia.2.BPH s/p TURP for 7-8 years.CAD risk factors:1.HTN-2.DM-3.AGE+4.
2、FHx-5.SMOKING-6.MALE+7.DYSLIPIDEMIA-HISTORY OF PRESENTING COMPLAINT1.Intermittent chest pain and chest tightness for 1 month2.Chest pain was effort related,no radiation to lower jaw or neck or shoulder.3.Lasted for 10 minutes and relieved by rest,no associated symptoms.4.Visited CV OPD 1 week before
3、 admission,cardiac esho showed 1.adequate LV global performance(EF=60%)2.No chamber dilatation.3.No pericardial effusion5.Stress and rest Tl-201 myocardial perfusion SPECT scintiphotos showed a non-compromised myocardial perfusion.6.Chest CT showed RML nodule;TB culture was collected.7.Antiplatelet
4、with Bokey 100 mg 1#qd was given for possible CAD.8.Admitted electively on 8/1 for further investigation cardiac catheterisationPhysical examinationVital signs:T=36c,P=64/min,R=20/min,BP=147/76 mmHgGCS 456JVP supple,estimated 7 cm H2O;no goiterChest BS clearHeart sounds dual no murmur,regularNo pitt
5、ing edema,good peripheral pulseInvestigationWBC 6200,Hb 13.0,PLT 176000BUN 18,Cr 1.0,GOT/GPT 19/17GLU 92,Na 140.7,K 4.02T.cholesetrol 207,TG 117Uric acid 5.88EKG normal sinus rythmCardiac angiography reportClinical diagnosis:angina pectorisIndication for cath:angina pectorisPost-cath diagnosis:CAD/l
6、eft main+3-V-DEF=54%,Left main:50-60%stenosis at distal left mainLAD:95%stenosis at LAD-PLCX:95%stenosis at ostium and a 90%stenois at LCX-DRCA:50%stenosis at RCA-MCollateral:noneCardiac angiography reportPost-cath Diagnosis:CAD left main+3VD s/p successful direct Taxus stenting for LAD-P and LCX-os
7、tium and POBA and stenting for LCX-D/TIMI III1.CABG is recommended for left main and 3VD.However the family refused the OP due to old age2.PCI for LAD-P and LCX-ostium and LCX-D is recommended.ProgressPatient recovered well the next dayNo active bleeding or hematoma over the puncture site,with good
8、distal pulse and sensation.Discharged with OPD follow up.Medication:1.Bokey 100 mg 1#qd po2.Gasgel 1#tid po3.Isosorbide 10 mg 1#tid po4.Acetylcystein 3 pk bid po5.Plavix 75 mg 1#qd poThe question in mind.Did her familys decision to perform PTCA instead of CABG affect her outcome(morbidity and mortal
9、ity)in the future?PTCA with stents VS coronary bypassPICOT 類型:treatmentP:ACUTE CORONARY SYNDROMEI:PTCAC:CORONARY BYPASSO:morbidity and mortalityT:TREATMENTKeywords1.Acute coronary syndrome2.Angiography3.Coronary bypassPercutaneous transluminal coronary angioplasty with stents versus coronary artery
10、bypass grafting for people with stable angina or acute coronary syndromesCochrane Database of Systemic Reviews 2005,2007Background Coronary artery bypass graft(CABG)is the surgical technique used to treat critical obstructions in coronary arteries caused by atherosclerotic plaque diseasesaphenous ve
11、ins OR internal mammary arteries OR radial artery risk of initial surgical mortality and morbidity need for a significant period of convalescence surgical centres require specialised staff and facilitates.Percutaneous Coronary Interventions(PCI),which include Percutaneous Transluminal Coronary Angio
12、plasty(PTCA),PTCA with stenting,brachytherapy and atherectomy technologieslocal anaesthetic,small vascular incisions in the groin or arm(percutaneously),as little as 15 minutes rates of restenosis(re-narrowing of the treated vessel),20 and 50%debate on whether surgery or PCI is the most appropriate
13、treatmentObjectivesTo assess the clinical effects of the use of coronary artery stents(as part of Percutaneous Transluminal Coronary Angioplasty)compared to Coronary Artery Bypass Graft surgery for the treatment of people with coronary artery disease.Criteria for considering studies for this reviewT
14、ypes of studies Randomised Controlled Trials(RCTs),published or unpublisheduse of coronary artery stents(in conjunction with Percutaneous Transluminal Coronary Angioplasty techniquescompared with the application of Coronary Artery Bypass Graft(CABG)techniques.Types of participants Adults Stable angi
15、na or Acute Coronary Syndrome(including AMI(ST segment elevation and depression,Q wave and non-Q wave)and unstable angina).Adults with single or multivessel coronary artery disease.Types of intervention Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting
16、 surgery.Types of outcome measures Clinical(1)Combined event rate or event free survival(e.g.Major Adverse Cardiac Events,Major Adverse Cardiac and Cerebrovascular Events,Target Vessel Failure or other composites of the events listed below);(2)Death(both cardiac and non-cardiac death);(3)Acute Myoca
17、rdial Infarction(AMI);(4)Target Vessel Revascularisation(TVR);(5)Target Lesion Revascularisation(TLR);(6)Repeat treatment(PTCA,stent or CABG).RadiologicalBinary restenosis(greater than 50%luminal narrowing compared to diameter at completion of the procedure).Quality of lifeWhere quality of life(QoL)
18、data were available the nature of the measures,timings of measurement and analytical tool used to assess QoL were recordedSearch methods for identification of studiesThe search incorporated a number of methods to identity completed or ongoing RCTs:(1)Searching of electronic databases;(2)Handsearchin
19、g of recent journals and conferences in relevant fields;(3)Subscription to e-mail-based information newsletters and regular examination of webpages(including those supported by stent manufacturers)relevant to the review topic;(4)Searching of bibliographies of identified sources;(5)Use of submissions
20、 to National Institute for Clinical Excellence(NICE),London,UK.Description of studiesIncluded studiesNine RCTs,involving a total of 3519 participants,are included in this review.Three studies included patients with multivessel diseaseFive included only people with single vessel disease one included
21、a mix of vessel involvement Reporting of outcomes extended beyond 1 year for ARTS;Drenth;ERACI II;SIMA;SOS,but were restricted to 6 months for Cisowski;Diegeler;Grip.Results1.Death Although stents appeared to be favoured in terms of lower mortality,these differences were not statistically differentS
22、OS study reports eight cancer related deaths in the stent arm The uneven distribution of non-cardiac deaths in SOS would appear to contribute to it appearing to favour CABG 2.AMI3.No significant difference observed,there was moderate to high degree of heterogeneity at 36 days,12 months and 2 yearsRe
23、sultsRevascularisationRepeat revascularisation procedures where less common in the CABG group Multiple vessel disease trials are included in the analysis at 12 months and 2 years,resulting in odds ratio 0.18 and odds ratio 0.21single vessel disease studies,producing an odds ratio 0.09 Binary resteno
24、sisBinary restenosis rate was reduced with CABG,odds ratio 0.29(95%confidence interval 0.17 to 0.51)in the three single vessel trials at 6 months;random effects odds ratio 0.21 DiscussionThe main findings of the meta-analysis:over the duration of follow-up available from current RCTs,there is consid
25、erable benefit,in terms of reduction in repeat revascularisation rates,with CABG over stenting.These reductions were similar in single and multiple vessel disease studies Multivessel disease The four studies(ARTS;ERACI II;OCTOSTENT;SOS)included in this meta-analysis demonstrate some differences in m
26、ortality between CABG and stent groups,however these did not reach statistical significance.BUT considerable heterogeneitySimilarly,the rates of AMI were also not significantly different.After 2 years the rates of AMI tend to favour surgery,but again this observation failed to reach statistical sign
27、ificanceAt 12 months the repeat revascularisation rates with CABG were approximately one fifth of the rates for stenting with an odds ratio 0.18;95%Single vessel diseaseIn the four single vessel studies(Cisowski;Diegeler;Drenth;Grip;SIMA),given that mortality rates in the short term were generally l
28、ow and the small number of total participants,the difference did not reach statistical significancebut would appear to favour stenting in contrast to the multivessel disease studiesThe AMI and combined endpoint results closely mimic the respective results seen in the multivessel studies with CABG ap
29、pearing to be better than stents in terms of composite event rate and repeat revascularisation at 6 months Clinical InterpretationThe mortality rate trend seen in the single vessel studies favouring stenting was not surprising given that stenting is performed under local anaesthetic and does not ent
30、ail the general anaesthesia required for surgery.While there would appear to be no significant difference in myocardial infarction rates at any time point,there is a trend in favour of CABG in those studies with longer follow up1.different enzyme rise thresholds for the two techniques2.grafts which
31、are invariably placed distally on native vessels may occlude with less myocardial impact than vessels opened proximally by stent procedures;3.interventionists are more inclined to request cardiac enzymes on patients with post-PCI chest pains then surgeons who are inclined to accept a degree of chest
32、 pain from patients due to the nature of the operative procedure;4.modest follow-up duration is likely to capture stent failure more fully as opposed to graft failureLimitations1.patients entered into such studies had to be suitable for either intervention and were not typical of all patients seen b
33、y cardiologists or cardiothoracic surgeons2.practice changed over the periods of the trials e.g.Glycoprotein IIB/IIIA has in more recent practice reduced early stent thrombosis and the amount of Ischaemic enzyme release peri procedurally 3.we could not consider subgroups of patients in the current m
34、eta-analysis4.analysis of other adverse events(for example,neurological complications)were not completed as these were not commonly or consistently reported.Authors conclusionsImplications for practice Considerably more data is needed to make firm long term conclusions on the implications for practi
35、ce,but in the short to medium term,CABG has far less repeat revascularisation procedures than PTCA with stents currently in common clinical use.Implications for research1.Re-evaluation of these technologies will be required as the development of new surgical techniques and stent designs is ongoing2.
36、Future trials should recruit more realistic patient groupings,as the population selected for inclusion in the current review were prone to bias3.selection tended to focus on patients with generally less co-morbidities and with better left ventricular function than the overall population presenting for revascularisation in the real world setting
