Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered. Objective: To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships. Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (Crl)) as a function of the additional time delay associated with angioplasty. \ Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean ( SE) angioplasty-related time delay ( over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis ( OR = 0.68 ( 95% Crl 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 ( 95% Crl 0.20 to 0.51); for non-fatal stroke OR = 0.24 ( 95% Crl 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation. Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1- month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays

Rupture of the arterial wall causes deflection in pressure time course during ex vivo balloon angioplasty

A relation between restenosis and arterial lesions resulting from balloon angioplasty has been suggested in literature. Nevertheless, it is unclear to what extent angioplasty-induced arterial wall lesions contribute to the occurrence of restenosis. One problem is that arterial ruptures cannot be detected during balloon inflation. This study describes a method to detect ruptures in the arterial wall, based on deflections observable in the development of the balloonpressure. We performed ex vivo angioplasty with constant strain rate on 28 human femoral artery segments, showing deflections in 21 cases. In 20 cases wall rupture was confirmed histologically. From seven cases not showing deflections, four showed intact wall at microscopy. These figures result in a selectivity of the proposed method of 87 ± 7% and a predictive value of the positive test of 95 ± 5%. We conclude that this method can enhance detection of arterial rupture during ex vivo angioplasty and may become important clinically

Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis

Objective: To assess the cost effectiveness of primary angioplasty, compared with medical management with thrombolytic drugs, to achieve reperfusion after acute myocardial infarction ( AMI) from the perspective of the UK NHS. Design: Bayesian evidence synthesis and decision analytic model. Methods: A systematic review was conducted and Bayesian statistical methods used to synthesise evidence from 22 randomised control trials. Resource utilisation was based on UK registry data, published literature and national databases, with unit costs taken from routine NHS sources and published literature. Main outcome measure: Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs). Results: For the base case, the incremental cost-effectiveness ratio of primary angioplasty was pound 9241 for each additional QALY, with a probability of being cost effective of 0.90 for a cost-effectiveness threshold of pound 20 000. Results were sensitive to variations in the additional time required to initiate treatment with primary angioplasty. Conclusions: Primary angioplasty is cost effective for the treatment of AMI on the basis of threshold cost-effectiveness values used in the NHS and subject to a delay of up to about 80 minutes. These findings are mainly explained by the superior mortality benefit and the prevention of non-fatal outcomes associated with primary angioplasty for delays of up to this length

S-Nitrosoglutathione reduces asymptomatic embolization after carotid angioplasty

Background: The major complication of carotid angioplasty is embolic stroke, which may occur after balloon inflation and deflation or in the early postintervention period. Platelet adhesion and aggregation to the angioplasty site with subsequent embolization seems to plays a major role in early postangioplasty embolization and stroke. During this period, asymptomatic embolic signals can be detected in patients by transcranial Doppler ultrasound despite aspirin and heparin treatment. S-Nitrosoglutathione (GSNO) is a nitric oxide donor that appears to have relative platelet specificity. We evaluated its effectiveness in reducing embolization after carotid angioplasty. Methods and results: Sixteen patients undergoing carotid angioplasty and stenting for symptomatic 70% internal carotid artery stenosis were randomized in a double-blind manner to GSNO or placebo given after surgery for 90 minutes. All patients were pretreated with aspirin and given heparin for 24 hours after the procedure. Transcranial Doppler recordings were made from the ipsilateral middle cerebral artery for 1 hour before treatment and at 0 to 3, 6, and 24 hours after treatment. GSNO resulted in a rapid reduction in the frequency of embolic signals of 95% at 0 to 3 hours and 100% at 6 hours (P=0.007 and P=0.01 versus placebo, respectively). In the placebo group, 2 patients experienced ipsilateral stroke after the angioplasty. No cerebrovascular events occurred in the GSNO group. Conclusions: S-Nitrosoglutathione was highly effective in rapidly reducing the frequency of embolic signals after endovascular treatment for symptomatic high-grade carotid stenosis

An examination of factors influencing the choice of therapy for patients with coronary artery disease

Background A diverse range of factors influence clinicians' decisions regarding the allocation of patients to different treatments for coronary artery disease in routine cardiology clinics. These include demographic measures, risk factors, co-morbidities, measures of objective cardiac disease, symptom reports and functional limitations. This study examined which of these factors differentiated patients receiving angioplasty from medication; bypass surgery from medication; and bypass surgery from angioplasty. Methods Univariate and multivariate logistic regression analyses were conducted on patient data from 214 coronary artery disease patients who at the time of recruitment had been received a clinical assessment and were reviewed by their cardiologist in order to determine the form of treatment they were to undergo: 70 would receive/continue medication, 71 were to undergo angioplasty and 73 were to undergo bypass surgery. Results Analyses differentiating patients receiving angioplasty from medication produced 9 significant univariate predictors, of which 5 were also multivariately significant (left anterior descending artery disease, previous coronary interventions, age, hypertension and frequency of angina). The analyses differentiating patients receiving surgery from angioplasty produced 12 significant univariate predictors, of which 4 were multivariately significant (limitations in mobility range, circumflex artery disease, previous coronary interventions and educational level). The analyses differentiating patients receiving surgery from medication produced 14 significant univariate predictors, of which 4 were multivariately significant (left anterior descending artery disease, previous cerebral events, limitations in mobility range and circumflex artery disease). Conclusion Variables emphasised in clinical guidelines are clearly involved in coronary artery disease treatment decisions. However, variables beyond these may also be important factors when therapy decisions are undertaken thus their roles require further investigation

Five years of peripheral percutaneous transluminal angioplasty : the St Luke’s Hospital experience

This article reviews the first series of 54 cases of Percutaneous Transluminal Angioplasty on the peripheral vasculature performed at the Radiological/Surgical Department at St. Luke’s Hospital, Malta, over a five year period. After describing in detail the technique used, the indications and the objective criteria utilised for assessment are reviewed and analysed. The two year patency rate for femoro-popliteal and iliac stenoses was 93% and 86% respectively, while for corresponding occlusions, the figures were 42% and 0% respectively. Thus, while the results were very encouraging for femoro-popliteal stenoses and occlusions, they were unacceptable for iliac occlusions. As expected the major risk factors were smoking, diabetes mellitus and associated ischaemic heart or cerebrovascular disease. This series had no mortality and there was minimal morbidity, mainly at the site of arterial access. Elective surgery for iliac re-stenosis was only required in one patient.peer-reviewe

ASCORE: an up-to-date cardiovascular risk score for hypertensive patients reflecting contemporary clinical practice developed using the (ASCOT-BPLA) trial data.

A number of risk scores already exist to predict cardiovascular (CV) events. However, scores developed with data collected some time ago might not accurately predict the CV risk of contemporary hypertensive patients that benefit from more modern treatments and management. Using data from the randomised clinical trial Anglo-Scandinavian Cardiac Outcomes Trial-BPLA, with 15 955 hypertensive patients without previous CV disease receiving contemporary preventive CV management, we developed a new risk score predicting the 5-year risk of a first CV event (CV death, myocardial infarction or stroke). Cox proportional hazard models were used to develop a risk equation from baseline predictors. The final risk model (ASCORE) included age, sex, smoking, diabetes, previous blood pressure (BP) treatment, systolic BP, total cholesterol, high-density lipoprotein-cholesterol, fasting glucose and creatinine baseline variables. A simplified model (ASCORE-S) excluding laboratory variables was also derived. Both models showed very good internal validity. User-friendly integer score tables are reported for both models. Applying the latest Framingham risk score to our data significantly overpredicted the observed 5-year risk of the composite CV outcome. We conclude that risk scores derived using older databases (such as Framingham) may overestimate the CV risk of patients receiving current BP treatments; therefore, 'updated' risk scores are needed for current patients

Processing Metonymy: a Domain-Model Heuristic Graph Traversal Approach

We address here the treatment of metonymic expressions from a knowledge representation perspective, that is, in the context of a text understanding system which aims to build a conceptual representation from texts according to a domain model expressed in a knowledge representation formalism. We focus in this paper on the part of the semantic analyser which deals with semantic composition. We explain how we use the domain model to handle metonymy dynamically, and more generally, to underlie semantic composition, using the knowledge descriptions attached to each concept of our ontology as a kind of concept-level, multiple-role qualia structure. We rely for this on a heuristic path search algorithm that exploits the graphic aspects of the conceptual graphs formalism. The methods described have been implemented and applied on French texts in the medical domain.Comment: 6 pages, LaTeX, one encapsulated PostScript figure, uses colap.sty (included) and epsf.sty (available from the cmp-lg macro library). To appear in Coling-9

Measurement of pressure and assessment of cavitation for a 22.5-kHz intra-arterial angioplasty device

This study was performed to understand better the mechanisms of action of an (22.5 kHz) ultrasonic wire catheter device used to remove atheromatous plaque in diseased blood vessels (ultrasonic angioplasty). During a clinical procedure, the wire acts as an acoustic waveguide to transfer acoustic energy from a generator outside the body to the ball tip of the wire, which is inserted in the blood vessel. The acoustic field radiated by the vibrating ball tip (1.5- to 3.0-mm diameter), was mapped in a relatively large (600 L) water tank and compared to the field from a well-characterized simple source. A dipolelike radiation pattern due to the translating ball tip was observed. At low power settings, standing wave effects in a smaller cylindrical volume (200-mm diameter, 350-mm height), which was used to simulate anthropometric dimensions, increase relative to the larger tank measurements. The standing wave ratio is dependent upon the pc characteristics of the medium and the dimensions of the volume, rather than on the absorption at this frequency. At high power-settings of the device, cavitation at the tip of the wire was measured using a 20-MHz passive cavitation detection scheme

The optimal treatment of multivessel coronary artery disease

The practice of percutaneous coronary intervention has overtaken coronary bypass surgery in the treatment of ischaemic heart disease. Several randomized controlled as well as registry and observational trials have addressed the issue of patient selection and outcomes in order to provide the cardiologist with data enabling optimal treatment selection. This article reviews the major trials performed over the past 25 years, underscoring their strengths and limitations and draws on lessons and guidelines that are relevant to our local practice.peer-reviewe