RESUMEN
BACKGROUND: The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear. METHODS: Among 601 patients who had coronary artery disease that was amenable to coronaryartery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photonemission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years. RESULTS: CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P=0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death. CONCLUSIONS: The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595.). (AU)
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Puente de Arteria Coronaria , Estudios Prospectivos , Ecocardiografía de Estrés/métodos , Tomografía Computarizada por Emisión de Fotón Único Sincronizada CardíacaRESUMEN
BACKGROUND: Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries. METHODS: This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection. RESULTS: A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination. CONCLUSIONS: Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.
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Lesiones Traumáticas del Encéfalo/terapia , Adulto , Lesiones Traumáticas del Encéfalo/mortalidad , Lesiones Traumáticas del Encéfalo/fisiopatología , Femenino , Escala de Coma de Glasgow , Escala de Consecuencias de Glasgow , Humanos , Presión Intracraneal , América Latina/epidemiología , Masculino , Análisis Multivariante , Oportunidad Relativa , Estudios Prospectivos , América del Sur/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
Objectives: In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction pluscoronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalizationcompared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients withcoronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypassgraft surgery and surgical ventricular reconstruction compared with bypass alone.Methods: Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patientsrandomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for IschemicHeart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecifiedcriteria.Results: At 3 years, there was no difference in mortality or the combined outcome of death or cardiachospitalization between those with and without viability, and there was no significant interaction between thetype of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization.Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those withand without anterior wall or apical scar, and no significant interaction between the presence of scar in theseregions and the type of surgery with respect to mortality.Conclusions: In patients with coronary artery disease and severe regional left ventricular dysfunction,assessment of myocardial viability does not identify patients who will derive a mortality benefit from addingsurgical ventricular reconstruction to coronary artery bypass graft surgery.
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Enfermedad de la Arteria Coronaria , Insuficiencia Cardíaca , Revascularización MiocárdicaRESUMEN
In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone.MethodsMyocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria.ResultsAt 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality.ConclusionsIn patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.
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Disfunción Ventricular , Insuficiencia Cardíaca , Revascularización MiocárdicaRESUMEN
Background The assessment of myocardial viability has been used to identify patients withcoronary artery disease and left ventricular dysfunction in whom coronary-arterybypass grafting (CABG) will provide a survival benefit. However, the efficacy of thisapproach is uncertain. Methods In a substudy of patients with coronary artery disease and left ventricular dysfunctionwho were enrolled in a randomized trial of medical therapy with or withoutCABG, we used single-photon-emission computed tomography (SPECT), dobutamineechocardiography, or both to assess myocardial viability on the basis of prespecifiedthresholds.ResultsAmong the 1212 patients enrolled in the randomized trial, 601 underwent assessmentof myocardial viability. Of these patients, we randomly assigned 298 to receivemedical therapy plus CABG and 303 to receive medical therapy alone. A total of 178of 487 patients with viable myocardium (37%) and 58 of 114 patients without viablemyocardium (51%) died (hazard ratio for death among patients with viable myocardium,0.64; 95% confidence interval [CI], 0.48 to 0.86; P = 0.003). However, afteradjustment for other baseline variables, this association with mortality was notsignificant (P = 0.21). There was no significant interaction between viability statusand treatment assignment with respect to mortality (P = 0.53).ConclusionsThe presence of viable myocardium was associated with a greater likelihood ofsurvival in patients with coronary artery disease and left ventricular dysfunction,but this relationship was not significant after adjustment for other baseline variables.The assessment of myocardial viability did not identify patients with a differentialsurvival benefit from CABG, as compared with medical therapy alone.(Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.govnumber, NCT00023595.)
Asunto(s)
Cardiomiopatías , Disfunción Ventricular , SupervivenciaAsunto(s)
Humanos , Masculino , Femenino , Enfermedades de las Arterias Carótidas , Angina Inestable , Infarto del MiocardioAsunto(s)
Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/prevención & control , Profilaxis Antibiótica/clasificación , Profilaxis Antibiótica/estadística & datos numéricos , Profilaxis Antibiótica/instrumentación , Atención Dental para Enfermos Crónicos/métodos , Atención Dental para Enfermos Crónicos , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/terapiaRESUMEN
O conteúdo dessa edição também foi melhorado de forma abrangente. Todos os 51 capítulos da 6ª.edição, mantidos para a edição atual, foram completamente revisados e atualizados. Além disso, 36 novos capítulos foram incluídos, cujos tópicos variam de tomada de decisão clínica a manifestações cardiovasculares de distúrbios autonômicos. Cinqüenta e sete novos autores fizeram contribuições. Portanto, a excelência na informação, servindo como fundamento da vitalidade intelectual do texto, foi mantida e fortalecida nesta edição. Referências bibliográficas foram limitadas geralmente às fontes publicadas em 1998, ou depois, para evitar o acréscimo de citações que podem consumir páginas valiosas sem oferecer a utilidade de conteúdo novo. Continuamos a apresentar a compreensão de mecanismos básicos subjacentes a doenças, mas também enfatizamos a avaliação prática e o tratamento de pacientes com esses problemas, bem como fornecemos um compêndio de Diretrizes atuais para a conveniência do leitor. A Parte I abrange as considerações gerais sobre a doença cardiovascular, com capítulos sobre ônus global, economia, tomada de decisão clínica, avaliação da qualidade dos cuidados cardiovasculares, princípios de terapia medicamentosa e cuidado de pacientes terminais com doenças do coração. A Parte II mantém a tradição da edição anterior, enfatizando história e exame físico, eletrocardiografia, teste de esforço e ecocardiografia. Entretanto, reconhecendo a importância crescente de novas técnicas, incluímos novos capítulos como radiologia do coração e grandes vasos, cardiologia nuclear, ressonância magnética, tomografia computadorizada, cateterismo cardíaco, angiografia coronariana e ultra-sonografia intravascular, bem como um capítulo que inclui as mais variadas modalidades de imagem em perspectiva. A insuficiência cardíaca surgiu como um dos problemas mais importantes na cardiologia, como está refletido na Parte III
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Enfermedades de las Válvulas Cardíacas , Enfermedades Cardiovasculares , Sistema Cardiovascular/patologíaRESUMEN
O conteúdo dessa edição também foi melhorado de forma abrangente. Todos os 51 capítulos da 6ª.edição, mantidos para a edição atual, foram completamente revisados e atualizados. Além disso, 36 novos capítulos foram incluídos, cujos tópicos variam de tomada de decisão clínica a manifestações cardiovasculares de distúrbios autonômicos. Cinqüenta e sete novos autores fizeram contribuições. Portanto, a excelência na informação, servindo como fundamento da vitalidade intelectual do texto, foi mantida e fortalecida nesta edição. Referências bibliográficas foram limitadas geralmente às fontes publicadas em 1998, ou depois, para evitar o acréscimo de citações que podem consumir páginas valiosas sem oferecer a utilidade de conteúdo novo. Continuamos a apresentar a compreensão de mecanismos básicos subjacentes a doenças, mas também enfatizamos a avaliação prática e o tratamento de pacientes com esses problemas, bem como fornecemos um compêndio de Diretrizes atuais para a conveniência do leitor.A Parte I abrange as considerações gerais sobre a doença cardiovascular, com capítulos sobre ônus global, economia, tomada de decisão clínica, avaliação da qualidade dos cuidados cardiovasculares, princípios de terapia medicamentosa e cuidado de pacientes terminais com doenças do coração. A Parte II mantém a tradição da edição anterior, enfatizando história e exame físico, eletrocardiografia, teste de esforço e ecocardiografia. Entretanto, reconhecendo a importância crescente de novas técnicas, incluímos novos capítulos como radiologia do coração e grandes vasos, cardiologia nuclear, ressonância magnética, tomografia computadorizada, cateterismo cardíaco, angiografia coronariana e ultra-sonografia intravascular, bem como um capítulo que inclui as mais variadas modalidades de imagem em perspectiva. A insuficiência cardíaca surgiu como um dos problemas mais importantes na cardiologia, como está refletido na Parte III