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1.  Risks and benefits of coronary angioplasty: the patients perspective: a preliminary study. 
Quality in Health Care  1997;6(3):131-139.
OBJECTIVES: To describe what cardiac patients in Northern Ireland understand to be the benefits of coronary angioplasty and assess the extent to which they have been able to make informed choices about their treatment. DESIGN: An interview based questionnaire survey completed after the patients had undergone coronary angiography, within hours of treatment counselling. SUBJECTS: 150 patients consecutively recruited from two regional cardiology centres in Belfast, Northern Ireland. MAIN OUTCOME MEASURES: The perceived complication rate and the perceived gain in life expectancy from coronary angioplasty. RESULTS: Although most subjects had asked the consultant questions, 70% (n = 104) thought that they contributed negligibly or not at all to the treatment decision. Although 75% (n = 112) recalled discussing the complication rate from the procedure, only 27% accurately estimated this rate (as between 0.5 and 1.5%). Eighty eight per cent (n = 131) thought that their mortality risks would be substantially or greatly reduced by having the procedure. The patients anticipated a gain in life expectancy of some 10 years (median) and this was significantly in excess of the potential gain in life expectancy which dietary prudence to lower blood cholesterol, not smoking, and taking more exercise might produce (median 5 years respectively; P < 0.0001, Wilcoxon matched pairs signed rank test). CONCLUSIONS: Patients vastly overrate the capacity of angioplasty to control their disease: angioplasty is seen as more effective than risk factor modification.
PMCID: PMC1055474  PMID: 10173770
2.  Impact of smoking on early clinical outcomes in patients undergoing coronary artery bypass grafting surgery 
To evaluate the impact of persistent smoking versus smoking cessation over one month prior to surgery on early clinical outcomes in Chinese patients undergoing isolated coronary artery bypass grafting (CABG) surgery in a retrospective study.
The peri-operative data of consecutive well-documented patients undergoing isolated CABG surgery from January 2007 to December 2013 were investigated and retrospectively analyzed. All included patients were divided into either a non-smoking group or a smoking group according to preoperative smoking records. Furthermore, smokers were divided into either a former smoking subgroup (smokers with smoking cessation over 1 month before surgery) or a current smoking subgroup (persistent smokers).
A total of 3730 consecutive patients (3207 male patients and mean 63.6 ± 9.5 years) undergoing isolated CABG surgery were analyzed. Persistent smokers had significantly higher incidence of postoperative pulmonary complications as compared to non-smokers (7.8% vs. 4.5%, p = 0.0002). No significantly differences in both surgical mortality and major postoperative morbidities between smokers with smoking cessation over 1 month before surgery and non-smokers were found. In multiple logistic regression analysis, the risk of postoperative pulmonary complications in persistent smokers was 2.41 times than that in non-smokers, whereas the risk of postoperative pulmonary complications in smokers with smoking cessation over 1 month before surgery was similar to non-smokers.
Persistent smokers had a higher incidence of pulmonary complications following CABG as compared to non-smokers. Smoking cessation more than 1 month before surgery was expected to reduce early major morbidities following CABG surgery.
PMCID: PMC4322818  PMID: 25654995
Persistent smoking; Smoking cessation; Early clinical outcomes; Coronary artery bypass grafting surgery
3.  Personalized Prediction of Lifetime Benefits with Statin Therapy for Asymptomatic Individuals: A Modeling Study 
PLoS Medicine  2012;9(12):e1001361.
In a modeling study conducted by Myriam Hunink and colleagues, a population-based cohort from Rotterdam is used to predict the possible lifetime benefits of statin therapy, on a personalized basis.
Physicians need to inform asymptomatic individuals about personalized outcomes of statin therapy for primary prevention of cardiovascular disease (CVD). However, current prediction models focus on short-term outcomes and ignore the competing risk of death due to other causes. We aimed to predict the potential lifetime benefits with statin therapy, taking into account competing risks.
Methods and Findings
A microsimulation model based on 5-y follow-up data from the Rotterdam Study, a population-based cohort of individuals aged 55 y and older living in the Ommoord district of Rotterdam, the Netherlands, was used to estimate lifetime outcomes with and without statin therapy. The model was validated in-sample using 10-y follow-up data. We used baseline variables and model output to construct (1) a web-based calculator for gains in total and CVD-free life expectancy and (2) color charts for comparing these gains to the Systematic Coronary Risk Evaluation (SCORE) charts. In 2,428 participants (mean age 67.7 y, 35.5% men), statin therapy increased total life expectancy by 0.3 y (SD 0.2) and CVD-free life expectancy by 0.7 y (SD 0.4). Age, sex, smoking, blood pressure, hypertension, lipids, diabetes, glucose, body mass index, waist-to-hip ratio, and creatinine were included in the calculator. Gains in total and CVD-free life expectancy increased with blood pressure, unfavorable lipid levels, and body mass index after multivariable adjustment. Gains decreased considerably with advancing age, while SCORE 10-y CVD mortality risk increased with age. Twenty-five percent of participants with a low SCORE risk achieved equal or larger gains in CVD-free life expectancy than the median gain in participants with a high SCORE risk.
We developed tools to predict personalized increases in total and CVD-free life expectancy with statin therapy. The predicted gains we found are small. If the underlying model is validated in an independent cohort, the tools may be useful in discussing with patients their individual outcomes with statin therapy.
Please see later in the article for the Editors' Summary
Editors' Summary
Cardiovascular disease (CVD) affects the heart and/or the blood vessels and is a major cause of illness and death worldwide. In the US, for example, coronary heart disease—a CVD in which narrowing of the heart's blood vessels by fatty deposits slows the blood supply to the heart and may eventually cause a heart attack—is the leading cause of death, and stroke—a CVD in which the brain's blood supply is interrupted—is the fourth leading cause of death. Established risk factors for CVD include smoking, high blood pressure, obesity, and high blood levels of a fat called low-density lipoprotein (“bad cholesterol”). Because many of these risk factors can be modified by lifestyle changes and by drugs, CVD can be prevented. Thus, physicians can assess a healthy individual's risk of developing CVD using a CVD prediction model (equations that take into account the CVD risk factors to which the individual is exposed) and can then recommend lifestyle changes and medications to reduce that individual's CVD risk.
Why Was This Study Done?
Current guidelines recommend that asymptomatic (healthy) individuals whose likely CVD risk is high should be encouraged to take statins—cholesterol-lowering drugs—as a preventative measure. Statins help to prevent CVD in healthy people with a high predicted risk of CVD, but, like all medicines, they have some unwanted side effects, so it is important that physicians can communicate both the benefits and drawbacks of statins to their patients in a way that allows them to make an informed decision about taking these drugs. Telling a patient that statins will reduce his or her short-term risk of CVD is not always helpful—patients really need to know the potential lifetime benefits of statin therapy. That is, they need to know how much longer they might live if they take statins. Here, the researchers use a mathematical model to predict the personalized lifetime benefits (increased total and CVD-free life expectancy) of statin therapy for individuals without a history of CVD.
What Did the Researchers Do and Find?
The researchers used the Rotterdam Ischemic Heart Disease & Stroke Computer Simulation (RISC) model, which simulates the life courses of individuals through six health states, from well through to CVD or non-CVD death, to estimate lifetime outcomes with and without statin therapy in a population of healthy elderly individuals. They then used these outcomes and information on baseline risk factors to develop a web-based calculator suitable for personalized prediction of the lifetime benefits of statins in routine clinical practice. The model estimated that statin therapy increases average life expectancy in the study population by 0.3 years and average CVD-free life expectancy by 0.7 years. The gains in total and CVD-free life expectancy associated with statin therapy increased with blood pressure, unfavorable cholesterol levels, and body mass index (an indicator of body fat) but decreased with age. Notably, the web-based calculator predicted that some individuals with a low ten-year CVD risk might achieve a similar or larger gain in CVD-free life expectancy with statin therapy than some individuals with a high ten-year risk. So, for example, both a 55-year-old non-smoking woman with a ten-year CVD mortality risk of 2% (a two in a hundred chance of dying of CVD within ten years) and a 65-year-old male smoker with a ten-year CVD mortality risk of 15% might both gain one year of CVD-free life expectancy with statin therapy.
What Do These Findings Mean?
These findings suggest that statin therapy can lead on average to small gains in total life expectancy and slightly larger gains in CVD-free life expectancy among healthy individuals, and show that life expectancy benefits can be predicted using an individual's risk factor profile. The accuracy and generalizability of these findings is limited by the assumptions included in the model (in particular, the model did not allow for the known side effects of statin therapy) and by the data fed into it—importantly, the risk prediction model needs to be validated using an independent dataset. If future research confirms the findings of this study, the researchers' web-based calculator could provide complementary information to the currently recommended ten-year CVD mortality risk assessment. Whether communication of personalized outcomes will ultimately result in better clinical outcomes remains to be seen, however, because patients may be less likely to choose statin therapy when provided with more information about its likely benefits.
Additional Information
Please access these websites via the online version of this summary at
The web-based calculator for personalized prediction of lifetime benefits with statin therapy is available (after agreement to software license)
The American Heart Association provides information about many types of cardiovascular disease for patients, carers, and professionals, including information about drug therapy for cholesterol and a heart attack risk calculator
The UK National Health Service Choices website provides information about cardiovascular disease and about statins
Information is available from the British Heart Foundation on heart disease and keeping the heart healthy; information is also available on statins, including personal stories about deciding to take statins
The US National Heart Lung and Blood Institute provides information on a wide range of cardiovascular diseases
The European Society of Cardiology's cardiovascular disease risk assessment model (SCORE) is available
MedlinePlus provides links to many other sources of information on heart diseases, vascular diseases, stroke, and statins (in English and Spanish)
PMCID: PMC3531501  PMID: 23300388
4.  Cigarette smoking and random serum cholesterol levels in a Northern Ireland general practice population of 18- to 20-year-old students and non-students. 
BACKGROUND: Coronary heart disease is the commonest cause of death in Northern Ireland, but few data exist on the incidence of risk factors in young adult students and non-students. AIM: To gather data on the prevalence of cigarette smoking and raised serum total cholesterol in a population of 18- to 20-year-old students and non-students. METHOD: Subjects were patients are Mountsandel Surgery, Coleraine on 1 January 1989 and were 18-20 years of age inclusive on that date. Subjects were interviewed by a research nurse who recorded socio-demographic data, tobacco consumption and random serum total cholesterol. Smoking status validation was by serum thiocyanate and expired air carbonmonoxide estimations. RESULTS: Out of the 832 subjects surveyed, 570 were students and 262 were non-students. Cigarettes were smoked by 239 (28.7%) subjects, and a significantly greater proportion of non-students compared with students were smokers (36.6% and 25.1%, respectively; P < 0.001). The proportion of males compared with females who smoked cigarettes was not significantly different, but males smoked significantly more cigarettes per day than females (14 and 11 cigarettes, respectively; P = 0.005). The average age for commencing regular cigarette smoking was 15.3 years, and 49.9% of smokers had started regular smoking by the age of 16 years. A greater proportion of non-students (65.7%) compared with students (39.2%) had started smoking before the age of 16 years. Out of those sampled, 156 (19.2%) had random serum cholesterol levels above 5.2 mmol l-1. Mean total cholesterol for non-students was significantly higher than for students (4.61 and 4.45 mmol l-1, respectively; P = 0.01) and increased significantly with increasing age (P = 0.03). Three subjects recorded cholesterol levels above 7.8 mmol l-1. CONCLUSION: Cigarette smoking and raised serum total cholesterol were prevalent among an apparently healthy population of students and non-students. These young adults may be significantly more at risk from subsequent coronary heart disease than was previously suspected.
PMCID: PMC1239821  PMID: 8978113
5.  Unrecognized Non-Q-Wave Myocardial Infarction: Prevalence and Prognostic Significance in Patients with Suspected Coronary Disease 
PLoS Medicine  2009;6(4):e1000057.
Using delayed-enhancement cardiovascular magnetic resonance, Han Kim and colleagues show that in patients with suspected coronary disease the prevalence of unrecognized myocardial infarction without Q-waves is more than 3-fold higher than that with Q-waves and predicts subsequent mortality.
Unrecognized myocardial infarction (UMI) is known to constitute a substantial portion of potentially lethal coronary heart disease. However, the diagnosis of UMI is based on the appearance of incidental Q-waves on 12-lead electrocardiography. Thus, the syndrome of non-Q-wave UMI has not been investigated. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can identify MI, even when small, subendocardial, or without associated Q-waves. The aim of this study was to investigate the prevalence and prognosis associated with non-Q-wave UMI identified by DE-CMR.
Methods and Findings
We conducted a prospective study of 185 patients with suspected coronary disease and without history of clinical myocardial infarction who were scheduled for invasive coronary angiography. Q-wave UMI was determined by electrocardiography (Minnesota Code). Non-Q-wave UMI was identified by DE-CMR in the absence of electrocardiographic Q-waves. Patients were followed to determine the prognostic significance of non-Q-wave UMI. The primary endpoint was all-cause mortality. The prevalence of non-Q-wave UMI was 27% (50/185), compared with 8% (15/185) for Q-wave UMI. Patients with non-Q-wave UMI were older, were more likely to have diabetes, and had higher Framingham risk than those without MI, but were similar to those with Q-wave UMI. Infarct size in non-Q-wave UMI was modest (8%±7% of left ventricular mass), and left ventricular ejection fraction (LVEF) by cine-CMR was usually preserved (52%±18%). The prevalence of non-Q-wave UMI increased with the extent and severity of coronary disease on angiography (p<0.0001 for both). Over 2.2 y (interquartile range 1.8–2.7), 16 deaths occurred: 13 in non-Q-wave UMI patients (26%), one in Q-wave UMI (7%), and two in patients without MI (2%). Multivariable analysis including New York Heart Association class and LVEF demonstrated that non-Q-wave UMI was an independent predictor of all-cause mortality (hazard ratio [HR] 11.4, 95% confidence interval [CI] 2.5–51.1) and cardiac mortality (HR 17.4, 95% CI 2.2–137.4).
In patients with suspected coronary disease, the prevalence of non-Q-wave UMI is more than 3-fold higher than Q-wave UMI. The presence of non-Q-wave UMI predicts subsequent mortality, and is incremental to LVEF.
Trial Registration NCT00493168
Editors' Summary
Coronary artery disease (CAD; also called coronary heart disease) is the leading cause of death among adults in developed countries. In the USA alone, it kills nearly half a million people every year. CAD is caused by narrowing of the coronary arteries, the blood vessels that supply the heart with oxygen and nutrients. With age, fatty deposits (atherosclerotic plaques) coat the walls of these arteries and restrict the heart's blood supply, which causes the characteristic symptoms of CAD—angina (chest pains that are usually relieved by rest) and shortness of breath. In addition, if a plaque breaks off the wall of a coronary artery, it can completely block that artery and kill part of the heart, which causes a potentially fatal heart attack (doctors call this a myocardial infarction or MI). Heart attacks are often characterized by long-lasting chest pain that is not relieved by rest. Risk factors for CAD include smoking, high blood pressure, high blood levels of cholesterol (a type of fat), and being overweight. Treatments for the condition include lifestyle changes (for example, losing weight), and medications that lower blood pressure and blood cholesterol. The narrowed arteries can also be widened using a device called a stent or surgically bypassed.
Why Was This Study Done?
Not everyone who has a heart attack has chest pain. In fact, some studies suggest that 40–60% of MIs have no obvious symptoms. It is important, however, that these “unrecognized” MIs (UMIs) are diagnosed because they have death rates similar to those of MIs with clinical symptoms and need to be treated in a similar way. Traditionally, UMIs have been diagnosed using an electrocardiogram (ECG). When the heart beats, it generates small electric waves that can be picked up by electrodes attached to the skin. The pattern of these waves (the ECG) provides information about the heart's health. Alterations in the ECG, leading to so-called Q-waves, indicate that a UMI has occurred some time previously. However, not all UMIs result in Q-waves. In this study, the researchers use a recently developed technique—delayed enhancement cardiovascular magnetic resonance (DE-CMR), which can detect heart damage even in patients whose Q-waves are absent—to measure the prevalence (the fraction of a population that has a disorder) of non-Q-wave UMI. The researchers also investigate whether non-Q-wave UMI increases the risk of death.
What Did the Researchers Do and Find?
The researchers used electrocardiography and DE-CMR to look for Q-wave and non-Q-wave UMI, respectively, in 185 patients with suspected CAD but no history of MI. They then followed the patients for 2 years to discover whether a diagnosis of non-Q-wave UMI predicted their likelihood of dying from any cause or from a heart problem. 27% of the patients had evidence of non-Q-wave UMI whereas only 8% had evidence of Q-wave UMI. Patients with non-Q-wave UMI tended to have only a small area of heart damage and, consistent with this limited damage, their hearts pumped near-normal volumes of blood. Examination of the patients' arteries with a technique called coronary angiography indicated that the patients with widespread and/or severe CAD had a higher prevalence of non-Q-wave UMI than those with limited CAD. Finally, patients with non-Q-wave UMI had an 11-fold higher risk of death from any cause and a 17-fold higher risk of death from a heart problem than patients without UMI.
What Do These Findings Mean?
These findings indicate that non-Q-wave UMI occurs more than 3-times as often in patients with suspected CAD than Q-wave UMI and that patients with non-Q-wave UMI have a much greater risk of dying than patients without MI. Thus, if all cases of UMI—both Q-wave and non-Q-wave UMI—could be identified, it might be possible to reduce the number of deaths among people with CAD. However, before any recommendations are made to include DE-CMR in the routine examination of people with suspected CAD to achieve this aim, additional studies must be undertaken to confirm that non-Q-wave UMI is a common feature of CAD and to test whether the early diagnosis of non-Q-wave UMI does extend the life expectancy of people with CAD.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Clara Chow
The MedlinePlus encyclopedia has pages on coronary heart disease, heart attacks, and electrocardiograms (in English and Spanish). MedlinePlus also provides links to further information on all aspects of heart disease (in English and Spanish)
Information is available from the US National Heart Lung and Blood Institute on coronary heart disease
The UK National Health Service Choices website also provides information about coronary heart disease (in several languages).
The Nobel Foundation provides an interactive electrocardiogram game
PMCID: PMC2661255  PMID: 19381280
6.  Comparative study of risk factors in patients undergoing coronary or femoropopliteal artery bypass grafting. 
British Heart Journal  1994;72(6):542-547.
OBJECTIVE--To compare risk factors in two populations of patients with advanced atheroma requiring coronary or femoropopliteal artery bypass grafting to try to account for the different localisations of vascular disease. DESIGN--Cross sectional epidemiological study. SETTING--Cardiovascular surgery department of a university hospital. SUBJECTS--464 men (mean age 59.25 (SD 8.57) years) undergoing coronary artery bypass grafting; 74 men (mean age 56.28 (13.3) years) undergoing femoropopliteal artery bypass grafting; and 204 control men (mean age 45.07 (6.59) years) who had been recruited in a preventive medicine department. INTERVENTIONS--Blood samples were drawn 24 hours before surgery. METHODS--Lipid and lipoprotein concentrations were measured for each patient and with adjustment for age were compared by analysis of covariance. The main risk factors (smoking, arterial hypertension, obesity, and diabetes) were determined by a standardised history, and the chi 2 test was used to compare the results in the two patient groups. Pairwise comparisons between the three populations were performed by logistic discriminant analysis. RESULTS--Both patient groups showed a significant rise in triglyceride concentration and in the ratio of total cholesterol to high density lipoprotein cholesterol (R1) and a drop in apolipoprotein AI and high density lipoprotein cholesterol concentrations. Disturbances were greater in patients undergoing coronary artery bypass grafting than in those undergoing femoropopliteal artery bypass grafting for the R1 ratio, apolipoprotein B concentration, and the ratio of apolipoprotein AI to apolipoprotein B (R2). A higher proportion of smokers was found in the femoropopliteal bypass group than in the coronary bypass group, whereas were often obese. Logistic discriminant analysis with adjustment for age and with the coronary bypass as the reference group selected three factors: smoking, the R2 ratio, and obesity. CONCLUSION--Disturbances in lipid and apoprotein concentrations varied with respect to bypass site. Other risk factors played a part in accelerating the atherogenic process, especially smoking in patients undergoing femoropopliteal artery bypass grafting and, to a lesser degree, obesity in patients undergoing coronary artery bypass grafting.
PMCID: PMC1025640  PMID: 7857737
7.  Yoga based cardiac rehabilitation after coronary artery bypass surgery: One-year results on LVEF, lipid profile and psychological states – A randomized controlled study 
Indian Heart Journal  2014;66(5):490-502.
To compare the long term effects of yoga based cardiac rehabilitation program with only physiotherapy based program as an add-on to conventional rehabilitation after coronary artery bypass grafting (CABG) on risk factors.
In this single blind prospective randomized parallel two armed active control study, 1026 patients posted for CABG at Narayana Hrudayalaya Institute of Cardiac Sciences, Bengaluru (India) were screened. Of these, 250 male participants (35–65 years) who satisfied the selection criteria and consented were randomized into two groups.
Within and between group comparisons were done at three points of follow up (i.e. 6th week, 6th month, and 12th month) by using Wilcoxon's signed ranks test and Mann Whitney U test respectively.
Yoga group had significantly (p = 0.001, Mann Whitney) better improvement in LVEF than control group in those with abnormal baseline EF (<53%) after 1 year. There was a better reduction in BMI in the yoga group (p = 0.038, between groups) in those with high baseline BMI (≥23) after 12 months. Yoga group showed significant (p = 0.008, Wilcoxon's) reduction in blood glucose at one year in those with high baseline FBS ≥110 mg/dl. There was significantly better improvement in yoga than the control group in HDL (p = 0.003), LDL (p = 0.01) and VLDL (p = 0.03) in those with abnormal baseline values. There was significantly better improvement (p = 0.02, between groups) in positive affect in yoga group. Within Yoga group, there was significant decrease in perceived stress (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), and negative affect (p = 0.03) while in the control group there was reduction (p = 0.003) only in scores on anxiety.
Addition of yoga based relaxation to conventional post-CABG cardiac rehabilitation helps in better management of risk factors in those with abnormal baseline values and may help in preventing recurrence.
PMCID: PMC4223225  PMID: 25443601
Yoga; Physiotherapy; Cardiac rehabilitation; LVEF; Risk factors
8.  Effect of cigarette smoking on quality of life in small cell lung cancer patients 
European Journal of Cancer  2012;48(11):1593-1601.
Continued cigarette smoking after small cell lung cancer (SCLC) diagnosis has been shown to shorten patients’ survival, but little is known about the impact of smoking and cessation on quality of life (QOL) profile (e.g., overall QOL, pain, fatigue, cough, dyspnea, appetite change, and performance status) in SCLC survivors (who survived at least 6 months post initial diagnosis). In this study, we sought to evaluate the relationship between cigarette smoking and QOL profiles in SCLC patients.
A total of 223 survivors were classified into five groups: never smokers, former smokers (quit more than 1 year prior to diagnosis), recent quitters (quit within 1 year surrounding diagnosis), late quitters (quit after 1 year post diagnosis) and never quitters. One hundred and sixty-eight of these survivors were matched with 334 lung-cancer-free controls on age, gender, and smoking status for comparative analysis. QOL scales were scored from 0 (worse) to 100 (best). Conditional logistic regression, linear mixed-effect models, and Wilcoxon signed rank tests were used.
SCLC survivors consistently showed a significant deficit in QOL profile; e.g., mean overall QOL in patients was 17.5 points worse than the controls (p < 0.0001). Among all smokers, former smokers reported the best QOL profile, while late or never quitters reported the worst. The recent quitters showed an improving trend in QOL profile and lower percent of reduced appetite (an average of 43%) compared to the late or never quitters (58%).
Our study confirmed the negative impact of smoking on SCLC survivors’ QOL and found that smoking cessation surrounding the time of diagnosis could improve overall QOL and symptoms. The findings of this study provide evidence for oncologists to recommend smoking cessation to their SCLC patients.
PMCID: PMC3404819  PMID: 22244802
Quality of life; Cigarette smoking; Small cell lung cancer; Symptom burden
9.  Impact of Cigarette Smoking on Outcome of Hepatocellular Carcinoma after Surgery in Patients with Hepatitis B 
PLoS ONE  2014;9(1):e85077.
Background and Objectives
Cigarette smoking is a potential risk factor for hepatocellular carcinoma (HCC) initiation, partially through interaction with hepatitis B virus (HBV). We examined the hypothesis that cigarette smoking might be associated with HBV-related HCC recurrence and patient survival after curative surgery.
Patients and Methods
Data of 302 patients with HBV infection who had undergone curative resection for HCC were prospectively collected from 2008 to 2011. Smoking status and smoking quantity (pack-years, PY) were asked at admission. Factors affecting recurrence-free survival (RFS) were examined. RFS and liver-specific mortality (LSM) stratified by risk factors were compared with log-rank test.
109 were current smokers. Current smokers were not different from non-smokers in tumor burden and surgical procedure. Univariate and multivariate analysis identified that heavy smoking (PY ≥20) was the most significant factor associated with HBV-related HCC recurrence after curative surgical resection (p = 0.001), followed by anti-HBV treatment (p<0.01), current smoking (p = 0.028), surgical margin <1 cm (p = 0.048) and blood transfusion >600 ml (p = 0.028). The median RFS in non-smokers, ex-smokers and current smokers was 34 months, 24 months and 26 months, respectively (p = 0.033). Current smokers had significantly worse RFS rate and increased 5-year cumulative LSM than non-smokers (p = 0.024, and p<0.001, respectively). Heavy smokers had significantly worse RFS than non- and light smokers (0
Smoking history and quantity appears to be risk factors for HBV-related HCC recurrence and LSM of patients after surgery. For smokers, continued smoking postoperatively might accelerate tumor recurrence and patient death. Therefore, smoking abstinence should be strongly recommended to patients pre- and postoperatively.
PMCID: PMC3893178  PMID: 24454795
ARYA Atherosclerosis  2012;7(4):151-156.
Cardiovascular disorders are an important public health problem worldwide. They are also the leading cause of mortality and morbidity. Therefore, American Heart Association proposed cardiac rehabilitation program as an essential part of care for cardiac patients to improve functional capacity. The aim of this study was to evaluate the effectiveness of cardiac rehabilitation program on functional status and some hemodynamic responses in patients after coronary artery bypass graft (CABG) surgery.
Thirty two patients were selected for this study. All patients underwent cardiac surgery two months before admission. They were allocated to two groups. While the rehabilitation group (n =17, mean age: 62 ± 12 years) completed the cardiac rehabilitation program for two months, the reference group (n = 15, mean age: 58.5 ± 12.5 years) did not have any supervised physical activity during this period. Cardiac rehabilitation program consisted of exercise, nutritional, psychological consultation and risk factor management. At the beginning of the study, functional capacity of patients was evaluated by exercise test, 6-minute walking test and echocardiography. Functional capacity was evaluated for a second time after two months of cardiac rehabilitation. Data were analyzed by SPSS15. For comparing the mean of outcomes, Mann-Whitney test and Wilcoxon signed ranks test were used.
As a result of cardiac rehabilitation, a significant improvement was observed in the distance walked in the rehabilitation group (P < 0.01) compared to the reference group (P = 0.33). It also caused a significant development in hemodynamic responses to exercise such as resting and maximum systolic and diastolic blood pressure, resting and maximum heart rate, ejection fraction and rate pressure product.
Cardiac rehabilitation significantly improves functional capacity and some hemodynamic responses post coronary artery bypass grafting. Therefore, patients need to be referred to rehabilitation units.
PMCID: PMC3413083  PMID: 23205048
Cardiac Rehabilitation Program; Hemodynamic Responses; Coronary Artery Bypass Graft Surgery (CABG)
Trials  2008;9:44.
Off-pump coronary artery bypass grafting has been accused of possibly compromising graft patency. Sixteen slice computed tomography has shown good diagnostic accuracy in the assessment of coronary bypass graft patency when compared with conventional coronary artery angiography and is less invasive. The study hypothesis is that coronary artery bypass grafting (CABG) performed without cardiopulmonary bypass (Off-Pump) has equivalent early graft patency as if performed with cardiopulmonary bypass (On-Pump) and may have reduced complication rate.
The Prospective Randomized Comparison of Off-Pump and On-Pump MultI-vessel Coronary Artery BypasS Surgery (PROMISS) is a controlled, single blinded, single centre clinical trial, comparing early graft patency using 16-slice computed tomography in patients with multi-vessel coronary artery disease operated either without or with extracorporeal circulation. Inclusion criteria are multivessel disease with an indication for first time, isolated, non emergent coronary artery bypass grafting with a minimum of three distal anastomoses. Secondary end points are peri-operative mortality, combined morbidity, length of stay, neuro-cognitive testing at 6 weeks and adverse events, stress test and quality of life at 6 months and one year. The sample size of one hundred and fifty patients was calculated in order to enable the detection of a 5% difference in graft patency, with 80% power, considering a minimum of 3 distal anastomoses per patient. Enrolment started in April 2005 and ended July 2007 with study closure in July 2008.
The PROMISS trial aims to shed new light on the effect of Off-Pump as compared to On-Pump coronary artery bypass surgery on graft patency, assessed by multidetector computed tomography, in unselected patients with multivessel coronary artery disease.
Trial Registration
Current Controlled Trials ISRCTN58800729
PMCID: PMC2492837  PMID: 18637191
Coronary artery bypass grafting surgery is an effective treatment modality for patients with severe coronary artery disease. The conduits used during the surgery include both the arterial and venous conduits. Long- term graft patency rate for the internal mammary arterial graft is superior, but the same is not true for the saphenous vein grafts. At 10 years, more than 50% of the vein grafts would have occluded and many of them are diseased. Why do the saphenous vein grafts fail the test of time? Many causes have been proposed for saphenous graft failure. Some are non-modifiable and the rest are modifiable. Non-modifiable causes include different histological structure of the vein compared to artery, size disparity between coronary artery and saphenous vein. However, researches are more interested in the modifiable causes, such as graft flow dynamics and wall shear stress distribution at the anastomotic sites. Formation of intimal hyperplasia at the anastomotic junction has been implicated as the root cause of long- term graft failure.
Many researchers have analyzed the complex flow patterns in the distal sapheno-coronary anastomotic region, using various simulated model in an attempt to explain the site of preferential intimal hyperplasia based on the flow disturbances and differential wall stress distribution. In this paper, the geometrical bypass models (aorto-left coronary bypass graft model and aorto-right coronary bypass graft model) are based on real-life situations. In our models, the dimensions of the aorta, saphenous vein and the coronary artery simulate the actual dimensions at surgery. Both the proximal and distal anastomoses are considered at the same time, and we also take into the consideration the cross-sectional shape change of the venous conduit from circular to elliptical. Contrary to previous works, we have carried out computational fluid dynamics (CFD) study in the entire aorta-graft-perfused artery domain. The results reported here focus on (i) the complex flow patterns both at the proximal and distal anastomotic sites, and (ii) the wall shear stress distribution, which is an important factor that contributes to graft patency.
The three-dimensional coronary bypass models of the aorto-right coronary bypass and the aorto-left coronary bypass systems are constructed using computational fluid-dynamics software (Fluent 6.0.1). To have a better understanding of the flow dynamics at specific time instants of the cardiac cycle, quasi-steady flow simulations are performed, using a finite-volume approach. The data input to the models are the physiological measurements of flow-rates at (i) the aortic entrance, (ii) the ascending aorta, (iii) the left coronary artery, and (iv) the right coronary artery.
The flow field and the wall shear stress are calculated throughout the cycle, but reported in this paper at two different instants of the cardiac cycle, one at the onset of ejection and the other during mid-diastole for both the right and left aorto-coronary bypass graft models. Plots of velocity-vector and the wall shear stress distributions are displayed in the aorto-graft-coronary arterial flow-field domain. We have shown (i) how the blocked coronary artery is being perfused in systole and diastole, (ii) the flow patterns at the two anastomotic junctions, proximal and distal anastomotic sites, and (iii) the shear stress distributions and their associations with arterial disease.
The computed results have revealed that (i) maximum perfusion of the occluded artery occurs during mid-diastole, and (ii) the maximum wall shear-stress variation is observed around the distal anastomotic region. These results can enable the clinicians to have a better understanding of vein graft disease, and hopefully we can offer a solution to alleviate or delay the occurrence of vein graft disease.
PMCID: PMC555577  PMID: 15745458
Executive Summary
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of using intravascular ultrasound (IVUS) as an adjunctive imaging tool to coronary angiography for guiding percutaneous coronary interventions.
Intravascular Ultrasound
Intravascular ultrasound is a procedure that uses high frequency sound waves to acquire 3-dimensional images from the lumen of a blood vessel. The equipment for performing IVUS consists of a percutaneous transducer catheter and a console for reconstructing images. IVUS has been used to study the structure of the arterial wall and nature of atherosclerotic plaques, and obtain measurements of the vessel lumen. Its role in guiding stent placement is also being investigated. IVUS is presently not an insured health service in Ontario.
Clinical Need
Coronary artery disease accounts for approximately 55% of cardiovascular deaths, the leading cause of death in Canada. In Ontario, the annual mortality rate due to ischemic heart disease was 141.8 per 100,000 population between 1995 and 1997. Percutaneous coronary intervention (PCI), a less invasive approach to treating coronary artery disease, is used more frequently than coronary bypass surgery in Ontario. The number of percutaneous coronary intervention procedures funded by the Ontario Ministry of Health and Long-term Care is expected to increase from approximately 17, 780 in 2004/2005 to 22,355 in 2006/2007 (an increase of 26%), with about 95% requiring the placement of one or more stents. Restenosis following percutaneous coronary interventions involving bare metal stents occurs in 15% to 30% of the cases, mainly because of smooth muscle proliferation and migration, and production of extracellular matrix. In-stent restenosis has been linked to suboptimal stent expansion and inadequate lesion coverage, while stent thrombosis has been attributed to incomplete stent-to-vessel wall apposition. Since coronary angiography (the imaging tool used to guide stent placement) has been shown to be inaccurate in assessing optimal stent placement, and IVUS can provide better views of the vessel lumen, the clinical utility of IVUS as an imaging tool adjunctive to coronary angiography in coronary intervention procedures has been explored in clinical studies.
A systematic review was conducted to answer the following questions:
What are the procedure-related complications associated with IVUS?
Does IVUS used in conjunction with angiography to guide percutaneous interventions improve patient outcomes compared to angiographic guidance without IVUS?
Who would benefit most in terms of clinical outcomes from the use of IVUS adjunctive to coronary angiography in guiding PCIs?
What is the effectiveness of IVUS guidance in the context of drug-eluting stents?
What is the cost-effectiveness ratio and budget impact of adjunctive IVUS in PCIs in Ontario?
A systematic search of databases OVID MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) database for the period beginning in May 2001 until the day of the search, November 4, 2005 yielded 2 systematic reviews, 1 meta-analysis, 6 randomized controlled trials, and 2 non-randomized studies on left main coronary arteries. The quality of the studies ranged from moderate to high. These reports were combined with reports from a previous systematic review for analysis. In addition to qualitative synthesis, pooled analyses of data from randomized controlled studies using a random effect model in the Cochrane Review Manager 4.2 software were conducted when possible.
Findings of Literature Review & Analysis
Intravascular ultrasound appears to be a safe tool when used in coronary interventions. Periprocedural complications associated with the use of IVUS in coronary interventions ranged from 0.5% in the largest study to 4%. Coronary rupture was reported in 1 study (1/54). Other complications included prolonged spasms of the artery after stenting, dissection, and femoral aneurysm.
Based on pooled analyses of data from randomized controlled studies, the use of intravascular ultrasound adjunctive to coronary intervention in percutaneous coronary interventions using bare metal stents yielded the following findings:
For lesions predominantly at low risk of restenosis:
There were no significant differences in preintervention angiographic minimal lumen diameter between the IVUS-guided and angiography-guided groups.
IVUS guidance resulted in a significantly larger mean postintervention angiographic minimal lumen diameter (weighted mean difference of 0.11 mm, P = .0003) compared to angiographic guidance alone.
The benefit in angiographic minimal lumen diameter from IVUS guidance was not maintained at 6-month follow-up, when no significant difference in angiographic minimal lumen diameter could be detected between the two arms (weighted mean difference 0.08, P = .13).
There were no statistically significant differences in angiographic binary restenosis rates between IVUS-guidance and no IVUS guidance (Odds ratio [OR] 0.87 in favour of IVUS, 95% Confidence Interval [CI] [0.64–1.18], P = 0.37).
IVUS guidance resulted in a reduction in the odds of target lesion revascularization (repeat percutaneous coronary intervention or coronary bypass graft) compared to angiographic guidance alone. The reduction was statistically significant at a follow-up period of 6 months to 1 year, and at a follow-up period of 18 month to 2 years (OR 0.52 in favour of IVUS, 95% CI [0.33–0.81], P = .004).
Total revascularization rate (either target lesion or target vessel revascularization) was significantly lower for IVUS-guided patients at 18 months to 2.5 years after intervention (OR 0.43 in favour of IVUS, 95% CI [0.29–0.63], p < .0001).
There were no statistically significant differences in the odds of death (OR 1.36 in favour of no IVUS, P =0.65) or myocardial infarction (OR 0.95 in favour of IVUS, P = 0.93) between IVUS-guidance and angiographic guidance alone at up to 2.5 years of follow-up
The odds of having a major cardiac event (defined as death, myocardial infarction, and target lesion or target vessel revascularization) were significantly lower for patients with IVUS guidance compared to angiographic guidance alone during follow-up periods of up to 2.5 years (OR 0.53, 95% CI [0.36–0.78], P = 0.001). Since there were no significant reductions in the odds of death or myocardial infarction, the reduction in the odds of combined events reflected mainly the reduction in revascularization rates.
For lesions at High Risk of Restenosis:
There is evidence from one small, randomized controlled trial (n=150) that IVUS-guided percutaneous coronary intervention in long de novo lesions (>20 mm) of native coronary arteries resulted in statistically significant larger minimal lumen Diameter, and statistically significant lower 6-month angiographic binary restenosis rate. Target vessel revascularization rate and the rate of combined events were also significantly reduced at 12 months.
A small subgroup analysis of a randomized controlled trial reported no benefit in clinical or angiographic outcomes for IVUS-guided percutaneous coronary interventions in patients with diabetes compared to those guided by angiography. However, due to the nature and size of the analysis, no firm conclusions could be reached.
Based on 2 small, prospective, non-randomized controlled studies, IVUS guidance in percutaneous coronary interventions of left main coronary lesions using bare metal stents or drug-eluting stents did not result in any benefits in angiographic or clinical outcomes. These findings need to be confirmed.
Interventions Using Drug-Eluting Stents
There is presently no evidence on whether the addition of IVUS guidance during the implantation of drug-eluting stents would reduce incomplete stent apposition, or improve the angiographic or clinical outcomes of patients.
Ontario-Based Economic Analysis
Cost-effectiveness analysis showed that PCIs using IVUS guidance would likely be less costly and more effective than PCIs without IVUS guidance. The upfront cost of adjunctive use of IVUS in PCIs ranged from $1.56 million at 6% uptake to $13.04 million at 50% uptake. Taking into consideration cost avoidance from reduction in revascularization associated with the use of IVUS, a net saving of $0.63 million to $5.2 million is expected. However, since it is uncertain whether the reduction in revascularization rate resulting from the use of IVUS can be generalized to clinical settings in Ontario, further analysis on the budget impact and cost-effectiveness need to be conducted once Ontario-specific revascularization rates are verified.
Factors to be Considered in the Ontario Context
Applicability of Findings to Ontario
The interim analysis of an Ontario field evaluation that compared drug-eluting stents to bare metal stents showed that the revascularization rates in low-risk patients with bare metal stents were much lower in Ontario compared to rates reported in randomized controlled trials (7.2% vs >17 %). Even though IVUS is presently not routinely used in the stenting of low-risk patients in Ontario, the revascularization rates in these patients in Ontario were shown to be lower than those reported for the IVUS groups reported in published studies. Based on this information and previous findings from the Ontario field evaluation on stenting, it is uncertain whether the reduction in revascularization rates from IVUS guidance can be generalized to Ontario. In light of the above findings, it is advisable to validate the reported benefits of IVUS guidance in percutaneous coronary interventions involving bare metal stents in the Ontario context.
Licensing Status
As of January 16, 2006, Health Canada has licensed 10 intravascular ultrasound imaging systems/catheters for transluminal intervention procedures, most as class 4 medical devices.
Current Funding
IVUS is presently not an insured procedure under the Ontario Health Insurance Plan and there are no professional fees for this procedure. All costs related to the use of IVUS are covered within hospitals’ global budgets. A single use IVUS catheter costs approximately $900CDN and the procedure adds approximately 20 minutes to 30 minutes to a percutaneous coronary intervention procedure.
According to an expert consultant, current use of IVUS in coronary interventions in Ontario is probably limited to high-risk cases such as interventions in long lesions, small vessels, and bifurcated lesions for which images from coronary angiography are indeterminate. It was estimated that IVUS is being used in about 6% of all percutaneous coronary interventions at a large Ontario cardiac centre.
Expert Opinion
IVUS greatly enhances the cardiac interventionists’ ability to visualize and assess high-risk lesions such as long lesions, narrow lesions, and bifurcated lesions that may have indeterminate angiographic images. Information from IVUS in these cases facilitates the choice of the most appropriate approach for the intervention.
The use of adjunctive IVUS in PCIs using bare metal stents in lesions predominantly at low risk for restenosis had no significant impact on survival, myocardial infarction, or angiographic restenosis rates up to 2.5 years after intervention.
The use of IVUS adjunctive to coronary angiography in percutaneous coronary interventions using bare metal stents in lesions predominantly at low risk for restenosis significantly reduced the target lesion and target vessel revascularization at a follow-up period of 18 months to 2.5 years.
One small study suggests that adjunctive IVUS in PCIs using bare metal stents in long lesions (>20 mm) significantly improved the 6-month angiographic restenosis rate and one-year target lesion revascularization rate. These results need to be confirmed with large randomized controlled trials.
Based on information from the Ontario field evaluation on stenting, it is uncertain whether the reduction in revascularization rate resulting from the use of IVUS in the placement of bare metal stents can be generalized to clinical settings in Ontario.
There is presently insufficient evidence available to determine the impact of adjunctive IVUS in percutaneous interventions in high-risk lesions (other than long lesions) or in PCIs using drug-eluting stents.
PMCID: PMC3379536  PMID: 23074482
Disturbances of the cardiac conduction system are frequent in the postoperative period of coronary artery bypass surgery. They are mostly reversible and associated with some injury of the conduction tissue, caused by the ischemic heart disease itself or by perioperative factors.
Primary: investigate the association between perioperative factors and the emergence of atrioventricular block in the postoperative period of coronary artery bypass surgery. Secondary: determine the need for temporary pacing and of a permanent pacemaker in the postoperative period of coronary artery bypass surgery and the impact on hospital stay and hospital mortality.
Analysis of a retrospective cohort of patients submitted to coronary artery bypass surgery from the database of the Postoperative Heart Surgery Unit of the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul, using the logistic regression method.
In the period from January 1996 to December 2012, 3532 coronary artery bypass surgery were carried out. Two hundred and eighty-eight (8.15% of the total sample) patients had atrioventricular block during the postoperative period of coronary artery bypass surgery, requiring temporary pacing. Eight of those who had atrioventricular block progressed to implantation of a permanent pacemaker (0.23% of the total sample). Multivariate analysis revealed a significant association of atrioventricular block with age above 60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37; CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95% 1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66; P=0.014), functional class III and IV of the New York Heart Association (OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the intra-aortic balloon in the postoperative period of coronary artery bypass surgery (OR=1.92; CI 95% 1.21-3.05; P=0.006). The presence of atrioventricular block resulted in a significant increase in mortality (17.9% vs. 7.3% in those who did not develop atrioventricular block) (OR=2.09; CI 95% 1.46-2.99; P<0.0001) and a longer hospital stay (12.75 days x 10.53 days for those who didn't develop atrioventricular block) (OR=1.01; CI 95% 1.00-1.02; P=0.01).
In most cases, atrioventricular block in the postoperative period of coronary artery bypass surgery is transient and associated with several perioperative factors: age above 60 years, female sex, chronic kidney disease, atrial fibrillation, New York Heart Association functional class III or IV, perioperative acute myocardial infarction and use of an intra-aortic balloon. Its occurrence prolongs hospitalization and, above all, doubles the risk of mortality.
PMCID: PMC4462961  PMID: 26107447
Atrioventricular block; Artificial Pacemaker; Coronary Artery Bypass; Postoperative Complications
The New England journal of medicine  2014;371(23):2178-2188.
Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitral-valve repair to coronary-artery bypass grafting (CABG) are uncertain.
We randomly assigned 301 patients with moderate ischemic mitral regurgitation to CABG alone or CABG plus mitral-valve repair (combined procedure). The primary end point was the left ventricular end-systolic volume index (LVESVI), a measure of left ventricular remodeling, at 1 year. This end point was assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized as the lowest LVESVI rank.
At 1 year, the mean LVESVI among surviving patients was 46.1±22.4 ml per square meter of body-surface area in the CABG-alone group and 49.6±31.5 ml per square meter in the combined-procedure group (mean change from baseline, −9.4 and −9.3 ml per square meter, respectively). The rate of death was 6.7% in the combined-procedure group and 7.3% in the CABG-alone group (hazard ratio with mitral-valve repair, 0.90; 95% confidence interval, 0.38 to 2.12; P = 0.81). The rank-based assessment of LVESVI at 1 year (incorporating deaths) showed no significant between-group difference (z score, 0.50; P = 0.61). The addition of mitral-valve repair was associated with a longer bypass time (P<0.001), a longer hospital stay after surgery (P = 0.002), and more neurologic events (P = 0.03). Moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%, P<0.001). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.
In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; number, NCT00806988.)
PMCID: PMC4303577  PMID: 25405390
Heart  1996;75(6):557-562.
OBJECTIVE: To examine the relation between smoking status, clinical need, and likelihood of coronary artery bypass grafting in middle aged men. DESIGN: A prospective study of cardiovascular disease in British men aged 40 to 59 years, screened in 1978-80 and followed until December 1991. SUBJECTS AND SETTING: 7735 men drawn from one general practice in each of 24 British towns. MAIN OUTCOME MEASURE: Coronary artery bypass graft surgery. RESULTS: Of the 3185 current smokers, 38 (1.03/1000/year) underwent coronary artery bypass surgery compared with 47 of 2715 (1.45/1000/year) ex-smokers, and 19 of 1817 (0.85/1000/year) never-smokers. Ex-smokers had a lower incidence of major ischaemic heart disease during follow up than current smokers. After adjustment for incidence of ischaemic heart disease during follow up, the hazard ratio of coronary artery bypass surgery for ex-smokers compared with smokers was 1.52 (95% confidence interval 0.99 to 2.34). Ex-smokers were more likely at screening to recall a doctor diagnosis of ischaemic heart disease than smokers (7.1% v 5.3%), but among those who recalled a doctor diagnosis, smokers were less likely to undergo coronary artery bypass surgery than ex-smokers (9.4% v 3.5%, P = 0.026). By 1992, men defined as smokers at screening were no less likely than ex-smokers to have been referred to a cardiologist (18.5% v 18.8%), nor to report having undergone coronary angiography less frequently than ex-smokers (12.7% v 11.4%). CONCLUSION: Even allowing for the strong relation between coronary artery bypass surgery and clinical need, continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers. A complex interplay exists between the men's experience of heart disease, the decision to stop smoking, and the willingness of doctors to consider coronary artery bypass surgery.
PMCID: PMC484376  PMID: 8697156
BMJ : British Medical Journal  2006;332(7554):1365.
Objective To compare the clinical, angiographic, neurocognitive, and quality of life outcomes of off-pump coronary artery bypass surgery with conventional coronary artery bypass grafting surgery using cardiopulmonary bypass.
Design Randomised controlled clinical trial.
Setting Tertiary cardiothoracic centre in Middlesex, England.
Participants 168 patients (27 women) requiring primary isolated coronary artery bypass grafting surgery.
Interventions Patients were randomised to conventional coronary artery bypass grafting surgery using cardiopulmonary bypass (n = 84) or off-pump coronary artery bypass surgery (n = 84), carried out by one surgeon. Angiographic examination was carried out at three months postoperatively. Neurocognitive tests were carried out at baseline and at six weeks and six months postoperatively.
Main outcome measures Clinical outcome, graft patency at three months, neurocognitive function at six weeks and six months, and health related quality of life.
Results Graft patency was evaluated by angiography in 151 (89.9%) patients and was similar between the cardiopulmonary bypass and off-pump groups (risk difference - 1%, 95% confidence interval - 5% to 4%), with the off-pump group considered the treatment group. Patients in the off-pump group required fewer blood transfusions (1.7 units v 1.0 unit, P = 0.02), shorter duration of mechanical ventilation (7.7 hours v 3.9 hours, P = 0.03), and shorter hospital stay (10.8 days v 8.9 days). Scores for neurocognitive function showed a significant difference in three memory subtests at six weeks and two memory subtests at six months in favour of the off-pump group.
Conclusions Patients who underwent off-pump coronary artery bypass surgery showed similar patency of grafts, better clinical outcome, shorter hospital stay, and better neurocognitive function than patients who underwent conventional coronary artery bypass grafting surgery using cardiopulmonary bypass.
PMCID: PMC1476725  PMID: 16740529
Texas Heart Institute Journal  2006;33(1):23-26.
Although most patients with left main coronary artery stenosis undergo urgent coronary artery bypass grafting, limited information is available regarding the risk factors that might lead to cardiac events between angiographic diagnosis and surgery.
We retrospectively reviewed 1,731 cases of coronary artery bypass grafting at our institution, 97 of which were performed in patients with significant (≥50%) left main coronary artery stenosis. These patients were placed in 1 of 2 groups: eventful waiting or uneventful waiting. We analyzed multiple preoperative variables, and the incidence of serious cardiac events (death, myocardial infarction, unstable angina, left ventricular failure, and life-threatening ventricular arrhythmias) during the waiting period between angiography and surgery.
Four patients (4.1%) experienced serious cardiac events while awaiting surgery (1 had non-ST-elevation myocardial infarction; 3 had life-threatening ventricular arrhythmias); none died. All the events occurred more than 24 hours after cardiac catheterization. Of the preoperative variables analyzed (acute coronary syndrome, age, history of diabetes, hypertension, hyperlipidemia, smoking, renal failure, severity of left main stenosis, right coronary artery involvement, ejection fraction, and use of intra-aortic balloon pump), only acute coronary syndrome predicted the incidence of preoperative cardiac events (P =0.001).
The occurrence of severe cardiac events while patients await coronary artery bypass grafting is rare. Carefully selected patients with severe left main coronary artery stenosis can safely await surgery. Concomitant acute coronary syndrome and severe left main coronary artery stenosis indicate a high risk for cardiac events. Therefore, in patients with these conditions, emergency coronary artery bypass may be preferable.
PMCID: PMC1413613  PMID: 16572864
Angina, unstable; arrhythmia, ventricular; coronary angiography; coronary diseases/diagnosis/surgery; heart catheterization; heart failure, congestive; left ventricular failure; myocardial infarction; myocardial revascularization; retrospective studies; death; time factors
BMC Public Health  2011;11:117.
Surveys have provided evidence that tobacco use is widely prevalent amongst the youth in Pakistan. Several reviews have evaluated the effectiveness of various tobacco control programs, however, few have taken into account the perceptions of students themselves regarding these measures. The aim of this study was to determine the most effective anti-smoking messages that can be delivered to high-school students in Pakistan, based on their self-rated perceptions. It also aimed to assess the impact of pictorial/multi-media messages compared with written health warnings and to discover differences in perceptions of smokers to those of non-smokers to health warning messages.
This study was carried out in five major cities of Pakistan in private English-medium schools. A presentation was delivered at each school that highlighted the well-established health consequences of smoking using both written health warnings and pictorial/multi-media health messages. Following the presentation, the participants filled out a graded questionnaire form, using which they rated the risk-factors and messages that they thought were most effective in stopping or preventing them from smoking. The Friedman test was used to rank responses to each of the questions in the form. The Wilcoxon Signed Rank test used to analyze the impact of pictorial/multi-media messages over written statements. The Mann Whitney U test was used to compare responses of smokers with those of non-smokers.
Picture of an oral cavity cancer, videos of a cancer patient using an electronic voice box and a patient on a ventilator, were perceived to be the most effective anti-smoking messages by students. Addiction, harming others through passive smoking and impact of smoking on disposable incomes were perceived to be less effective messages. Pictorial/multi-media messages were perceived to be more effective than written health warnings. Health warnings were perceived as less effective amongst smokers compared to non-smokers.
Graphic pictorial/multi-media health warnings that depict cosmetic and functional distortions were perceived as effective anti-smoking messages by English-medium high school students in Pakistan. Smokers demonstrated greater resistance to health promotion messages compared with non-smokers. Targeted interventions for high school students may be beneficial.
PMCID: PMC3051908  PMID: 21333006
Saudi Journal of Anaesthesia  2013;7(2):151-154.
Forced expiratory volume in one second (FEV1) is a good predictor of chronic obstructive pulmonary disease (COPD). COPD is characterized by a chronic limitation of airflow. This study was designed to compare the effects and complications of theophylline alone, N-acetylcysteine (NAC) alone, and a combination of the two drugs on the rates of FEV1 in patients with COPD who were candidates for off-pump coronary artery bypass graft (CABG) surgery.
This clinical trial was performed on 100 patients who had a smoking history of 27 pack years with a range of 20 to 40 pack years but were not heavy smokers and were candidates for elective off-pump CABG surgery in Afshar Cardiovascular Hospital, Yazd, Iran. The patients with a history of asthma and bronchospasm and non-COPD respiratory disorders were excluded. There were three groups, that is, the theophylline group (n=33) that received theophylline 10 mg/kg TDS after consumption of food, NAC group (n=33) who received NAC 10-15 mg/kg BD after consumption of food, and the combined group (n=32) who received theophylline and NAC together. Data were analyzed by analysis of variance (ANOVA), Chi-square, and exact test for quantitative and qualitative variables.
One hundred patients with COPD enrolled in this study as possible candidates for CABG surgery. Average age of the patients was 60.36±10.21 years. Of the participants, 83 (83.3%) were male and 17 (17%) were female. Rate of postoperative FEV1 to basal FEV1 was 0.76±0.32, 0.66±0.22, and 0.69±0.24 in the treatments with theophylline, NAC, and the combination, respectively. Theophylline, NAC, and a combination of these drugs can decrease the rate of postoperative FEV1 compared to basal FEV1 significantly. (P=0.0001)
Theophylline alone, NAC alone, and a combination of these drugs improve pulmonary function, and there are no significant differences between these protocols. Stomach discomfort and cardiac complications in treatment with theophylline alone is significantly higher than NAC alone and the combination.
PMCID: PMC3737690  PMID: 23956714
Chronic obstructive pulmonary disease; elective off-pump coronary artery bypass graft; N-acetylcysteine; theophylline
Heart  1999;81(6):586-592.
OBJECTIVES—To review the New Zealand coronary artery bypass priority score instituted in May 1996, and specifically to determine whether it prioritises patients at high risk of cardiac events while waiting. The New Zealand score is compared with the Ontario urgency rating score, and waiting times for surgery are compared with the maximum times recommended by the Ontario consensus panel.
DESIGN—Retrospective review of patients accepted for isolated coronary artery bypass surgery between 1 January 1993 and 31 January 1996.
SETTING—Green Lane Hospital, Auckland, New Zealand. 
MAIN OUTCOME MEASURES—Waiting time, cardiac death, myocardial infarction, and cardiac readmission. 
RESULTS—The median waiting times were five days for hospital cases (n = 721) and 146 days for out of hospital cases (n = 701). Of the latter group, 28% waited more than a year, 33% had their surgery expedited because of worsening symptoms, and 19% failed to meet the cut off point set by the New Zealand score for acceptance onto the list. Twenty two patients died, 18 on the outpatient waiting list (waiting list mortality 2.6%, risk 0.28% per month of waiting), and 132 were readmitted, 12% with myocardial infarction and 76% with unstable angina. Risk factors for a composite end point of death or myocardial infarction and/or cardiac readmission were: previous coronary artery bypass surgery (p = 0.001), class III or IV angina (p = 0.002), and hypertension (p = 0.005). The New Zealand score did not identify those at risk. Excluding hospital cases, 32% had surgery within the time recommended by the Ontario consensus panel.
CONCLUSIONS—Waiting times for coronary artery bypass surgery in New Zealand are considerably longer than those in Ontario, Canada. By using a numerical cut off point, implementation of the New Zealand priority scoring system has restricted access to coronary surgery on the basis of funding constraints rather than clinical appropriateness. The score does not add greatly to the clinicians' prioritisation in predicting those patients who will suffer events while waiting.

Keywords: coronary artery bypass surgery; prioritisation
PMCID: PMC1729055  PMID: 10336915
The knowledge of the prevalence of risk factors and comorbidities, as well as the evolution and complications in patients undergoing coronary artery bypass graft allows comparison between institutions and evidence of changes in the profile of patients and postoperative evolution over time.
To profile (risk factors and comorbidities) and clinical outcome (complications) in patients undergoing coronary artery bypass graft in a national institution of great surgical volume.
A retrospective cohort study of patients undergoing coronary artery bypass graft in the hospital Beneficência Portuguesa de São Paulo, from July 2009 to July 2010.
We included 3,010 patients, mean age of 62.2 years and 69.9% male. 83.8% of patients were hypertensive, 36.6% diabetic, 44.5% had dyslipidemia, 15.3% were smokers, 65.7% were overweight/obese, 29.3% had a family history of coronary heart disease. The expected mortality calculated by logistic EuroSCORE was 2.7%. The isolated CABG occurred in 89.3% and 11.9% surgery was performed without cardiopulmonary bypass. The most common complication was cardiac arrhythmia (18.7%), especially acute atrial fibrillation (14.3%). Pneumonia occurred in 6.2% of patients, acute renal failure in 4.4%, mediastinites in 2.1%, stroke in 1.8% and AMI in 1.2%. The in-hospital mortality was 5.4% and in isolated coronary artery bypass graft was 3.5%. The average hospital stay was 11 days with a median of eight days (3-244 days).
The profile of patients undergoing coronary artery bypass graft surgery in this study is similar to other published studies.
PMCID: PMC4389527  PMID: 25859865
Coronary Artery Bypass; Epidemiology; Risk Factors
Health Economists in Denmark have reported poor outcomes and low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). In this setting it is important to evaluate outcomes following this commonly performed operation to justify undertaking it on our patients. The purpose of the study was to evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work.
Prospective cohort study and retrospective review of data from the Nottingham Shoulder database. Inclusion criteria: Patients diagnosed clinically with SAIS by an experienced shoulder surgeon, who have failed conservative treatment (physiotherapy and sub-acromial injection), undergoing ASAD. Pre-operative and 6-month post-operative Oxford Shoulder Score (OSS) and Constant Score (CS) were compared. The rates of return to pre-operative work and hobbies were also analysed. Statistical analysis was carried out using the Wilcoxon signed rank test.
73 patients with OSS (51 also with CS documentation) were included. The improvement in median OSS between pre-operative (24) and 6-month follow-up (39) was +15 (Z = -6.726, p < 0.0001, T = 6, r = 0.55). The difference in median CS between pre-operative (39) and 6-month follow-up (67) was +28 (Z = -5.435, p < 0.0001,T = 6, r = 0.59). Improvement in median pain score was +5 (7,12, p < 0.0001) median ADL was +5.5 (10.5,16, p < 0.0001) median ROM was +13 (18,31, p < 0.0001) and median strength was +4 (3,7, p < 0.0001). 76% returned to their pre-operative level of work (mean time = 11.5 weeks post surgery). 79% returned to pre-operative hobbies at a mean of 11.8 weeks after surgery.
There is a significant improvement in both subjective and objective outcome 6 months after ASAD in patients with SAIS who have had previous failed conservative treatment. The rate of return to work was good for these patients in contrast to that reported for Danish patients. ASAD is a successful method of treatment for patients with SAIS who have had an initial trial of failed conservative treatment.
PMCID: PMC4190469  PMID: 25266967
AIM—The effect of breathing 100% oxygen on retinal and optic nerve head capillary blood flow in smokers and non-smokers was investigated using scanning laser Doppler flowmetry (SLDF) as a new non-invasive method to visualise and quantify ocular blood flow.
METHOD—10 eyes of 10 young healthy non-smoking volunteers (mean age 26 (SD 3) years) and nine eyes of nine young healthy smoking volunteers (mean age 26 (4) years) were investigated. All participants were asked not to smoke or consume caffeine containing drinks for at least 4 hours before the measurements. Blood flow measurements were performed before and after 100% oxygen was applied to the subjects through a mask over a period of 5 minutes (6 litres per minute). Juxtapapillary retinal and optic nerve head blood flow were determined in arbitrary units using SLDF representing a combination of laser Doppler flowmetry and a scanning laser system allowing visualisation and quantification of the retinal and optic nerve head blood flow. Blood flow was determined in an area of 100 µm × 100 µm. The level of carboxyhaemoglobin was determined in all subjects. A Wilcoxon matched pairs signed ranks test (non-parametric) was used for statistical evaluation.
RESULTS—In the non-smoking group, retinal `flow' was reduced by 33% (p = 0.005), optic nerve head `flow' by 37% (p = 0.005). In the smoking group retinal flow was reduced by 10% (p = 0.01), optic nerve head flow by 13% (p <0.008). The difference in reactivity to oxygen breathing between smokers and non-smokers was highly significant (p <0.00001). Increased carboxyhaemoglobin levels were not found in either of the groups. A significant reduction of the mean arterial blood pressure of 6% (5%) (p <0.02) was observed in the non-smoking group after administration of oxygen.
CONCLUSION—These results indicate that hyperoxia leads to a decrease in capillary blood flow of the retina and optic nerve head secondary to vasoconstriction, and that smokers do not respond to oxygen breathing as non-smokers do. The findings might be based on factors such as long term effects of nicotine on the sympathetic and parasympathetic nervous system.

PMCID: PMC1722181  PMID: 9227200
Trials  2011;12:243.
In coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature.
Endoscopic Saphenous harvesting with an Open CO2 System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre.
The goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting.
The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery.
Trial registration NCT01121341.
PMCID: PMC3261821  PMID: 22098690
coronary disease; minimally invasive surgery; saphenous vein harvest

Results 1-25 (1186649)