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實證醫學文獻討論Acaseofchesttightness實證醫學文獻討論Acaseofchesttightn1CasesummaryProfile:An80y/omaleChiefcomplaint:exertionalchesttightnessfor1monthPastmedicalandsurgicalhistory:Patientdeniedofanysignificantpastmedicalhistory,noHTN,DM,dyslipidemia.BPHs/pTURPfor7-8years.CasesummaryProfile:An80y/o2CADriskfactors:HTN-DM-AGE+FHx-SMOKING-MALE+DYSLIPIDEMIA-CADriskfactors:3HISTORYOFPRESENTINGCOMPLAINTIntermittentchestpainandchesttightnessfor1monthChestpainwaseffortrelated,noradiationtolowerjaworneckorshoulder.Lastedfor10minutesandrelievedbyrest,noassociatedsymptoms.VisitedCVOPD1weekbeforeadmission,cardiaceshoshowed1.adequateLVglobalperformance(EF=60%)2.Nochamberdilatation.3.NopericardialeffusionStressandrestTl-201myocardialperfusionSPECTscintiphotosshowedanon-compromisedmyocardialperfusion.ChestCTshowedRMLnodule;TBculturewascollected.AntiplateletwithBokey100mg1#qdwasgivenforpossibleCAD.Admittedelectivelyon8/1forfurtherinvestigation–cardiaccatheterisationHISTORYOFPRESENTINGCOMPLAIN4PhysicalexaminationVitalsigns:T=36°c,P=64/min,R=20/min,BP=147/76mmHgGCS456JVPsupple,estimated7cmH2O;nogoiterChestBSclearHeartsoundsdualnomurmur,regularNopittingedema,goodperipheralpulsePhysicalexaminationVitalsign5InvestigationWBC6200,Hb13.0,PLT176000BUN18,Cr1.0,GOT/GPT19/17GLU92,Na140.7,K4.02T.cholesetrol207,TG117Uricacid5.88EKGnormalsinusrythmInvestigationWBC6200,Hb13.06CardiacangiographyreportClinicaldiagnosis:anginapectorisIndicationforcath:anginapectorisPost-cathdiagnosis:CAD/leftmain+3-V-DEF=54%,Leftmain:50-60%stenosisatdistalleftmainLAD:95%stenosisatLAD-PLCX:95%stenosisatostiumanda90%stenoisatLCX-DRCA:50%stenosisatRCA-MCollateral:noneCardiacangiographyreportClin7CardiacangiographyreportPost-cathDiagnosis:CADleftmain+3VDs/psuccessfuldirectTaxusstentingforLAD-PandLCX-ostiumandPOBAandstentingforLCX-D/TIMIIIICABGisrecommendedforleftmainand3VD.HoweverthefamilyrefusedtheOPduetooldagePCIforLAD-PandLCX-ostiumandLCX-Disrecommended.CardiacangiographyreportPost8ProgressPatientrecoveredwellthenextdayNoactivebleedingorhematomaoverthepuncturesite,withgooddistalpulseandsensation.DischargedwithOPDfollowup.Medication:Bokey100mg1#qdpoGasgel1#tidpoIsosorbide10mg1#tidpoAcetylcystein3pkbidpoPlavix75mg1#qdpoProgressPatientrecoveredwell9Thequestioninmind…..Didherfamily’sdecisiontoperformPTCAinsteadofCABGaffectheroutcome(morbidityandmortality)inthefuture?Thequestioninmind…..Didher10PTCAwithstentsVScoronarybypassPICOT類型:treatmentP:ACUTECORONARYSYNDROMEI:PTCAC:CORONARYBYPASSO:morbidityandmortalityT:TREATMENTPTCAwithstentsVScoronaryb11KeywordsAcutecoronarysyndromeAngiographyCoronarybypassKeywordsAcutecoronarysyndrom12PercutaneoustransluminalcoronaryangioplastywithstentsversuscoronaryarterybypassgraftingforpeoplewithstableanginaoracutecoronarysyndromesCochraneDatabaseofSystemicReviews2005,2007Percutaneoustransluminalcoro13BackgroundCoronaryarterybypassgraft(CABG)isthesurgicaltechniqueusedtotreatcriticalobstructionsincoronaryarteriescausedbyatheroscleroticplaquediseasesaphenousveinsORinternalmammaryarteriesORradialarteryriskofinitialsurgicalmortalityandmorbidityneedforasignificantperiodofconvalescencesurgicalcentresrequirespecialisedstaffandfacilitates.
BackgroundCoronaryarterybyp14PercutaneousCoronaryInterventions(PCI),whichincludePercutaneousTransluminalCoronaryAngioplasty(PTCA),PTCAwithstenting,brachytherapy
andatherectomytechnologieslocalanaesthetic,smallvascularincisionsinthegroinorarm(percutaneously),aslittleas15minutesratesofrestenosis(re-narrowingofthetreatedvessel),20and50%debateonwhethersurgeryorPCIisthemostappropriatetreatmentPercutaneousCoronaryInterven15
Objectives
Toassesstheclinicaleffectsoftheuseofcoronaryarterystents(aspartofPercutaneousTransluminalCoronaryAngioplasty)comparedtoCoronaryArteryBypassGraftsurgeryforthetreatmentofpeoplewithcoronaryarterydisease.
Objectives
Toassessthecli16CriteriaforconsideringstudiesforthisreviewTypesofstudies
RandomisedControlledTrials(RCTs),publishedorunpublisheduseofcoronaryarterystents(inconjunctionwithPercutaneousTransluminalCoronaryAngioplastytechniquescomparedwiththeapplicationofCoronaryArteryBypassGraft(CABG)techniques.
Criteriaforconsideringstudi17Typesofparticipants
AdultsStableanginaorAcuteCoronarySyndrome(includingAMI(STsegmentelevationanddepression,Qwaveandnon-Qwave)andunstableangina).Adultswithsingleormultivesselcoronaryarterydisease.Typesofintervention
Percutaneoustransluminalcoronaryangioplastywithstentsversuscoronaryarterybypassgraftingsurgery.
Typesofparticipants18TypesofoutcomemeasuresClinical
(1)Combinedeventrateoreventfreesurvival(e.g.MajorAdverseCardiacEvents,MajorAdverseCardiacandCerebrovascularEvents,TargetVesselFailureorothercompositesoftheeventslistedbelow);
(2)Death(bothcardiacandnon-cardiacdeath);
(3)AcuteMyocardialInfarction(AMI);
(4)TargetVesselRevascularisation(TVR);
(5)TargetLesionRevascularisation(TLR);
(6)Repeattreatment(PTCA,stentorCABG).
Radiological
Binaryrestenosis(greaterthan50%luminalnarrowingcomparedtodiameteratcompletionoftheprocedure).
Qualityoflife
Wherequalityoflife(QoL)datawereavailablethenatureofthemeasures,timingsofmeasurementandanalyticaltoolusedtoassessQoLwererecordedTypesofoutcomemeasures19Searchmethodsforidentificationofstudies
ThesearchincorporatedanumberofmethodstoidentitycompletedorongoingRCTs:
(1)Searchingofelectronicdatabases;
(2)Handsearchingofrecentjournalsandconferencesinrelevantfields;
(3)Subscriptiontoe-mail-basedinformationnewslettersandregularexaminationofwebpages(includingthosesupportedbystentmanufacturers)relevanttothereviewtopic;
(4)Searchingofbibliographiesofidentifiedsources;
(5)UseofsubmissionstoNationalInstituteforClinicalExcellence(NICE),London,UK.
Searchmethodsforidentificat20DescriptionofstudiesIncludedstudies
NineRCTs,involvingatotalof3519participants,areincludedinthisreview.
.ThreestudiesincludedpatientswithmultivesseldiseaseFiveincludedonlypeoplewithsinglevesseldiseaseoneincludedamixofvesselinvolvementReportingofoutcomesextendedbeyond1yearforARTS;Drenth;ERACIII;SIMA;SOS,butwererestrictedto6monthsforCisowski;Diegeler;Grip.DescriptionofstudiesIncluded21Results1.DeathAlthoughstentsappearedtobefavouredintermsoflowermortality,thesedifferenceswerenotstatisticallydifferentSOSstudyreportseightcancerrelateddeathsinthestentarmTheunevendistributionofnon-cardiacdeathsinSOSwouldappeartocontributetoitappearingtofavourCABGAMI
Nosignificantdifferenceobserved,therewasmoderatetohighdegreeofheterogeneityat36days,12monthsand2yearsResults1.Death22ResultsRevascularisation
RepeatrevascularisationprocedureswherelesscommonintheCABGgroupMultiplevesseldiseasetrialsareincludedintheanalysisat12monthsand2years,resultinginoddsratio0.18andoddsratio0.21singlevesseldiseasestudies,producinganoddsratio0.09
Binaryrestenosis
BinaryrestenosisratewasreducedwithCABG,oddsratio0.29(95%confidenceinterval0.17to0.51)inthethreesinglevesseltrialsat6months;randomeffectsoddsratio0.21ResultsRevascularisation
23Discussion
Themainfindingsofthemeta-analysis:overthedurationoffollow-upavailablefromcurrentRCTs,thereisconsiderablebenefit,intermsofreductioninrepeatrevascularisationrates,withCABGoverstenting.ThesereductionsweresimilarinsingleandmultiplevesseldiseasestudiesDiscussion
Themainfindings24Multivesseldisease
Thefourstudies(ARTS;ERACIII;OCTOSTENT;SOS)includedinthismeta-analysisdemonstratesomedifferencesinmortalitybetweenCABGandstentgroups,howeverthesedidnotreachstatisticalsignificance.BUTconsiderableheterogeneitySimilarly,theratesofAMIwerealsonotsignificantlydifferent.After2yearstheratesofAMItendtofavoursurgery,butagainthisobservationfailedtoreachstatisticalsignificanceAt12monthstherepeatrevascularisationrateswithCABGwereapproximatelyonefifthoftheratesforstentingwithanoddsratio0.18;95%Multivesseldisease
25SinglevesseldiseaseInthefoursinglevesselstudies(Cisowski;Diegeler;Drenth;Grip;SIMA),giventhatmortalityratesintheshorttermweregenerallylowandthesmallnumberoftotalparticipants,thedifferencedidnotreachstatisticalsignificancebutwouldappeartofavourstentingincontrasttothemultivesseldiseasestudiesThe
AMIandcombinedendpointresultscloselymimictherespectiveresultsseeninthemultivesselstudieswithCABGappearingtobebetterthanstentsintermsofcompositeeventrateandrepeatrevascularisationat6monthsSinglevesseldisease26ClinicalInterpretation
Themortalityratetrendseeninthesinglevesselstudiesfavouringstentingwasnotsurprisinggiventhatstentingisperformedunderlocalanaestheticanddoesnotentailthegeneralanaesthesiarequiredforsurgery.Whiletherewouldappeartobenosignificantdifferenceinmyocardialinfarctionratesatanytimepoint,thereisatrendinfavourofCABGinthosestudieswithlongerfollowup1.differentenzymerisethresholdsforthetwotechniques2.graftswhichareinvariablyplaceddistallyonnativevesselsmayoccludewithlessmyocardialimpactthanvesselsopenedproximallybystentprocedures;
3.interventionistsaremoreinclinedtorequestcardiacenzymesonpatientswithpost-PCIchestpainsthensurgeonswhoareinclinedtoacceptadegreeofchestpainfrompatientsduetothenatureoftheoperativeprocedure;4.modestfollow-updurationislikelytocapturestentfailuremorefullyasopposedtograftfailureClinicalInterpretation
Themo27Limitations
1.
patientsenteredintosuchstudieshadtobesuitableforeitherinterventionandwerenottypicalofallpatientsseenbycardiologistsorcardiothoracicsurgeons2.practicechangedovertheperiodsofthetrialse.g.GlycoproteinIIB/IIIAhasinmorerecentpracticereducedearlystentthrombosisandtheamountofIschaemicenzymereleaseperiprocedurally3.wecouldnotconsidersubgroupsofpatientsinthecurrentmeta-analysis4.analysisof'other'adverseevents(forexample,neurologicalcomplications)werenotcompletedasthesewerenotcommonlyorconsistentlyreported.Limitations
1.patientsentere28Authors'conclusions
Implicationsforpractice
Considerablymoredataisneededtomakefirmlongtermconclusionsontheimplicationsforpractice,butintheshorttomediumterm,CABGhasfarlessrepeatrevascularisationproceduresthanPTCAwithstentscurrentlyincommonclinicaluse.
ImplicationsforresearchRe-evaluationofthesetechnologieswillberequiredasthedevelopmentofnewsurgicaltechniquesandstentdesignsisongoingFuturetrialsshouldrecruitmorerealisticpatientgroupings,asthepopulationselectedforinclusioninthecurrentreviewwerepronetobiasselectiontendedtofocusonpatientswithgenerallylessco-morbiditiesandwithbetterleftventricularfunctionthantheoverallpopulationpresentingforrevascularisationintherealworldsettingAuthors'conclusions
Implicati29實證醫學文獻討論Acaseofchesttightness實證醫學文獻討論Acaseofchesttightn30CasesummaryProfile:An80y/omaleChiefcomplaint:exertionalchesttightnessfor1monthPastmedicalandsurgicalhistory:Patientdeniedofanysignificantpastmedicalhistory,noHTN,DM,dyslipidemia.BPHs/pTURPfor7-8years.CasesummaryProfile:An80y/o31CADriskfactors:HTN-DM-AGE+FHx-SMOKING-MALE+DYSLIPIDEMIA-CADriskfactors:32HISTORYOFPRESENTINGCOMPLAINTIntermittentchestpainandchesttightnessfor1monthChestpainwaseffortrelated,noradiationtolowerjaworneckorshoulder.Lastedfor10minutesandrelievedbyrest,noassociatedsymptoms.VisitedCVOPD1weekbeforeadmission,cardiaceshoshowed1.adequateLVglobalperformance(EF=60%)2.Nochamberdilatation.3.NopericardialeffusionStressandrestTl-201myocardialperfusionSPECTscintiphotosshowedanon-compromisedmyocardialperfusion.ChestCTshowedRMLnodule;TBculturewascollected.AntiplateletwithBokey100mg1#qdwasgivenforpossibleCAD.Admittedelectivelyon8/1forfurtherinvestigation–cardiaccatheterisationHISTORYOFPRESENTINGCOMPLAIN33PhysicalexaminationVitalsigns:T=36°c,P=64/min,R=20/min,BP=147/76mmHgGCS456JVPsupple,estimated7cmH2O;nogoiterChestBSclearHeartsoundsdualnomurmur,regularNopittingedema,goodperipheralpulsePhysicalexaminationVitalsign34InvestigationWBC6200,Hb13.0,PLT176000BUN18,Cr1.0,GOT/GPT19/17GLU92,Na140.7,K4.02T.cholesetrol207,TG117Uricacid5.88EKGnormalsinusrythmInvestigationWBC6200,Hb13.035CardiacangiographyreportClinicaldiagnosis:anginapectorisIndicationforcath:anginapectorisPost-cathdiagnosis:CAD/leftmain+3-V-DEF=54%,Leftmain:50-60%stenosisatdistalleftmainLAD:95%stenosisatLAD-PLCX:95%stenosisatostiumanda90%stenoisatLCX-DRCA:50%stenosisatRCA-MCollateral:noneCardiacangiographyreportClin36CardiacangiographyreportPost-cathDiagnosis:CADleftmain+3VDs/psuccessfuldirectTaxusstentingforLAD-PandLCX-ostiumandPOBAandstentingforLCX-D/TIMIIIICABGisrecommendedforleftmainand3VD.HoweverthefamilyrefusedtheOPduetooldagePCIforLAD-PandLCX-ostiumandLCX-Disrecommended.CardiacangiographyreportPost37ProgressPatientrecoveredwellthenextdayNoactivebleedingorhematomaoverthepuncturesite,withgooddistalpulseandsensation.DischargedwithOPDfollowup.Medication:Bokey100mg1#qdpoGasgel1#tidpoIsosorbide10mg1#tidpoAcetylcystein3pkbidpoPlavix75mg1#qdpoProgressPatientrecoveredwell38Thequestioninmind…..Didherfamily’sdecisiontoperformPTCAinsteadofCABGaffectheroutcome(morbidityandmortality)inthefuture?Thequestioninmind…..Didher39PTCAwithstentsVScoronarybypassPICOT類型:treatmentP:ACUTECORONARYSYNDROMEI:PTCAC:CORONARYBYPASSO:morbidityandmortalityT:TREATMENTPTCAwithstentsVScoronaryb40KeywordsAcutecoronarysyndromeAngiographyCoronarybypassKeywordsAcutecoronarysyndrom41PercutaneoustransluminalcoronaryangioplastywithstentsversuscoronaryarterybypassgraftingforpeoplewithstableanginaoracutecoronarysyndromesCochraneDatabaseofSystemicReviews2005,2007Percutaneoustransluminalcoro42BackgroundCoronaryarterybypassgraft(CABG)isthesurgicaltechniqueusedtotreatcriticalobstructionsincoronaryarteriescausedbyatheroscleroticplaquediseasesaphenousveinsORinternalmammaryarteriesORradialarteryriskofinitialsurgicalmortalityandmorbidityneedforasignificantperiodofconvalescencesurgicalcentresrequirespecialisedstaffandfacilitates.
BackgroundCoronaryarterybyp43PercutaneousCoronaryInterventions(PCI),whichincludePercutaneousTransluminalCoronaryAngioplasty(PTCA),PTCAwithstenting,brachytherapy
andatherectomytechnologieslocalanaesthetic,smallvascularincisionsinthegroinorarm(percutaneously),aslittleas15minutesratesofrestenosis(re-narrowingofthetreatedvessel),20and50%debateonwhethersurgeryorPCIisthemostappropriatetreatmentPercutaneousCoronaryInterven44
Objectives
Toassesstheclinicaleffectsoftheuseofcoronaryarterystents(aspartofPercutaneousTransluminalCoronaryAngioplasty)comparedtoCoronaryArteryBypassGraftsurgeryforthetreatmentofpeoplewithcoronaryarterydisease.
Objectives
Toassessthecli45CriteriaforconsideringstudiesforthisreviewTypesofstudies
RandomisedControlledTrials(RCTs),publishedorunpublisheduseofcoronaryarterystents(inconjunctionwithPercutaneousTransluminalCoronaryAngioplastytechniquescomparedwiththeapplicationofCoronaryArteryBypassGraft(CABG)techniques.
Criteriaforconsideringstudi46Typesofparticipants
AdultsStableanginaorAcuteCoronarySyndrome(includingAMI(STsegmentelevationanddepression,Qwaveandnon-Qwave)andunstableangina).Adultswithsingleormultivesselcoronaryarterydisease.Typesofintervention
Percutaneoustransluminalcoronaryangioplastywithstentsversuscoronaryarterybypassgraftingsurgery.
Typesofparticipants47TypesofoutcomemeasuresClinical
(1)Combinedeventrateoreventfreesurvival(e.g.MajorAdverseCardiacEvents,MajorAdverseCardiacandCerebrovascularEvents,TargetVesselFailureorothercompositesoftheeventslistedbelow);
(2)Death(bothcardiacandnon-cardiacdeath);
(3)AcuteMyocardialInfarction(AMI);
(4)TargetVesselRevascularisation(TVR);
(5)TargetLesionRevascularisation(TLR);
(6)Repeattreatment(PTCA,stentorCABG).
Radiological
Binaryrestenosis(greaterthan50%luminalnarrowingcomparedtodiameteratcompletionoftheprocedure).
Qualityoflife
Wherequalityoflife(QoL)datawereavailablethenatureofthemeasures,timingsofmeasurementandanalyticaltoolusedtoassessQoLwererecordedTypesofoutcomemeasures48Searchmethodsforidentificationofstudies
ThesearchincorporatedanumberofmethodstoidentitycompletedorongoingRCTs:
(1)Searchingofelectronicdatabases;
(2)Handsearchingofrecentjournalsandconferencesinrelevantfields;
(3)Subscriptiontoe-mail-basedinformationnewslettersandregularexaminationofwebpages(includingthosesupportedbystentmanufacturers)relevanttothereviewtopic;
(4)Searchingofbibliographiesofidentifiedsources;
(5)UseofsubmissionstoNationalInstituteforClinicalExcellence(NICE),London,UK.
Searchmethodsforidentificat49DescriptionofstudiesIncludedstudies
NineRCTs,involvingatotalof3519participants,areincludedinthisreview.
.ThreestudiesincludedpatientswithmultivesseldiseaseFiveincludedonlypeoplewithsinglevesseldiseaseoneincludedamixofvesselinvolvementReportingofoutcomesextendedbeyond1yearforARTS;Drenth;ERACIII;SIMA;SOS,butwererestrictedto6monthsforCisowski;Diegeler;Grip.DescriptionofstudiesIncluded50Results1.DeathAlthoughstentsappearedtobefavouredintermsoflowermortality,thesedifferenceswerenotstatisticallydifferentSOSstudyreportseightcancerrelateddeathsinthestentarmTheunevendistributionofnon-cardiacdeathsinSOSwouldappeartocontributetoitappearingtofavourCABGAMI
Nosignificantdifferenceobserved,therewasmoderatetohighdegreeofheterogeneityat36days,12monthsand2yearsResults1.Death51ResultsRevascularisation
RepeatrevascularisationprocedureswherelesscommonintheCABGgroupMultiplevesseldiseasetrialsareincludedintheanalysisat12monthsand2years,resultinginoddsratio0.18andoddsratio0.21singlevesseldiseasestudies,producinganoddsratio0.09
Binaryrestenosis
BinaryrestenosisratewasreducedwithCABG,oddsratio0.29(95%confidenceinterval0.17to0.51)inthethreesinglevesseltrialsat6months;randomeffectsoddsratio0.21ResultsRevascularisation
52Discussion
Themainfindingsofthemeta-analysis:overthedurationoffollow-upavailablefromcurrentRCTs,thereisconsiderablebenefit,intermsofreductioninrepeatrevascularisationrates,withCABGoverstenting.ThesereductionsweresimilarinsingleandmultiplevesseldiseasestudiesDiscussion
Themainfindings53Multivesseldisease
Thefourstudies(ARTS;ERACIII;OCTOSTENT;SOS)includedinthismeta-analysisdemonstratesomedifferencesinmortalitybetweenCABGandstentgroups,howeverthesedidnotreachstatisticalsignificance.BUTconsiderableheterogeneitySimilarly,theratesofAMIwerealsonotsignificantlydifferent.After2yearstheratesofAMItendtofavoursurgery,butagainthisobservationfailedtoreachstatisticalsignificanceAt12monthstherepeatrevascularisationrateswithCABGwereapproximatelyonefifthoftheratesforstentingwithanoddsratio0.18;95%Multivesseldisease
54SinglevesseldiseaseInthefoursinglevesselstudies(Cisowski;Diegeler;Drenth;Grip;SIMA),giventhatmortalityratesintheshorttermweregenerallylowandthesmallnumberoftotalparticipants,thedifferencedidnotreachstatisticalsignificancebutwouldappeartofavourstentingincontrasttothemultivesseldiseasestudiesThe
AMIandcombinedendpointresultscloselymimictherespectiveresultsseeninthemultivesselstudieswithCABGappearingtobebetterthanstentsintermsofcompositeeventrateandrepeatrevascularisationat6monthsSinglevesseldisease55ClinicalInterpretation
Themortalityrat
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