#46
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А, вот, вспомнила еще один вариант глухого отказа в операции: критический аортальный стеноз в сочетании с НК III-IV ФК. Мотив отказа везде стандартный: "а вот вы (терапевты) больного компенсируйте (как мы это должны сделать при площади просвета АК, к примеру, 4 кв.мм, остается за скобками), а мы потом прооперируем"...
Кстати, в продолжение этого вопроса. Коллеги-интервенциологи, кто-нибудь знает, делают ли в России паллиативную вальвулопластику при критическом аортальном стенозе? |
#47
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"Прежде всего надо иметь в виду, что эмиграция -- это часто, если не всегда, психическая болезнь"
"Наконец, совершенно правы здесь те, кто призывают делиться своим опытом, а не вообще российским или американским." - Др Осипов. Коллеги, как человек психически болеющий (переболевший?) эмиграцией - Максиму Александровичу виднее, какое определение лучше ко мне подходит - позволю себе заметить, что делиться общим американским, европейским, российским опытом можно в уважительном и не назидательном тоне, и с большой пользой для всех (тем более, что не все врачи в России побывали на паре стажировок за рубежом, и знают как оно там делается). Посему, хотя свой опыт всегда особо интересен, не вижу проблемы и в обмене общей тактикой подхода к какой-либо ситуации.... |
#48
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Раз уж зешел такой эмоциональный разговор о том что лучше АКШ, или стент приведу свой опыт. Совершенно не evidence-based просто так, наблюдения деревенского участкового. Рассмотрим двух пациентов, которые встречаются в практике сплошь и рядом.
1. John Smith 65 лет. Ветеран войны во Вьетнаме. Бывший курильщик. LDL 65, HDL 38, BP 110/70. Получает аспирин 325 мг, аторвастатин 80 мг, эзетимайб 10 мг. Пять лет назад перенес нижний инфаркт (NSTEMI). Поступил в госпиталь VA (для ветеранов) обнарущено 80% Mid RCA, 75% proxim LAD. EF = 75%. Выполнено АКШ (два шунта справа и слева). Реабилитация. Приходит ко мне за направлением на замену двух коленных и одного тазобедренного сустава. Мои действия 1. Спрашиваю есть ли боли при нагрузке. Если нет - готов к операции. Назначу атенолол 100 мг в сутки и все. 2. Jane Smith 65 лет. Домохозяйка. Хочет поменять два сустава и заодно почистить правую сонную артерию. В анамнезе тоже ИБС и стентирование после положительного стресс теста 5 лет назад. На ангиографии выявлено 70% поражение CIRC, необструктивное 40-50% поражение RCA и distal LAD. LDL 100, ApoB = 900, HDL 45, glucose 110, не курит. Получает аспирин, симвастатин 80 мг, атенолол 50 мг, лизиноприл 20 мг, эсциталопрам (антидепрессант) 20 мг. Мои действия 1. Есть боли? Нет, но я не бегаю по утрам и поправилась на 30 фунтов за последние 2 года. 2. Стресс тест с MIBI. Пробежала 6 минут на Bruce. На SPECT фиксированный девект передней стеки. сомнительная ревертия (? диафрагма) нижней стенки. Ангиография - стент стенозирован, в LAD и RCA стенозы по 60-70%. FFR 70%. Решили не стентировать. Медикаментозная терапия с инстукцией обращаться к лечашему врачу при возникновении болей. 3. В дальнейшем встречи с этой пациенткой 2 раза в месяц в приемнике, поступления на телеметрию при малейшем показывании в груди. Повторные стесс тесты и т.д. ВЫВОД : Вести пациента после CABG значительно проще, чем после стентирования. Количество повторных процедур меньше. В моей практике пациент после АКШ менее 10 лет назад будет направлен к кардиологу только после нового острого инфаркта. Таких у меня.... только ОДИН. Вести пациента (а еще хуже пациентку) после стентирования - кошмар. Любые боли в груди рассматриваются врачами приемника как ACS. Если есть факторы риска, пациентка конечно получает аспирин - вот вам в TIMI скор 3-4 - а значит нужно тащить на катетеризацию. При этом у многих пациентов развивается тяжелейший как раньше говорили "кардионевроз", а проще говоря после третьей ангиографии и 10 госпитализации они становятся тяжелейшими ипохондриками. В одном из недавних Ланцетов был прекрасный обзор на эту тему. Если у кого есть полный доступ (Vad?) не поленитесь - выложите инфу. У меня только бумажный варинт дома лежит. PS. |
#49
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Искренне, Вадим Валерьевич. |
#50
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NEJM 2005
* Hannan EL, * Racz MJ, * Walford G, * Jones RH, * Ryan TJ, * Bennett E, * Culliford AT, * Isom OW, * Gold JP, * Rose EA. University at Albany, State University of New York, Albany, NY, USA. BACKGROUND: Several studies have compared outcomes for coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), but most were done before the availability of stenting, which has revolutionized the latter approach. METHODS: We used New York's cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. We determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients' severity of illness before revascularization. RESULTS: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implantation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal left anterior descending coronary artery and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the nonproximal left anterior descending coronary artery. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6 percent for subsequent PCI). CONCLUSIONS: For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. Copyright 2005 Massachusetts Medical Society. PMID: 15917382 [PubMed - indexed for MEDLINE] И еще, для меня лично не существует понятия single vessel disease. Атеросклероз - процесс поражающий ВСЕ без исключения артерии и не только коронарные. Как мы знаем подавляющее большинство инфарктов происходят в зоне необструктивных бляшек (просто статистически из в 1000 раз больше, чем 70%-х). 70%, или не 70% имеет значение только для определения того связаны симптомы с этим сосудом, или нет, и вовсе не для определения прогноза. |
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#52
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Ага, не совсем Ланцет и не совсем недавний
В этой связи доступ к этой публикации уже нелимитирован (free): [Ссылки доступны только зарегистрированным пользователям ] А вот дискуссию этой публикации (N Engl J Med. 2005 Aug 18;353(7):735-7) помещаю без ссылок: To the Editor: The analysis by Hannan and colleagues (May 26 issue)1 comparing coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) is seriously flawed. The data were derived retrospectively from two separate New York State registries. The 12 risk factors for increased mortality that made up the propensity model are more common among patients undergoing CABG than among those undergoing PCI. Differences between the two groups in variables such as the incidence of carotid-artery disease (14.0 percent vs. 3.5 percent, respectively) and chronic obstructive pulmonary disease (COPD) (16.4 percent vs. 5.9 percent) have not been previously reported in registries that prospectively assessed risk before revascularization was chosen.2,3 Among patients in the Bypass Angioplasty Revascularization Investigation registry who underwent CABG or PCI, there was a similar likelihood of peripheral vascular disease (15 percent vs. 14 percent) and COPD (5 percent vs. 4 percent). The clinical assessment conducted before CABG is more extensive than that before PCI. Ultrasonography and spirometry of the carotid artery are often performed before CABG but not before PCI. Thus, in the study by Hannan et al., risk-ascertainment bias may have caused the substantial differences between the unadjusted and adjusted mortality rates. Furthermore, the public reporting of risk-adjusted, physician-specific mortality rates for CABG and PCI in New York State strongly influences case selection and the reporting of risk factors.4,5 James D. Flaherty, M.D. Charles J. Davidson, M.D. Northwestern University Feinberg School of Medicine Chicago, IL 60611 ------------------ To the Editor: The study by Hannan et al. comparing bypass surgery with percutaneous revascularization provides new insight into the potential efficacy of these two procedures for patients with multivessel coronary artery disease. In all observational studies, however, a multitude of potential biases can trip up the investigator. In 1991,1 a colleague and I observed marked differences in behavioral changes in patients who had undergone bypass surgery as compared with those who had undergone angioplasty: whereas 55 percent of patients who underwent bypass surgery quit smoking and had not resumed after one year, only 25 percent of patients who underwent angioplasty did so. Changes in smoking status may reflect multiple behavioral changes by patients that are difficult to quantify and that are more profound after surgery than after angioplasty; such changes may also reflect closer physician follow-up and pharmacologic intervention. All these factors might attenuate risk in the surgical group. John R. Crouse III, M.D. Wake Forest University School of Medicine Winston-Salem, NC 27157 ----------------------- To the Editor: By searching a public database, [Ссылки доступны только зарегистрированным пользователям ], for CABG and PCI, we found that the actual number of revascularization procedures performed in New York State from 1996 through 2000 was 75,271 for CABG and 137,798 for PCI. However, the article by Hannan et al. reports the survival for only 37,212 patients who underwent CABG (49 percent of the total) and 22,102 who underwent PCI (16 percent); patients who had prior revascularization, disease of the left main coronary artery, or early acute myocardial infarction were excluded, as were those from out of state. Although the first three exclusions are appropriate for the comparison of mortality rates associated with these two revascularization procedures, the last seems unwarranted, since data on the deaths of out-of-state patients should be accessible. Regardless, the provision of numbers and clinical characteristics of patients who were excluded would assist the clinician in determining the extent and character of selection bias in this cohort analysis. The absence of this information limits the physician's ability to generalize and apply the study results to choices in coronary revascularization. In addition, the low percentage of cases for both procedures included in the study — particularly for the PCI group — needs to be explained. Stanley A. Rubin, M.D. Freny V. Mody, M.D. Department of Veterans Affairs, Greater Los Angeles Los Angeles, CA 90073 --------------------- The authors reply: In response to Drs. Flaherty and Davidson: the reason we used a propensity analysis was to adjust for differences in the prevalence of risk factors, which are usually present in observational studies. If there were no differences, there would be no need for propensity analyses. It is not difficult to accept the finding of increased carotid-artery disease in patients who undergo CABG, given the concordant findings of increased rates of stroke, aortoiliac disease, and femoral or popliteal disease, all of which can be easily ascertained by the cardiologist before stenting and are primarily clinical diagnoses. In addition, the easily identified clinical findings of increased age, diabetes, three-vessel coronary disease, and renal failure support the likelihood of more severe carotid-artery disease in the CABG group. We disagree with the contention that public reporting results in the avoidance of PCI in patients at high risk. However, even if this were true, it would seemingly shift the sicker patients to CABG surgery, which undermines Flaherty and Davidson's earlier claim that ascertainment bias is an explanation for differences in risk factors. Regarding Dr. Crouse's comments: it is possible that differences in the rate of smoking cessation between the CABG and PCI groups could contribute to the superiority of long-term outcomes with CABG. However, if this is the case, we do not regard it as a bias in the study but, rather, as a problem that must be dealt with by improving the outcomes of PCI through closer follow-up. In response to Drs. Rubin and Mody: there were 137,798 patients who underwent PCI and 75,271 who underwent isolated CABG in New York from 1997 through 2000, the years of the study. After records were combined for patients who had multiple procedures and a relatively small number of patients without valid Social Security numbers were excluded, there were 106,551 patients who underwent PCI and 66,250 who underwent isolated CABG. The relatively low percentage of patients with PCI was a result of the elimination from both procedures of those with single-vessel disease, which resulted in 47,470 patients who underwent PCI and 59,441 who underwent CABG. Another 7255 patients who did not receive stents were removed from the PCI group, and another 17,279 with stents in the PCI group and 20,747 in the CABG group were removed because of previous revascularizations, left main coronary artery disease, an acute myocardial infarction within 24 hours before the procedure, or all of these. A relatively small number of patients (834 in the PCI group and 1482 in the CABG group) were excluded because they were from outside New York State. We did not have access to the National Death Index because of resource constraints, but earlier studies of ours have demonstrated that the absence of data from this source does not introduce a bias.
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Искренне, Вадим Валерьевич. |
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#56
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Sorry, Vad. I have poster NEJM abstract before I saw your question . The Lancet article was a review not a study. I will try to look it up... Stupid Lancet does not want to give me access even to abstract without registration (I forgot my login information).
By the way, does the AS clinically look tight? Carotid upstroke is slow? With pressures like that even I would have shortness of breath and chest tightness... How did you calculate the area? Is is planimetry, gradient or continuity? After I started doing 3D for these valves I find that a lot of thimes the gradient gets overestimated secondary to the pressure recovery phenomenon (but never seen that much). Tomorrow I am going for E3 on aortic valve. All day talks about AV... must be Borring... Was normal E/A ratio confirmed by tissue doppler? |
#57
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Тут на днях попытался посчитать сколько у меня в практике пациентов с ИБС для местного регистра. Оказалось, что почти у ВСЕХ. Половинее пациентов после 70 лет была сделана ангиография . Стенты стоят у 15% пациентов после 70 лет. И, главное, умирают только исключительно от рака или деменции. Вывод - плохо работаем, целых 50% пациентов не прокатетеризированы. Будем работать над этим... |
#58
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#59
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Это не шутка. Анализ на СПИД/гепатит/RW по нашим правилам обязателен перед любой операцией. Гепатит+RW делают ВСЕМ пациентам в стационаре. Бред, конечно... Тоже не эвиденс, но... Пациенты после стента мой порог не обивают, а вот получающие таблетки от ИБС - сколько угодно. То АД начинает скакать, то еще чего.
ЗЫ:А атенололом я практически не пользуюсь. Жесткий он какой-то. По мне лучше метопролол сукцинат или небиволол или бисопролол. А апоВ - рутинный анализ? |
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