Myocardial revascularization
In medicine, myocardial revascularization is "the restoration of blood supply to the myocardium."[1]
Revascularization procedures include:
- Coronary artery bypass grafting(CABG) which is a "surgical therapy of ischemic 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."[2]
- 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."[3]
- 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."[4]
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
- ↑ Anonymous (2024), Myocardial revascularization (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Coronary Artery Bypass (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Percutaneous transluminal coronary angioplasty (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Coronary Atherectomy (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ 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.
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<ref>tag; name "pmid22064601" defined multiple times with different content - ↑ 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
- ↑ 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]
- ↑ 8.0 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.
- ↑ (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]
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 15.0 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.
- ↑ 16.0 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.