Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3614_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 2 Treatment ofcoronary artery disease
https://t.me/medicina_free
88
16% vs 10% (HR 1.50, 95% CI 1.04– 2.17; P=0.032), stroke 5% vs
2% (HR 2.25, 95% CI 0.93– 5.48; P=0.073)). It should be emphasized that given the restrictive inclusion/ exclusion anatomical criteria of NOBLE, with more than three non- complex lesions and all
‘complex’ lesions eectively excluded, NOBLE was a comparison
of outcomes between CABG and PCI among a patient subgroup
that was relatively ‘PCI friendly’. Conversely, given the long recruitment period of NOBLE (>6years), that systematic screening
logs were not available in 31 of the 36 centres and the lack of an
‘all- comers’ design, there are concerns about signicant selection
bias in the trial— an issue that had plagued earlier pre- SYNTAX
CABG vs. PCI trials.– Comparatively, within EXCEL, the design
was ‘all- comers’ for patients up to intermediate anatomical complexity (SYNTAX Score <33), and importantly screened patients
were captured in registries.
Reasons for the diverging results between EXCEL (‘neutral’) and
NOBLE (favours CABG) have been extensively debated. However,
in reality both trials are likely pointing in the same direction, namely
CABG oers a more favourable net clinical benet in patients
with more complex CAD, and that the ‘downstream’ anatomical
complexity— i.e. plaque burden— and patient clinical co- morbidity,
as exemplied in the SYNTAX score II, is what drives long terms
outcomes to favour CABG over PCI.
As previously stated, unlike in NOBLE, it is important to emphasize that in EXCEL, there was a registry (n=1000) to allow documentation of treatment choice for all screened patients who could
not be randomized. Based on additional analyses of the screening
registry in EXCEL, the investigators estimated that approximately
62% of all patients with ULMCA may be eligible for PCI, and approximately 80% may be eligible for CABG. Longer- term follow- up
(10years) of both trials, with analyses of important subgroups, and
the impact of site vs. corelab anatomical SYNTAX Scores, may shed
further light on the reasons for the dierences in outcomes between
EXCEL and NOBLE.
Sex
Within SYNTAX, the presence of female sex was shown to be an
further evidence to support the sex hypothesis,, namely that
lower SYNTAX scores are needed in women with complex CAD
to allow for equipoise in long- term mortality between CABG
and PCI. The main hypotheses to account for these findings is
that women with complex CAD may have a plaque burden with
a more unfavourable plaque composition, particularly with the
progressive loss, with advancing age, of the protective effects of
oestrogen.,,
Diabetes
e absence of diabetic status from the SYNTAX score II has
proven to be a point of confusion and controversy, particularly
because it appears to be odds with international revascularization
guidelines. During the initial development of the SYNTAX score
II, it was demonstrated that diabetes was not an independent predictor of mortality in patients with complex artery disease from the
SYNTAX Trial when corrected for the end organ manifestations of
diabetes. ese factors included the anatomical SYNTAX score and
age/ creatinine clearance/ LVEF expressed as continuous (numerical) variables.
It should be emphasized that the SYNTAX score II was built on
the seminal work undertaken by a cardiac surgeon (Ranucci etal.)
who demonstrated that a simple integer— derived from three clinical variables expressed as a continuous variable (age, preoperative serum creatinine, and LVEF)— was at least comparable to the
EuroSCORE (composed of 17 variables) in predicting in- hospital
mortality aer CABG (Fig. 9.9).–
e nding that the presence of diabetes in itself to not provide
any further prognostic (or decision- making) information once the
anatomical SYNTAX score and age/ creatinine clearance/ LVEF (expressed numerically) were accounted for, is supported by populationbased data. Within these studies it was demonstrated that individuals
with CKD and proteinuria, but without diabetes, to have a stronger
association with the risk of myocardial infarction and a higher rate of
mortality, compared to those with diabetes, and that the relative risk
of long- term mortality associated with CKD was “much the same irrespective of the presence or absence of diabetes.”–
independent correlate for long- term mortality in the PCI arm.
Within the CABG arm this was not evident, with the result that substantially lower anatomical SYNTAX scores were required to allow
for equipoise for long- term mortality between CABG and PCI.,
During the development of the SYNTAX score II, the interaction
Impact ofdiabetic status ondecisionmaking incomplex coronary
arterydisease
eect for female sex was clearly in favour of CABG compared to PCI
for long- term mortality when corrected for other risk factors (HR
CABG 0.59 (95% CI 0.32– 1.10), HR PCI 1.70 (95% CI 1.11– 2.60),
interaction eect 2.87 (95% CI 1.35– 6.07; P=0.0059)). Within the
DELTA registry (n=2891), in which the SYNTAX score II was originally externally validated, a similar nding for female sex on longterm mortality was made (HR CABG 0.52 (95% CI 0.31– 0.87), HR
PCI 1.09 (95% CI 0.82– 1.46), interaction eect 2.09 (95% CI 1.16–
3.76; P=0.014)).,
Notably within EXCEL, subgroup analyses demonstrated a
substantial trend towards more favourable outcomes (primary
endpoint of all- cause death, myocardial infarction, or stroke)
for CABG compared to PCI in women (HR male 0.87 (95% CI
0.66– 1.14), HR female 1.48 (95% CI 0.93– 2.41); P- value for inter-
action 0.06). Although external validation of the SYNTAX score
II is awaited from EXCEL, this finding nevertheless provides
In international guidelines, diabetes has been regarded diabetes as
a unique cardiovascular risk factor,– and the American College
of Cardiology/ American Heart Association guidelines recommend
that patients with diabetes mellitus be treated as having a CAD
equivalent. It is well established that the atherosclerotic vascular
disease process is accelerated in diabetes, both type Iand type II,
predisposing to a two- to fourfold increase in the development of
CAD compared to non- diabetic patients and with 75% of diabetic
patients dying as a result of a cardiovascular cause., In addition,
diabetic patients (compared to those without diabetes) have been
shown to have a substantially higher incidence of multivessel disease and greater plaque burden at presentation, with the severity
of the CAD proportional to the duration of diabetes. is is undoubtedly related to the metabolic abnormalities characteristic of
diabetes that provoke molecular mechanisms that contribute to
72
Predicted mortality rate (%)
ACEF Score
5,2
https://t.me/medicina_free
70
ACEF score = Age (years) + 1 (if serum creatinine ≥ 2mg/dL)
68
66
64
62
60
58
56
54
52
50
48
46
44
42
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
0,0
0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6 1,8 2,0 2,2 2,4 2,6
EF (%)
2,8 3,0 3,2 3,4 3,6 3,8 4,0 4,2 4,4 4,6 4,8 5,0
899 Evidence basis fordecision-making betweencoronary artery bypass grafting and percutaneous coronaryintervention
Fig.9.9 Assessment of operative mortality risk in elective cardiac operations:the ACEF score (age, creatinine, ejection fraction) and the law of
parsimony. Arisk score limited to 3 independent predictors of operative mortality expressed as continuous variables was shown to have at least similar
(or improved) accuracy compared to more complex operative risk scores in elective cardiac operations. Univariate association (logistic regression)
between ACEF score and mortality risk is illustrated.
Reproduced from Ranucci M, Castelvecchio S, Menicanti L, Frigiola A, Pelissero G.Risk of assessing mortality risk in elective cardiac operations:age, creatinine, ejection fraction, and
the law of parsimony. Circulation. 2009 Jun 23;119(24):3053– 61. doi:10.1161/ CIRCULATIONAHA.108.842393 with permission from Wolters Kluwer.
vascular dysfunction.– ese include hyperglycaemia— with an
almost linear relationship between HbA1c and clinical outcomes,
insulin resistance, increased free fatty acids, dyslipidaemia, platelet
dysfunction, hypercoagulability, and an impaired response to injury.
Timing ofrevascularization indiabetes
e question of timing and mode of revascularization for diabetic patients (or indeed any patient) with complex CAD is not
yet resolved. Currently, guidelines support CABG as the primary
revascularization modality when a diabetic patient develops 3VD on
the assumption that the degree of plaque burden is so extensive that
bypass graing oers a prophylactic benet against future events.
On the one hand, oering diabetic patients CABG too early, particularly with limited plaque burden, may increase the potential
risk of the gras failing in the long- term, although this risk may
be reduced by the appropriate use of multiple arterial conduits. On
the other hand, by oering CABG to diabetic patients too late, the
perioperative risks of CABG may be increased because of increasing
patient comorbidity and frailty, extensive diuse coronary disease,
or too distal stent implantation precluding optimal gra placement,
thereby diminishing the potential mortality advantage of CABG.,
Striking the balance between these two scenarios is the challenge
for the Heart Team in clinical practice (Fig. 9.10), and is where clinical tools— such as the anatomical SYNTAX score or SYNTAX score
II— may aid in providing more objective evidence to guide recommendations for intervention, which modality, and its timing.
Finally, it is crucial not to under- estimate the vital role played by
guideline- directed optimal medical therapy and lifestyle modication, in substantially reducing adverse clinical events in patients
with complex CAD, in both diabetic and non- diabetic patients.–
Ongoingstudies
SYNTAX IItrial
In the ongoing SYNTAX II trial (ClinicalTrials.gov identier:NCT02015832), the SYNTAX score II is being used by the
Heart Team as a tool to recruit subjects with de novo three- vessel
CAD (without le main involvement) who have a postulated similar
long- term mortality between CABG and PCI (Fig. 9.11, upper
panel). Notably, subjects from all tertiles of the SYNTAX score are
eligible. As in the single arm study of ARTS- II (that led on to the
randomised SYNTAX Trial), SYNTAX II is a single- arm study,
with the CABG and PCI arms of the original SYNTAX trial being
used as historical control arms. e SYNTAX II PCI strategy utilizes
appropriate patient selection with the SYNTAX score II, a newergeneration metal DES platform with a biodegradable polymer,
contemporary CTO revascularization strategies, and functional/
intravascular ultrasound- guided stent implantation. Importantly,
the use of functional- guided PCI in SYNTAX II leading to a deferral of PCI in almost one- third of lesions (31%) (Fig. 9.11, lower
le panel) compared to the original SYNTAX trial, where intervention was solely determined on angiographic visual grounds. In
SECTION 2 Treatment ofcoronary artery disease
Higher anatomical complexity
Lower anatomical complexity
Equivalent anatomical revascularization
surgical specialty
worker
https://t.me/medicina_free
90
FAVOURS CABG
Lower operative (CABG) risk
Stable patient
Younger age
Reduced kidney function
Lower LVEF
Good life expectancy
Preserved FEV1
Concomitant valvular heart
disease*
Diabetic status**
Revascularization guidelines
Resource availability
Operator skill
Patients wishes
Socioeconomic status
Cultural attitudes
Heart
Team
Higher operative (CABG) risk
Unstable patient
Older age
Preserved kidney function
Preserved LVEF
Reduced life expectancy
Reduced FEV1
Left main disease
Patient frailty
FAVOURS PCI
* Unless suitable for transaortic
valve replacement (TAVR)
* * Diabetic status may be
considered as part of SYNTAX
Score II
Fig.9.10 The Heart Team and decision- making. The complex interaction between anatomical complexity, clinical factors/ comorbidity, patient wishes,
and local resources the Heart Team need to consider in decision- making in patients with complex coronary artery disease.
Reproduced from Farooq V, Di Mario C, Serruys PW. Balancing idealism with realism to safeguard the welfare of patients:The importance of Heart Team led decision- making in
patients with complex coronary artery disease. Indian Heart J 2016;68:1– 5 with permission from Elsevier.
addition, 87% of attempted CTOs were successfully revascularized
(compared to 53% in the original SYNTAX trial), and intravascular
ultrasound guidance was used in 84.1% of patients (compared to
4.8% of patients in the original SYNTAX trial).
At 2- year follow- up of SYNTAX II,, the SYNTAX II PCI strategy
led to substantially improved clinical outcomes compared to the PCI
strategy adopted in SYNTAX I(Fig. 9.11, lower right panel). Moreover,
clinical outcomes were similar in 3VD patients with a low anatomical
SYNTAX s core (≤22)— in which revascularization guidelines currently
support PCI or CABG— compared to more anatomically complex 3VD
(anatomical SYNTAX score >22) in which current revascularization
guidelines support CABG. Notably, at an early follow- up of only 2years
no safety concerns were identied despite deferral of stenting in almost
one- third of lesions— with no increase in myocardial infarction in the
territory of the initially deferred lesions. It will be important to see if the
same holds true at 5years and longer of follow- up.
Exploratory endpoint comparing CABG withPCI
In the exploratory comparison of the SYNTAX II PCI strategy to the
predened CABG cohort from the original SYNTAX trial, equipoise
in MACCE was evident at early (2- year) follow- up. Notably, there
was an absence of convergence and crossing over of endpoints for
CABG and PCI at 2years, which was evident in ARTS Iand II.,
Consequently, a minimum of 5- year follow- up is essential to truly
evaluate any potential benet of the SYNTAX II strategy.
Non- invasive imaging toguide
decision- making
Papadopoulou etal. rst described the feasibility and reproducibility
of a multislice computed tomography (MSCT)- derived SYNTAX
score in 80 consecutive patients with symptomatic angina, using definitions of the angiographically dened SYNTAX score adapted for
MSCT capabilities. e underlying concept is to optimize patient
Cardiac
surgeon
Other medical/
Clinical
cardiologist
Interventional
cardiologist
Nurse/social
management by allowing an anatomical SYNTAX score to be calculated non- invasively prior to any invasive diagnostic procedure or
intervention. Now several studies have independently retrospectively validated this concept utilizing the anatomical SYNTAX score
alone.– In addition, the ongoing SYNTAX II trial has prospectively developed a non- invasive, MSCT- derived SYNTAX score II in
patients with de novo 3VD. Notably, the non- invasive SYNTAX score
II demonstrated at least substantial agreement with conventional
invasive angiography in guiding decision- making between CABG
and PCI.
SYNTAX III Revolution trial— non- invasive
Heart Team assessment ofmultivessel coronary
disease withcoronary CTangiography
e SYNTAX III Revolution trial (ClinicalTrials.gov identier
NCT02813473) is designed to provide evidence in decision- making by
randomizing two Heart Teams— composed of a cardiac surgeon, radiologist, and interventional cardiologist— to develop a ‘virtual’ treatment decision (CABG or PCI) in patients with le main or de novo
3VD, using information received strictly from non- invasive MSCT
angiography with functional assessment (HeartFlow), or from conventional invasive angiography (Fig. 9.12). e study was conducted in
223 patients over an 18- month period in six participating European
centres with statistical interpretation of the level of agreement between
the two Heart Teams in terms of their treatment decision based on the
MSCT- rst assessment or angiography- rst evaluation.
Treatment decisions were shown to be matched in 92.8% of patients (Cohen’s kappa coecient 0.82; 95% CI 0.73– 0.91). In addition, CTFFR was shown to be feasible in 196/ 223 patients, and
changed the treatment decision in 7% of patients, mostly from
CABG to PCI. Notably, the Heart Team agreed on the number of
bypasses, how many stents should be used, and their location in the
coronary circulation in 80% of cases.
Fig.9.11 SYNTAX II trial. Upper panel:study flow chart of the ongoing SYNTAX II trial— utilizing the state- of- art SYNTAX II PCI strategy of appropriate
https://t.me/medicina_free
patient selection with the SYNTAX score II, newer- generation stent platform with a biodegradable polymer, contemporary CTO revascularization
strategies, and functional and IVUS- guided PCI.37 Lower left panel:impact of the SYNTAX II PCI strategy— coronary physiology (a), CTO revascularization
(b)and IVUS (c)— in the SYNTAX II trial
superiority of the SYNTAX II PCI strategy compared to the PCI arm of the original SYNTAX Itrial (primary endpoint) at 2years (a). Similar 2- year outcomes
in patients stratified by low (≤22) and intermediate- high (>22) anatomical SYNTAX scores undergoing the SYNTAX II PCI strategy in the SYNTAX II trial
(b); similar outcomes of the SYNTAX II PCI strategy compared to CABG in the SYNTAX Itrial (exploratory endpoint) at 2years (c). CTO, chronic total
occlusion, IVUS intravascular ultrasound; MACCE, major adverse cardiac and cerebrovascular events; PCI, percutaneous coronary intervention.
Images adapted and used with permission from the SYNTAX Trial Investigators.
37,89,98
compared to the original SYNTAX Itrial. Lower right panel:outcomes of the SYNTAX II trial, demonstrating
SECTION 2 Treatment ofcoronary artery disease
https://t.me/medicina_free
92
SYNTAX III REVOLUTION
Presence of 3-vessel disease with/without LM on
conventional angiography (223 patients)
Heart Team A
Angio first (invasive CA)
223 assessments 223 assessments
Information
solely on Angio
1st Decision-making and treatment strategy
based on anatomic CA SYNTAX
score SYNTAX score II
(anatomy and comorbidities)
Information on Angio + MSCT
2nd Decision-making and treatment strategy
based on anatomic CA and CTA SYNTAX score,
FFRCT (functional anatomy), SYNTAX score II
(anatomy + comorbidities), functional anatomy
+ comorbidities (‘SYNTAX score III’)
MSCT (GE Revolution)
2 Heart Teams
R
Primary Endpoint
‘
Unblinding
Each Heart Team was randomized
to 1 of 2 diagnostic algorithms
Heart Team B
CT first (non-invasive CA)
Information
solely on MSCT
1st Decision-making and treatment strategy
based on anatomic CTA SYNTAX score,
SYNTAX score II (anatomy + comorbidities)
2nd Decision-making and treatment strategy based on
CTA with FFRCT (functional anatomic SYNTAX score),
SYNTAX score III and II (functional anatomy + comorbidities)
Information on MSCT + Angio
3rd Decision-making and treatment strategy based on
anatomic CTA with CA SYNTAX score, FFRCT (functional anatomy),
SYNTAX score II (anatomy + comorbidities), functional
anatomy + comorbidities (‘SYNTAX score III’)
Fig.9.12 Study design of the ongoing SYNTAX III Revolution trial.
Images adapted and used with permission from the SYNTAX Trial Investigators.
e next phase will be a rst- in- man trial with cardiac surgeons
treating patients based on MSCT scan alone without looking at coronary angiography.
Conclusion
Currently, best evidence dictates that CABG is superior to PCI for
the majority of patients with multivessel CAD with SYNTAX scores
greater than 22 and those with le main disease with SYNTAX
scores greater than 32. ere is, however, little doubt that decisionmaking in complex CAD is becoming increasingly multifaceted and
that clinical tools are needed to simplify the process and to make
it more objective for the Heart Team. In evaluating the existing
evidence basis for decision- making, it is vital to understand the selection of patients entered into trials and the duration of follow- up,
Clinical treatment
which must be an absolute minimum of 5years; indeed, even 5- year
follow- up should only be considered an ‘interim analysis’, as such
data are generally applied to decision- making for patients whose life
expectancy greatly exceeds 5years.
While current European guidelines (Table 9.1) advocate using
the anatomical SYNTAX score to aid in this process, clinicians
find this process time- consuming and cumbersome, and as
highlighted in SYNTAX and EXCEL, a significant disparity
exists between site- versus core laboratory- analysed anatomical SYNTAX scores which may have a detrimental impact on
patient care.
Reecting the importance of clinical factors in decision- making
between CABG and PCI, their incorporation into the SYNTAX
score II appears to circumvent some of the issues related to dierences in on- site versus core laboratory analyses, while simultaneously improving decision- making between CABG and PCI on the
9 Evidence basis fordecision-making betweencoronary artery bypass grafting and percutaneous coronaryintervention 93
https://t.me/medicina_free
Table9.1 European guidelines forthe choice betweenCABG and PCI
(a) Recommendations oncriteria forthe choice betweencoronary artery bypass grafting and percutaneous coronary intervention
Recommendations ClassaLevel
Assessment of surgical risk
It is recommended that the STS score is calculated to assess in- hospital or 30- day mortality, and in- hospital morbidity after CABG I B
Calculation of the EuroSCORE II score may be considered to assess in- hospital mortality after CABG IIb B
Assessment of CAD complexity
In patients with LM or multivessel disease, it is recommended that the SYNTAX score is calculated to assess the anatomical complexity of CAD
and the long- term risk of mortality and morbidity after PCI
When considering the decision between CABG and PCI, completeness of revascularization should be prioritized Ila B
CABG, coronary artery bypass grafting; CAD, coronary artery disease; EuroSCORE, European System for Cardiac Operative Risk Evaluation; LM, left main; PCI, percutaneous coronary
intervention; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
a
Class of recommendation.
b
Level of evidence.
c
Level of evidence refers to prediction of outcomes.
c
I B
b
(b) Recommendation forthe type ofrevascularization inpatients withstable coronary artery disease withsuitable coronary anatomy
forboth procedures and low predicted surgical mortality
d
Recommendations according to extent of CAD CABG PCI
Class
a
Level
b
Class
a
Level
b
One- vessel CAD
Without proximal LAD stenosis IIb C I C
With proximal LAD stenosis I A I A
Two- vessel CAD
Without proximal LAD stenosis IIb C I C
With proximal LAD stenosis I B I C
Left main CAD
Left main disease with low SYNTAX score (0– 24) I A I A
Left main disease with intermediate SYNTAX score (23– 32) I A IIa A
Left main disease with high SYNTAX score (≥33)
c
I A III B
Three- vessel CAD without diabetes mellitus
Three- vessel disease with low SYNTAX score (0– 22) I A I A
Three- vessel disease with intermediate or high SYNTAX score (>22)
c
I A III A
Three- vessel CAD with diabetes mellitus
Three- vessel disease with low SYNTAX score 0– 22 I A IIb A
Three- vessel disease with intermediate or high SYNTAX score (>22)
SYNTAX score calculation information is available at http:// www.syntaxscore.com.
CABG, coronary artery bypass grafting; CAD, coronary artery disease; LAD, left anterior descending coronary artery; PCI, percutaneous coronary intervention; SYNTAX, Synergy
between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
a
Class of recommendation.
b
Level of evidence.
c
PCI should be considered if the Heart Team is concerned about the surgical risk or if the patient refuses CABG after adequate counselling by the Heart Team.
d
For example, absence of previous cardiac surgery, severe morbidities, frailty, or immobility precluding CABG.
c
I A III A
Reproduced from Neumann FJ, Sousa- Uva M, Ahlsson Aetal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:87– 165 with
permission from Oxford University Press.
grounds of long- term mortality. Further external validation studies
are awaited. e prospect of non- invasive imaging may also circumvent this issue by streamlining decision- making, provided this is
used within the context of the Heart Team.
As clinical evidence continues to accumulate, we should focus our
attention on well- designed, prospective, contemporary clinical trials
to improve our understanding and treatment of complex CAD.
REFERENCES
1. Taggart DP. omas B. Ferguson Lecture. Coronary artery bypass
graing is still the best treatment for multivessel and le main disease,
but patients need to know. Ann orac Surg. 2006;82:1966– 75.
2. Soran O, Manchanda A, Schueler S. Percutaneous coronary
intervention versus coronary artery bypass surgery in multivessel
SECTION 2 Treatment ofcoronary artery disease
https://t.me/medicina_free
94
disease:a current perspective. Interact Cardiovasc orac Surg.
2009;8:666– 71.
3. Taggart DP. CABG or stents in coronary artery disease:end of the
debate? Lancet. 2013;381:605– 7.
4. Farooq V, Serruys PW. “Cherry- picking” patients for randomized,
controlled trials- reliving the past. J Am Coll Cardiol. 2013;61:2492.
5. Serruys PW. e Heart Team– perpetually mutating.
EuroIntervention. 2016;12:693.
6. Zimmerman M, Mattia JI, Posternak MA. Are subjects in
pharmacological treatment trials of depression representative of
patients in routine clinical practice? Am J Psychiatry. 2002;159:469– 73.
7. Serruys PW, Farooq V. Cherry- picking historical data to legitimize
contemporary practice:should diabetic status inuence decisionmaking in complex CAD? J Am Coll Cardiol. 2017;69:404– 408.
8. Hlatky MA, Boothroyd DB, Bravata DM etal. Coronary artery bypass
surgery compared with percutaneous coronary interventions for
multivessel disease:a collaborative analysis of individual patient data
from ten randomised trials. e Lancet 2009;373:1190– 97.
9. Homan SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong
JB. A meta- analysis of randomized controlled trials comparing
coronary artery bypass gra with percutaneous transluminal
coronary angioplasty:one- to eight- year outcomes. Journal of the
American College of Cardiology 2003;41:1293– 304.
10. Verma S, Farkouh ME, Yanagawa B etal. Comparison of coronary
artery bypass surgery and percutaneous coronary intervention in
patients with diabetes:a meta- analysis of randomised controlled
trials. Lancet Diabetes Endocrinol 2013;1:317– 28.
11. Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary
artery bypass graing vs percutaneous coronary intervention and
long- term mortality and morbidity in multivessel disease:metaanalysis of randomized clinical trials of the arterial graing and
stenting era. JAMA internal medicine 2014;174:223– 30.
12. Flather M, Rhee JW, Boothroyd DB etal. e eect of age on outcomes
of coronary artery bypass surgery compared with balloon angioplasty
or bare- metal stent implantation among patients with multivessel
coronary disease. Acollaborative analysis of individual patient data
from 10 randomized trials. J Am Coll Cardiol 2012;60:2150– 7.
13. Farooq V, van Klaveren D, Steyerberg EW etal. Anatomical
and clinical characteristics to guide decision making between
coronary artery bypass surgery and percutaneous coronary
intervention for individual patients:development and validation
of SYNTAX score II. Lancet. 2013;381:639– 50.
14. Farooq V, van Klaveren D, Steyerberg EW, Serruys PW. SYNTAX
score II– Authors’ reply. Lancet. 2013;381:1899– 900.
15. Ong AT, Serruys PW, Mohr FW etal. e SYNergy between
percutaneous coronary intervention with TAXus and cardiac
surgery (SYNTAX) study:design, rationale, and run- in phase.
Am Heart J. 2006;151:1194– 204.
16. Serruys PW, Morice MC, Kappetein AP etal. Percutaneous
coronary intervention versus coronary- artery bypass graing for
severe coronary artery disease. N Engl J Med. 2009;360:961– 72.
17. Kappetein AP, Feldman TE, Mack MJ etal. Comparison of
coronary bypass surgery with drug- eluting stenting for the
treatment of le main and/ or three- vessel disease:3- year followup of the SYNTAX trial. Eur Heart J. 2011;32:2125– 34.
18. Mohr FW, Morice MC, Kappetein AP etal. Coronary artery bypass
gra surgery versus percutaneous coronary intervention in patients
with three- vessel disease and le main coronary disease:5- year followup of the randomised, clinical SYNTAX trial. Lancet 2013;381:629– 38.
19. uijs DJFM, Kappetein AP, Serruys PW etal. Percutaneous
coronary intervention versus coronary artery bypass graing in
patients with three- vessel or le main coronary artery disease:10year follow- up of the multicentre randomised controlled SYNTAX
trial. Lancet. 2019;394(10206):1325– 34. doi:10.1016/ S01406736(19)31997- X. Epub 2019 Sep 2.PMID:31488373 Clinical Trial.
20. Mohr FW, Rastan AJ, Serruys PW, Kappetein AP, Holmes
DR, Pomar JL, Westaby S, Leadley K, Dawkins KD, Mack MJ.
Complex coronary anatomy in coronary artery bypass gra
surgery:impact of complex coronary anatomy in modern bypass
surgery? Lessons learned from the SYNTAX trial aer two years.
J orac Cardiovasc Surg. 2011;141(1):130– 40. doi:10.1016/
j.jtcvs.2010.07.094.PMID:21168023.
21. Farooq V, Serruys PW. Complex coronary artery disease:would
outcomes from the SYNTAX(synergy between percutaneous
coronary intervention with taxus and cardiac surgery) trial
have diered with newer- generation drug- elutingstents?
JACC Cardiovasc Interv. 2013;6(10):1023– 5. doi:10.1016/
j.jcin.2013.07.004.PMID:24156963.
22. Farkouh ME, Dangas G, Leon MB etal. Design of the Future
REvascularization Evaluation in patients with Diabetes
mellitus:Optimal management of Multivessel disease
(FREEDOM) trial. Am Heart J 2008;155:215– 23.
23. Farkouh ME, Domanski M, Sleeper LA etal. Strategies for
multivessel revascularization in patients with diabetes. N Engl J
Med 2012;367:2375– 84.
24. Park SJ, Ahn JM, Kim YH etal. Trial of everolimus- eluting stents or
bypass surgery for coronary disease. N Engl J Med 2015;372:1204– 12.
25. Farkouh ME, Domanski M, etal. Long- term survival following
multivessel revascularization in patients with diabetes:e
FREEDOM follow- on study. J Am Coll Cardiol 2019;73(6):629–
38. doi:10.1016/ j.jacc.2018.11.001. Epub 2018 Nov 11.
26. Sianos G, Morel MA, A.P. K etal. e SYNTAX score:an
angiographic tool grading the complexity of coronary artery
disease. EuroIntervention, 2005 219– 227.
27. Head SJ, Farooq V, Serruys PW, Kappetein AP. e SYNTAX
score and its clinical implications. Heart 2014;100:169– 77.
28. Leaman DM, Brower RW, Meester GT, Serruys P, van den Brand
M. Coronary artery atherosclerosis:severity of the disease,
severity of angina pectoris and compromised le ventricular
function. Circulation 1981;63:285– 99.
29. Smith SC, Jr., Feldman TE, Hirshfeld JW, Jr. etal. ACC/ AHA/ SCAI
2005 guideline update for percutaneous coronary intervention:a
report of the American College of Cardiology/ American Heart
Association Task Force on Practice Guidelines (ACC/ AHA/ SCAI
Writing Committee to Update the 2001 Guidelines for Percutaneous
Coronary Intervention). J Am Coll Cardiol 2006;47:e1– 121.
30. Scanlon PJ, Faxon DP, Audet AM etal. ACC/ AHA guidelines for
coronary angiography:executive summary and recommendations.
Areport of the American College of Cardiology/ American Heart
Association Task Force on Practice Guidelines (Committee on Coronary
Angiography) developed in collaboration with the Society for Cardiac
Angiography and Interventions. Circulation 1999;99:2345– 57.
31. Medina A, Suarez de Lezo J, Pan M. [A new classication of
coronary bifurcation lesions]. Rev Esp Cardiol 2006;59:183.
32. Hamburger JN, Serruys PW, Scabra- Gomes R etal. Recanalization
of total coronary occlusions using a laser guidewire (the European
TOTAL Surveillance Study). Am J Cardiol 1997;80:1419– 23.
33. Serruys PW, Onuma Y, Garg S etal. 5- Year Clinical Outcomes of the
ARTS II (Arterial Revascularization erapies Study II) of the SirolimusEluting Stent in the Treatment of Patients With Multivessel De Novo
Coronary Artery Lesions. J Am Coll Cardiol 2010;55:1093– 1101.
34. Campos CM, van Klaveren D, Farooq V etal. Long- term forecasting
and comparison of mortality in the Evaluation of the Xience
Everolimus Eluting Stent vs Coronary Artery Bypass Surgery for
Eectiveness of Le Main Revascularization (EXCEL) trial:prospective
validation of the SYNTAX Score II. Eur Heart J 2015;36:1231– 41.
9 Evidence basis fordecision-making betweencoronary artery bypass grafting and percutaneous coronaryintervention 95
https://t.me/medicina_free
35. Kappetein AP, Serruys PW, Sabik JF etal. Design and rationale for a
randomised comparison of everolimus- eluting stents and coronary
artery bypass gra surgery in selected patients with le main coronary
artery disease:the EXCEL trial. EuroIntervention 2016;12:861– 72.
36. Stone GW, Sabik JF, Serruys PW etal. Everolimus- Eluting Stents
or Bypass Surgery for Le Main Coronary Artery Disease. N Engl
J Med 2016;375:2223– 35.
37. Escaned J, Banning A, Farooq V etal. Rationale and design of the
SYNTAX II trial evaluating the short to long- term outcomes of stateof- the- art percutaneous coronary revascularisation in patients with
de novo three- vessel disease. EuroIntervention 2016;12:e224– 34.
38. Serruys PW, Farooq V, Vranckx P etal. A global risk approach to
identify patients with le main or 3- vessel disease who could safely and
ecaciously be treated with percutaneous coronary intervention:the
SYNTAX trial at 3years. JACC Cardiovasc Interv 2012;5:606– 17.
39. Cheruvu PK, Finn AV, Gardner C etal. Frequency and
distribution of thin- cap broatheroma and ruptured plaques in
human coronary arteries:a pathologic study. J Am Coll Cardiol
2007;50:940– 9.
40. Farooq V, Di Mario C, Serruys PW. e triad of residual
ischaemia, plaque burden, and plaque vulnerability:a known
known?... a known unknown?... or an unknown unknown?
EuroIntervention 2015;11:611– 9.
41. Mancini GB, Hartigan PM, Shaw LJ etal. Predicting outcome
in the COURAGE trial (Clinical Outcomes Utilizing
Revascularization and Aggressive Drug Evaluation):coronary
anatomy versus ischemia. JACC Cardiovasc Interv 2014;7:195– 201.
42. King SB, 3rd. Is it form or function?:the “COURAGE” to ask.
JACC Cardiovasc Interv 2014;7:202– 3.
43. Mushtaq S, De Araujo Goncalves P, Garcia- Garcia HM etal.
Long- term prognostic eect of coronary atherosclerotic
burden:validation of the computed tomography- Leaman score.
Circ Cardiovasc Imaging 2015;8:e002332.
44. Head SJ, Kaul S, Mack MJ etal. e rationale for Heart Team
decision- making for patients with stable, complex coronary
artery disease. Eur Heart J 2013;34:2510– 8.
45. Farooq V, Serruys PW, Zhang Y etal. Short- term and longterm clinical impact of stent thrombosis and gra occlusion in
the SYNTAX trial at 5years:Synergy Between Percutaneous
Coronary Intervention with Taxus and Cardiac Surgery trial. J
Am Coll Cardiol 2013;62:2360– 9.
46. Doenst T, Haverich A, Serruys P etal. PCI and CABG for
Treating Stable Coronary Artery Disease:JACC Review Topic of
the Week. J Am Coll Cardiol 2019;73:964– 76.
47. Taggart DP, D’Amico R, Altman DG. Eect of arterial
revascularisation on survival:a systematic review of studies
comparing bilateral and single internal mammary arteries. Lancet
2001;358:870– 5.
48. Taggart DP, Altman DG, Gray AM etal. Randomized trial to
compare bilateral vs single internal mammary coronary artery
bypass graing:1- year results of the Arterial Revascularisation
Trial (ART). Eur Heart J 2010;31:2470– 81.
49. Taggart DP, Altman DG, Gray AM etal. Randomized Trial of
Bilateral versus Single Internal- oracic- Artery Gras. N Engl J
Med 2016;375:2540– 9.
50. Taggart DP, Benedetto U, Gerry S etal. Bilateral versus Single
Internal- oracic- Artery Gras at 10 Years. N Engl J Med
2019;380:437– 46.
51. Pereg D, Fefer P, Samuel M etal. Native coronary artery patency
aer coronary artery bypass surgery. JACC Cardiovasc Interv
2014;7:761– 7.
52. Farooq V, Serruys PW, Garcia- Garcia HM etal. e negative
impact of incomplete angiographic revascularization on clinical
outcomes and its association with total occlusions:the SYNTAX
(Synergy Between Percutaneous Coronary Intervention with Taxus
and Cardiac Surgery) trial. J Am Coll Cardiol 2013;61:282– 94.
53. Farooq V, Girasis C, Magro M etal. e CABG SYNTAX
score:an angiographic tool to grade the complexity of coronary
disease following coronary artery bypass gra surgery:from
the SYNTAX Le Main Angiographic (SYNTAX- LE MANS)
substudy. EuroIntervention 2013;8:1277– 85.
54. Farooq V, Girasis C, Magro M etal. e coronary artery bypass
gra SYNTAX Score:nal ve- year outcomes from the SYNTAXLE MANS le main angiographic substudy. EuroIntervention
2013;9:1009– 10.
55. Panza JA, Velazquez EJ, She L etal. Extent of coronary and myocardial
disease and benet from surgical revascularization in ischemic LV
dysfunction [Corrected]. J Am Coll Cardiol 2014;64:553– 61.
56. Velazquez EJ, Lee KL, Jones RH etal. Coronary- Artery Bypass
Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med
2016;374:1511– 20.
57. O’Connor SA, Garot P, Sanguineti F etal. Meta- Analysis of the
Impact on Mortality of Noninfarct- Related Artery Coronary
Chronic Total Occlusion in Patients Presenting With ST- Segment
Elevation Myocardial Infarction. Am J Cardiol 2015;116:8– 14.
58. Claessen BE, Dangas GD, Weisz G etal. Prognostic impact of a
chronic total occlusion in a non- infarct- related artery in patients
with ST- segment elevation myocardial infarction:3- year results
from the HORIZONS- AMI trial. Eur Heart J 2012;33:768– 75.
59. Meier P, Hemingway H, Lansky AJ, Knapp G, Pitt B, Seiler C.
e impact of the coronary collateral circulation on mortality:a
meta- analysis. Eur Heart J 2012;33:614– 21.
60. Seiler C, Stoller M, Pitt B, Meier P. e human coronary collateral
circulation:development and clinical importance. Eur Heart J
2013;34:2674– 82.
61. Chan W, Ivanov J, Ko D etal. Clinical outcomes of treatment by
percutaneous coronary intervention versus coronary artery bypass
gra surgery in patients with chronic kidney disease undergoing
index revascularization in Ontario. Circ Cardiovasc Interv 2015;8.
62. Baber U, Farkouh ME, Arbel Y etal. Comparative ecacy of coronary
artery bypass surgery vs percutaneous coronary intervention in
patients with diabetes and multivessel coronary artery disease with or
without chronic kidney disease. Eur Heart J 2016;37:3440– 47.
63. Morice MC, Serruys PW, Kappetein AP etal. Outcomes in
patients with de novo le main disease treated with either
percutaneous coronary intervention using paclitaxel- eluting
stents or coronary artery bypass gra treatment in the Synergy
Between Percutaneous Coronary Intervention with TAXUS and
Cardiac Surgery (SYNTAX) trial. Circulation 2010;121:2645– 53.
64. Stone GW, Kappetein AP, Sabik JF etal. Five- Year Outcomes aer
PCI or CABG for Le Main Coronary Disease. N Engl J Med.
2019;381(19):1820– 30. doi:10.1056/ NEJMoa1909406. Epub 2019
September 28.PMID:31562798.
65. Zhang YJ, Iqbal J, Campos CM etal. Prognostic value of site
SYNTAX score and rationale for combining anatomic and clinical
factors in decision making:insights from the SYNTAX trial. J Am
Coll Cardiol 2014;64:423– 32.
66. Makikallio T, Holm NR, Lindsay M etal. Percutaneous coronary
angioplasty versus coronary artery bypass graing in treatment of
unprotected le main stenosis (NOBLE):a prospective, randomised,
open- label, non- inferiority trial. Lancet 2016;388:2743– 52.
67. Mack M, Holmes DR. Randomised trials in le main disease:a
NOBLE eort. Lancet 2016;388:2715– 16.
68. Farooq V, Serruys PW, Bourantas C etal. Incidence and
multivariable correlates of long- term mortality in patients treated
with surgical or percutaneous revascularization in the synergy
SECTION 2 Treatment ofcoronary artery disease
https://t.me/medicina_free
96
between percutaneous coronary intervention with taxus and
cardiac surgery (SYNTAX) trial. Eur Heart J 2012;33:3105– 13.
69. Lansky AJ, Ng VG, Maehara A etal. Gender and the extent of coronary
atherosclerosis, plaque composition, and clinical outcomes in acute
coronary syndromes. JACC Cardiovascular imaging 2012;5:S62– 72.
70. Ruiz- Garcia J, Lerman A, Weisz G etal. Age- and gender- related
changes in plaque composition in patients with acute coronary
syndrome:the PROSPECT study. EuroIntervention 2012;8:929– 38.
71. Ranucci M, Castelvecchio S, Conte M etal. e easier, the
better:age, creatinine, ejection fraction score for operative mortality
risk stratication in a series of 29,659 patients undergoing elective
cardiac surgery. J orac Cardiovasc Surg 2011;142:581– 6.
72. Ranucci M, Castelvecchio S, Menicanti L, Frigiola A, Pelissero G.
Risk of assessing mortality risk in elective cardiac operations:age,
creatinine, ejection fraction, and the law of parsimony.
Circulation 2009;119:3053– 61.
73. Ranucci M, Castelvecchio S. e ACEF score one year aer:a
skeleton waiting for muscles, skin, and internal organs.
EuroIntervention 2010;6:549– 53.
74. Fox CS, Matsushita K, Woodward M etal. Associations of kidney
disease measures with mortality and end- stage renal disease in
individuals with and without diabetes:a meta- analysis. Lancet
2012;380:1662– 73.
75. Tonelli M, Muntner P, Lloyd A etal. Risk of coronary events
in people with chronic kidney disease compared with those
with diabetes:a population- level cohort study. Lancet
2012;380:807– 14.
76. Neumann FJ, Sousa- Uva M, Ahlsson A etal. 2018 ESC/ EACTS
Guidelines on myocardial revascularization. Eur Heart J
2019;40:87– 165.
77. Authors/ Task Force m, Windecker S, Kolh P etal. 2014 ESC/
EACTS Guidelines on myocardial revascularization:e Task
Force on Myocardial Revascularization of the European Society
of Cardiology (ESC) and the European Association for Cardiooracic Surgery (EACTS)Developed with the special contribution
of the European Association of Percutaneous Cardiovascular
Interventions (EAPCI). Eur Heart J 2014;35:2541– 619.
78. Fihn SD, Blankenship JC, Alexander KP etal. 2014 ACC/ AHA/
AATS/ PCNA/ SCAI/ STS focused update of the guideline for
the diagnosis and management of patients with stable ischemic
heart disease:a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines,
and the American Association for oracic Surgery, Preventive
Cardiovascular Nurses Association, Society for Cardiovascular
Angiography and Interventions, and Society of oracic
Surgeons. J Am Coll Cardiol 2014;64:1929– 49.
79. Armstrong EJ, Rutledge JC, Rogers JH. Coronary artery
revascularization in patients with diabetes mellitus. Circulation
2013;128:1675– 85.
80. Paneni F, Beckman JA, Creager MA, Cosentino F. Diabetes and
vascular disease:pathophysiology, clinical consequences, and
medical therapy:part I. Eur Heart J 2013;34:2436– 43.
81. Creager MA, Luscher TF, Cosentino F, Beckman JA. Diabetes and
vascular disease:pathophysiology, clinical consequences, and
medical therapy:Part I. Circulation 2003;108:1527– 32.
82. Turner RC, Millns H, Neil HA etal. Risk factors for coronary artery
disease in non- insulin dependent diabetes mellitus:United Kingdom
Prospective Diabetes Study (UKPDS:23). BMJ 1998;316:823– 8.
83. Beckman JA, Paneni F, Cosentino F, Creager MA. Diabetes and
vascular disease:pathophysiology, clinical consequences, and
medical therapy:part II. Eur Heart J 2013;34:2444– 52.
84. Ellis SG. Coronary revascularization for patients with
diabetes:updated data favor coronary artery bypass graing. J
Am Coll Cardiol 2013;61:817– 9.
85. van Domburg RT, Kappetein AP, Bogers AJ. e clinical outcome
aer coronary bypass surgery:a 30- year follow- up study. Eur
Heart J 2009;30:453– 8.
86. Iqbal J, Zhang YJ, Holmes DR etal. Optimal medical
therapy improves clinical outcomes in patients undergoing
revascularization with percutaneous coronary intervention
or coronary artery bypass graing:insights from the Synergy
Between Percutaneous Coronary Intervention with TAXUS
and Cardiac Surgery (SYNTAX) trial at the 5- year follow- up.
Circulation 2015;131:1269– 77.
87. Zhang YJ, Iqbal J, van Klaveren D etal. Smoking is associated
with adverse clinical outcomes in patients undergoing
revascularization with PCI or CABG:the SYNTAX trial at 5- year
follow- up. J Am Coll Cardiol 2015;65:1107– 15.
88. Farkouh ME, Boden WE, Bittner V etal. Risk factor control
for coronary artery disease secondary prevention in large
randomized trials. J Am Coll Cardiol 2013;61:1607– 15.
89. Serruys PW, Kogame N, Katagiri Y etal. Clinical outcomes
of state- of- the- art percutaneous coronary revascularization
in patients with three- vessel disease:2- year follow- up of the
SYNTAX II study. EuroIntervention 2019;15(3):e244– e252.
90. Escaned J, Banning A, Farooq V, Serruys P. SYNTAX II:Two- year
clinical outcomes of the study using state- of- the- art percutaneous
coronary revascularisation in patients with de novo- vessel
disease. Eur Heart J. 2017;38(42):3124– 3134..
91. Serruys PW, Ong AT, van Herwerden LA etal. Five- year
outcomes aer coronary stenting versus bypass surgery for the
treatment of multivessel disease:the nal analysis of the Arterial
Revascularization erapies Study (ARTS) randomized trial. J
Am Coll Cardiol 2005;46:575– 81.
92. Papadopoulou SL, Girasis C, Dharampal A etal. CT- SYNTAX
score:a feasibility and reproducibility Study. JACC Cardiovasc
Imaging 2013;6:413– 5.
93. Pozo E, Alvarez- Acosta L, Alonso D etal. Diagnostic accuracy of
coronary ct for the quantication of the syntax score in patients
with le main and/ or 3- vessel coronary disease. Comparison
with invasive angiography. Int J Cardiol 2015;182:549– 56.
94. Shalev A, Nakazato R, Arsanjani R etal. SYNTAX score derived from
coronary CT angiography for prediction of complex percutaneous
coronary interventions. Acad Radiol 2016;23:1384– 92.
95. Yuceler Z, Kantarci M, Tanboga IH etal. Coronary lesion
complexity assessed by SYNTAX score in 256- slice dual- source
MDCT angiography. Diagn Interv Radiol 2016;22:334– 40.
96. Suh YJ, Hong YJ, Lee HJ etal. Accuracy of CT for selecting
candidates for coronary artery bypass gra surgery:combination
with the SYNTAX score. Radiology 2015;276:390– 9.
97. Cavalcante R, Onuma Y, Sotomi Y etal. Non- invasive Heart
Team assessment of multivessel coronary disease with coronary
computed tomography angiography based on SYNTAX score
II treatment recommendations:design and rationale of the
randomised SYNTAX III Revolution trial. EuroIntervention
2017;12:2001– 8.
98. Farooq V, Head SJ, Kappetein AP, Serruys PW. Widening clinical
applications of the SYNTAX Score. Heart 2014;100:276– 87.
99. Escaned J, Collet C, Ryan N etal. Clinical outcomes of state- ofthe- art percutaneous coronary revascularization in patients with
de novo three vessel disease:1- year results of the SYNTAX II
study. Eur Heart J 2017;38:3124– 34.
https://t.me/medicina_free
10
Lifestyle management and secondary
prevention ofcoronary arterydisease
Mansoor Ahmad, Sandra A. Weiss, and William S. Weintraub
Introduction
work, gardening, and household work. is results in improved
cardiorespiratory tness and moves patients out of the least t, least
Cardiovascular (CV) disease has been the leading cause of death
in industrialized nations since the early 1900s. According to the
American Heart Association (AHA), there are more than 1million
new and recurrent cardiac events occurring each year. ose with
a history of cardiac ischaemic events have a high risk of recurrent
events; however, the death rate from coronary artery disease (CAD)
declined from 1995 to 2005 by 26%. us, the burden of chronic
non- fatal CAD remains high and therefore underscores the importance of secondary prevention measures.
Clinical studies have shown that eective secondary prevention
can reduce mortality and improve quality of life. Secondary prevention comprises medical therapy, therapeutic lifestyle changes, and
revascularization in the form of coronary artery bypass graing or
percutaneous coronary intervention. From 1980 to 2000, CV death
rates in the United States have decreased by 50% with improvements
in CV risk factors, especially reduction in tobacco use and better
cholesterol and hypertension management accounting for most of
this dramatic decrease.
In this chapter we will focus on lifestyle modication, which is considered a major component of secondary prevention. Eectiveness
of lifestyle modications in reducing mortality has been proven. In
patients with CAD, smoking cessation, physical activity, and dietary
changes have shown mortality reduction of between 20% and 35%,
comparable to eect size estimates of cardioprotective drugs.
active high- risk cohort.
Effect onmorbidity andmortality
In one analysis, it was estimated that just by eliminating physical inactivity, 6% of CAD worldwide can be eliminated and life
expectancy of the world population may increase by 0.68years.
A meta- analysis of secondary prevention programmes that included 63 randomized trials and 21,295 patients with CAD showed
exercise- based programmes signicantly reduced mortality risk
(risk ratio 0.72, 95% condence interval (CI) 0.54– 0.95). Of note,
the survival benet seen in recent trials was similar to that seen
two decades earlier, which was before the development of current
cardioprotective drug regimens. is therefore demonstrates an
incremental benet of physical activity over medicinal therapies
that are shown to be eective in secondary prevention. Another
demonstrated benet of long- term exercise training is possible
attenuation of unfavourable remodelling of the le ventricle in
postinfarction patients.
How does it work?
Improvement ofcardiac riskfactors
Regular physical activity can improve multiple cardiac risk factors.
Lipids
A prospective randomized controlled trial including sedentary,
Physicalactivity
Physical activity is known to reduce comorbid risk factors, improve
quality of life, and is a major component of secondary prevention
of CAD. AHA guidelines recommend a goal of 30– 60 minutes of
moderate- intensity aerobic activity, such as brisk walking, at least
5days and preferably 7days per week.
Regular physical activity should also be supplemented by an increase in daily lifestyle activities that can include walking breaks at
overweight individuals with mild to moderate dyslipidaemia
showed that exercise training at a caloric equivalent of 17– 18
miles/ week jogging at a moderate pace signicantly decreased the
number of small low- density lipoprotein (LDL) particles, reduced
triglycerides, and increased total high- density lipoprotein (HDL)
concentration.
Insulinresistance
Regular physical activity is also known to improve insulin resistance
and glucose intolerance.
Соседние файлы в папке Библиотека им академика М.И. Перельмана