Bruce K. Dixon

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure. “Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after work-up. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said. Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” Dr. Fortin added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” she said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures, as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she noted.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH, including systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin explained. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

Factors that can contribute to a mistaken diagnosis of PAH include systemic hypertension and obesity. DR. FORTIN

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure. “Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after work-up. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said. Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” Dr. Fortin added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” she said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures, as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she noted.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH, including systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin explained. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

Factors that can contribute to a mistaken diagnosis of PAH include systemic hypertension and obesity. DR. FORTIN

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure. “Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after work-up. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said. Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” Dr. Fortin added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” she said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures, as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she noted.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH, including systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin explained. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

Factors that can contribute to a mistaken diagnosis of PAH include systemic hypertension and obesity. DR. FORTIN

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease. The data, from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” lead investigator Dr. Lawrence J. Dacey said in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. In-hospital mortality was 6% in the 991 patients who underwent coronary artery bypass grafting (CABG) and 3% in the PCI group. Survival in the first 6 months was slightly better in the PCI cohort. From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease.

“However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” the Dartmouth physician said. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death. For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure. PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so,” he concluded.

The seven-center study was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey noted.

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease. The data, from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” lead investigator Dr. Lawrence J. Dacey said in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. In-hospital mortality was 6% in the 991 patients who underwent coronary artery bypass grafting (CABG) and 3% in the PCI group. Survival in the first 6 months was slightly better in the PCI cohort. From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease.

“However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” the Dartmouth physician said. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death. For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure. PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so,” he concluded.

The seven-center study was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey noted.

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease. The data, from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” lead investigator Dr. Lawrence J. Dacey said in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. In-hospital mortality was 6% in the 991 patients who underwent coronary artery bypass grafting (CABG) and 3% in the PCI group. Survival in the first 6 months was slightly better in the PCI cohort. From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease.

“However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” the Dartmouth physician said. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death. For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure. PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so,” he concluded.

The seven-center study was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey noted.

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruc-tion and significant mitral regurgitation, as well as those who died after medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome. The goal was to assess the effectiveness of different types of treatments for CAD. The data were broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified by severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease). Patients remained in their initial treatment groups regardless of subsequent crossover to alternative therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-severity disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said. “PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease.”

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts. “Thus, revascularization with either PCI or bypass grafting improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, prominent thoracic surgeons praised Dr. Smith and his team. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues … on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Cardiologists have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of low-risk patient subsets that inflate PCI survival rates, he added.

“There is compelling evidence now that coronary bypass is superior to percutaneous intervention for multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple-vessel disease, including the proximal left anterior descending. But the cardiologists responded, 'now we have stents,' and told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. Cardiologists responded, 'now we have drug-eluting stents,'” Dr. Guyton said, adding that coronary occlusion, not restenosis, delivers the fatal blow.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruc-tion and significant mitral regurgitation, as well as those who died after medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome. The goal was to assess the effectiveness of different types of treatments for CAD. The data were broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified by severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease). Patients remained in their initial treatment groups regardless of subsequent crossover to alternative therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-severity disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said. “PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease.”

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts. “Thus, revascularization with either PCI or bypass grafting improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, prominent thoracic surgeons praised Dr. Smith and his team. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues … on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Cardiologists have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of low-risk patient subsets that inflate PCI survival rates, he added.

“There is compelling evidence now that coronary bypass is superior to percutaneous intervention for multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple-vessel disease, including the proximal left anterior descending. But the cardiologists responded, 'now we have stents,' and told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. Cardiologists responded, 'now we have drug-eluting stents,'” Dr. Guyton said, adding that coronary occlusion, not restenosis, delivers the fatal blow.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruc-tion and significant mitral regurgitation, as well as those who died after medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome. The goal was to assess the effectiveness of different types of treatments for CAD. The data were broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified by severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease). Patients remained in their initial treatment groups regardless of subsequent crossover to alternative therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-severity disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said. “PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease.”

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts. “Thus, revascularization with either PCI or bypass grafting improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, prominent thoracic surgeons praised Dr. Smith and his team. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues … on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Cardiologists have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of low-risk patient subsets that inflate PCI survival rates, he added.

“There is compelling evidence now that coronary bypass is superior to percutaneous intervention for multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple-vessel disease, including the proximal left anterior descending. But the cardiologists responded, 'now we have stents,' and told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. Cardiologists responded, 'now we have drug-eluting stents,'” Dr. Guyton said, adding that coronary occlusion, not restenosis, delivers the fatal blow.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often, the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians. “The etiology of their mild pulmonary hypertension often is multifactorial and can present a diagnostic dilemma.”

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units.

Patients with left ventricular systolic dysfunction, pulmonary hypertension (PH) clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild PH and with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, she said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained.

Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said.

In addition, the study investigators found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin observed. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. These include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It is not necessary to proceed directly to performing a diagnostic test, Dr. Fortin noted, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often, the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians. “The etiology of their mild pulmonary hypertension often is multifactorial and can present a diagnostic dilemma.”

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units.

Patients with left ventricular systolic dysfunction, pulmonary hypertension (PH) clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild PH and with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, she said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained.

Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said.

In addition, the study investigators found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin observed. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. These include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It is not necessary to proceed directly to performing a diagnostic test, Dr. Fortin noted, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often, the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians. “The etiology of their mild pulmonary hypertension often is multifactorial and can present a diagnostic dilemma.”

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units.

Patients with left ventricular systolic dysfunction, pulmonary hypertension (PH) clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild PH and with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, she said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained.

Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said.

In addition, the study investigators found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin observed. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. These include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It is not necessary to proceed directly to performing a diagnostic test, Dr. Fortin noted, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease.

The data are from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The data were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” said lead investigator Dr. Lawrence J. Dacey in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. Of the 991 patients who underwent coronary artery bypass grafting (CABG), the in-hospital mortality rate was 6%, compared with 3% among the PCI group. Under further analysis, survival in the first 6 months was slightly better among the PCI cohort.

From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease. “However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” said the Dartmouth physician. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death.

For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease, stated Dr. Dacey.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure, while PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina, Dr. Dacey said. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so.”

There were limitations of the seven-center study: It was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey said.

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease.

The data are from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The data were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” said lead investigator Dr. Lawrence J. Dacey in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. Of the 991 patients who underwent coronary artery bypass grafting (CABG), the in-hospital mortality rate was 6%, compared with 3% among the PCI group. Under further analysis, survival in the first 6 months was slightly better among the PCI cohort.

From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease. “However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” said the Dartmouth physician. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death.

For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease, stated Dr. Dacey.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure, while PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina, Dr. Dacey said. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so.”

There were limitations of the seven-center study: It was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey said.

CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.

The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease.

The data are from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The data were presented at the annual meeting of the Society of Thoracic Surgeons.

“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” said lead investigator Dr. Lawrence J. Dacey in an interview.

Over the study period, there were 514 deaths and 5,530 person-years of data. Of the 991 patients who underwent coronary artery bypass grafting (CABG), the in-hospital mortality rate was 6%, compared with 3% among the PCI group. Under further analysis, survival in the first 6 months was slightly better among the PCI cohort.

From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease. “However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” said the Dartmouth physician. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death.

For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease, stated Dr. Dacey.

The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure, while PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.

There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.

Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina, Dr. Dacey said. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so.”

There were limitations of the seven-center study: It was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey said.

CHICAGO — Magnetic resonance imaging done prior to treatment for breast cancer can reveal cancer missed by mammography and ultrasonography, yielding more accurate information about the extent of disease, according to a poster presented at the annual meeting of the Radiological Society of North America.

“We found almost 29% more cancer by doing the magnetic resonance imaging before surgery or radiation therapy than we thought we had diagnosed with standard mammography, ultrasound, and clinical examination,” said Dr. Gillian Newstead of the University of Chicago in an interview. Identifying more cancer up front will influence the course of treatment and ideally produce a more positive long-term outcome, she said.

The researchers classified newly diagnosed breast cancers in 140 women (mean age 56.5 years), of which 53.5% were invasive ductal carcinoma (IDC) with extensive intraductal component (EIC). Additional lesions identified by MRI in 40 women included 26 in the same quadrant, 11 in a different quadrant, and 3 in the contralateral breast. Specifically, 23 of the lesions were identified as IDC with EIC, 6 as IDC, 6 as ductal carcinoma in situ, and 5 as invasive lobular cancer.

Clinical management was changed in 31 of the 40 women: 20 underwent more extensive surgery, 8 were converted from breast conservation to mastectomy, and 3 were given additional neoadjuvant chemotherapy.

Although mammography and ultrasonography are still the primary imaging methods for breast cancer screening and diagnosis, the higher soft tissue contrast and gadolinium-enhanced images obtained by MRI improve the sensitivity of detection and allow more accurate evaluation of the cancer. Most breast cancers enhance rapidly after IV injection of contrast agents because of higher vascularity and the angiogenic factors that produce an increase in capillary permeability, changes in osmolar pressure, and expansion of the interstitial space, the investigators said.

“The MR is looking at the new blood vessel growth, or angiogenesis, in tumors and it's a functional test in that sense, so we see lesions that may not show up on mammograms, especially in dense breasts. And there are some tumors that grow in such a way that makes them more difficult to perceive on a mammogram,” Dr. Newstead added.

“Patients underwent imaging in the prone position with the breasts gently immobilized within lateral compression plates. Contrast injection was made with IV administration of 0.1 mmol/kg gadodiamide followed by a 20-mL saline flush at the rate of 2.0 mL per second. MR images were acquired using a 1.5-T scanner with use of a dedicated breast coil,” the investigators said. The resolution on the MRI machine was 1.6 mm.

Hospitals have been slow to assimilate MRI into clinical practice because there have been a lot of different techniques proposed by academic centers, Dr. Newstead said. “That's becoming less of an issue as our magnets are getting faster and we don't have to make as many compromises; so I would say that any person with a fairly modern magnet and a modern breast coil should be able to achieve satisfactory resolution both spatially and temporally,” she said.

MRI has found a home at the University of Chicago's breast imaging section, not only for pretreatment assessment but also to detect cancer recurrence post treatment and to screen high-risk women.

“Early detection of local recurrence improves long-term survival, but postoperative mammographic and ultrasound evaluation often is limited, especially in patients with dense, fibroglandular tissue and postsurgical or postradiation fibrosis,” the authors wrote, noting that residual or recurrent tumor exhibits early enhancement.

“MR is a sensitive modality for detection of early recurrent tumor, and breast cancer recurrence must be differentiated from acute and subacute posttreatment changes. Most recurrent tumor, unlike unrecognized residual tumor, usually presents at least 2 years following breast conservation treatment. Normal parenchymal enhancement usually is diminished after breast irradiation. Recurrent tumor may therefore be readily visible in the postradiation breast,” they said.

False-positive findings are not a problem with high-resolution MRI and correct procedure, according to Dr. Newstead. “When we find something on MR that wasn't seen before on mammography or ultrasound, typically we'll bring the patient back for a repeat ultrasound and mammogram. If we see something, we'll do a biopsy right then. But if we can't find anything [with conventional imaging]—which happens in about 40% of our cases—and MR is the only finding, then we'll bring the patient back and repeat the MRI study. If it still looks worrisome, we'll go ahead and biopsy at the same time, so she only has to come back once,” Dr. Newstead explained.

'We see lesions that may not show up on mammograms, especially in dense breasts.' DR. NEWSTEAD

Elsevier Global Medical News

CHICAGO — Magnetic resonance imaging done prior to treatment for breast cancer can reveal cancer missed by mammography and ultrasonography, yielding more accurate information about the extent of disease, according to a poster presented at the annual meeting of the Radiological Society of North America.

“We found almost 29% more cancer by doing the magnetic resonance imaging before surgery or radiation therapy than we thought we had diagnosed with standard mammography, ultrasound, and clinical examination,” said Dr. Gillian Newstead of the University of Chicago in an interview. Identifying more cancer up front will influence the course of treatment and ideally produce a more positive long-term outcome, she said.

The researchers classified newly diagnosed breast cancers in 140 women (mean age 56.5 years), of which 53.5% were invasive ductal carcinoma (IDC) with extensive intraductal component (EIC). Additional lesions identified by MRI in 40 women included 26 in the same quadrant, 11 in a different quadrant, and 3 in the contralateral breast. Specifically, 23 of the lesions were identified as IDC with EIC, 6 as IDC, 6 as ductal carcinoma in situ, and 5 as invasive lobular cancer.

Clinical management was changed in 31 of the 40 women: 20 underwent more extensive surgery, 8 were converted from breast conservation to mastectomy, and 3 were given additional neoadjuvant chemotherapy.

Although mammography and ultrasonography are still the primary imaging methods for breast cancer screening and diagnosis, the higher soft tissue contrast and gadolinium-enhanced images obtained by MRI improve the sensitivity of detection and allow more accurate evaluation of the cancer. Most breast cancers enhance rapidly after IV injection of contrast agents because of higher vascularity and the angiogenic factors that produce an increase in capillary permeability, changes in osmolar pressure, and expansion of the interstitial space, the investigators said.

“The MR is looking at the new blood vessel growth, or angiogenesis, in tumors and it's a functional test in that sense, so we see lesions that may not show up on mammograms, especially in dense breasts. And there are some tumors that grow in such a way that makes them more difficult to perceive on a mammogram,” Dr. Newstead added.

“Patients underwent imaging in the prone position with the breasts gently immobilized within lateral compression plates. Contrast injection was made with IV administration of 0.1 mmol/kg gadodiamide followed by a 20-mL saline flush at the rate of 2.0 mL per second. MR images were acquired using a 1.5-T scanner with use of a dedicated breast coil,” the investigators said. The resolution on the MRI machine was 1.6 mm.

Hospitals have been slow to assimilate MRI into clinical practice because there have been a lot of different techniques proposed by academic centers, Dr. Newstead said. “That's becoming less of an issue as our magnets are getting faster and we don't have to make as many compromises; so I would say that any person with a fairly modern magnet and a modern breast coil should be able to achieve satisfactory resolution both spatially and temporally,” she said.

MRI has found a home at the University of Chicago's breast imaging section, not only for pretreatment assessment but also to detect cancer recurrence post treatment and to screen high-risk women.

“Early detection of local recurrence improves long-term survival, but postoperative mammographic and ultrasound evaluation often is limited, especially in patients with dense, fibroglandular tissue and postsurgical or postradiation fibrosis,” the authors wrote, noting that residual or recurrent tumor exhibits early enhancement.

“MR is a sensitive modality for detection of early recurrent tumor, and breast cancer recurrence must be differentiated from acute and subacute posttreatment changes. Most recurrent tumor, unlike unrecognized residual tumor, usually presents at least 2 years following breast conservation treatment. Normal parenchymal enhancement usually is diminished after breast irradiation. Recurrent tumor may therefore be readily visible in the postradiation breast,” they said.

False-positive findings are not a problem with high-resolution MRI and correct procedure, according to Dr. Newstead. “When we find something on MR that wasn't seen before on mammography or ultrasound, typically we'll bring the patient back for a repeat ultrasound and mammogram. If we see something, we'll do a biopsy right then. But if we can't find anything [with conventional imaging]—which happens in about 40% of our cases—and MR is the only finding, then we'll bring the patient back and repeat the MRI study. If it still looks worrisome, we'll go ahead and biopsy at the same time, so she only has to come back once,” Dr. Newstead explained.

'We see lesions that may not show up on mammograms, especially in dense breasts.' DR. NEWSTEAD

Elsevier Global Medical News

CHICAGO — Magnetic resonance imaging done prior to treatment for breast cancer can reveal cancer missed by mammography and ultrasonography, yielding more accurate information about the extent of disease, according to a poster presented at the annual meeting of the Radiological Society of North America.

“We found almost 29% more cancer by doing the magnetic resonance imaging before surgery or radiation therapy than we thought we had diagnosed with standard mammography, ultrasound, and clinical examination,” said Dr. Gillian Newstead of the University of Chicago in an interview. Identifying more cancer up front will influence the course of treatment and ideally produce a more positive long-term outcome, she said.

The researchers classified newly diagnosed breast cancers in 140 women (mean age 56.5 years), of which 53.5% were invasive ductal carcinoma (IDC) with extensive intraductal component (EIC). Additional lesions identified by MRI in 40 women included 26 in the same quadrant, 11 in a different quadrant, and 3 in the contralateral breast. Specifically, 23 of the lesions were identified as IDC with EIC, 6 as IDC, 6 as ductal carcinoma in situ, and 5 as invasive lobular cancer.

Clinical management was changed in 31 of the 40 women: 20 underwent more extensive surgery, 8 were converted from breast conservation to mastectomy, and 3 were given additional neoadjuvant chemotherapy.

Although mammography and ultrasonography are still the primary imaging methods for breast cancer screening and diagnosis, the higher soft tissue contrast and gadolinium-enhanced images obtained by MRI improve the sensitivity of detection and allow more accurate evaluation of the cancer. Most breast cancers enhance rapidly after IV injection of contrast agents because of higher vascularity and the angiogenic factors that produce an increase in capillary permeability, changes in osmolar pressure, and expansion of the interstitial space, the investigators said.

“The MR is looking at the new blood vessel growth, or angiogenesis, in tumors and it's a functional test in that sense, so we see lesions that may not show up on mammograms, especially in dense breasts. And there are some tumors that grow in such a way that makes them more difficult to perceive on a mammogram,” Dr. Newstead added.

“Patients underwent imaging in the prone position with the breasts gently immobilized within lateral compression plates. Contrast injection was made with IV administration of 0.1 mmol/kg gadodiamide followed by a 20-mL saline flush at the rate of 2.0 mL per second. MR images were acquired using a 1.5-T scanner with use of a dedicated breast coil,” the investigators said. The resolution on the MRI machine was 1.6 mm.

Hospitals have been slow to assimilate MRI into clinical practice because there have been a lot of different techniques proposed by academic centers, Dr. Newstead said. “That's becoming less of an issue as our magnets are getting faster and we don't have to make as many compromises; so I would say that any person with a fairly modern magnet and a modern breast coil should be able to achieve satisfactory resolution both spatially and temporally,” she said.

MRI has found a home at the University of Chicago's breast imaging section, not only for pretreatment assessment but also to detect cancer recurrence post treatment and to screen high-risk women.

“Early detection of local recurrence improves long-term survival, but postoperative mammographic and ultrasound evaluation often is limited, especially in patients with dense, fibroglandular tissue and postsurgical or postradiation fibrosis,” the authors wrote, noting that residual or recurrent tumor exhibits early enhancement.

“MR is a sensitive modality for detection of early recurrent tumor, and breast cancer recurrence must be differentiated from acute and subacute posttreatment changes. Most recurrent tumor, unlike unrecognized residual tumor, usually presents at least 2 years following breast conservation treatment. Normal parenchymal enhancement usually is diminished after breast irradiation. Recurrent tumor may therefore be readily visible in the postradiation breast,” they said.

False-positive findings are not a problem with high-resolution MRI and correct procedure, according to Dr. Newstead. “When we find something on MR that wasn't seen before on mammography or ultrasound, typically we'll bring the patient back for a repeat ultrasound and mammogram. If we see something, we'll do a biopsy right then. But if we can't find anything [with conventional imaging]—which happens in about 40% of our cases—and MR is the only finding, then we'll bring the patient back and repeat the MRI study. If it still looks worrisome, we'll go ahead and biopsy at the same time, so she only has to come back once,” Dr. Newstead explained.

'We see lesions that may not show up on mammograms, especially in dense breasts.' DR. NEWSTEAD

Elsevier Global Medical News

CHICAGO — The long-term clinical benefits associated with multiple internal mammary artery bypass grafting in patients with multivessel coronary disease, compared with single internal mammary artery grafting, were confirmed in a 20-year follow-up study presented at the annual meeting of the Society of Thoracic Surgeons.

“Long-term rates of all adverse events are reduced with multiple internal mammary artery bypass, compared with single internal mammary artery bypass, as long as the grafts are placed to the two largest coronary systems,” said Dr. J. Scott Rankin, who said the procedure should be considered the “therapeutic standard.”

Investigators used the Duke University Cardiovascular Databank to assess 20-year outcomes and benefits of multiple internal mammary artery (MIMA) versus single internal mammary artery (SIMA) grafting and to evaluate possible differences in results between two multiple IMA configurations: left anterior descending (LAD) plus left circumflex grafts versus LAD plus right coronary grafts.

The series represents consecutive coronary bypass procedures by two surgeons working in the same practice at Duke University Medical Center, Durham, N.C., over a 3-year period beginning July 1, 1984.

One surgeon emphasized MIMA grafting for multivessel disease, and performed 654 procedures over the 3-year period. The other emphasized SIMA grafting, performing 413 procedures. “Both used primarily saphenous veins for adjunctive grafts,” said Dr. Rankin, who is now with Vanderbilt University in Nashville, Tenn.

In the final analysis, there were 490 patients in the SIMA cohort and 377 in the MIMA group. Two-thirds of the latter group underwent the LAD/left circumflex combination.

“In general, the philosophy was to use the IMAs for the two largest vessels. The LAD/circumflex patients had primarily pedicled right IMA grafts to the LAD and left IMAs to the circumflex,” he said.

End points for the data analysis were all-cause death, nonfatal MI, percutaneous coronary intervention, and redo coronary bypass; all four were combined as a composite end point. There were no statistically significant differences between the mostly male groups with respect to median ejection fractions, sternal infections, hospital mortality, or the 4-year requirement for redo bypass. There were small, statistically significant differences in rates of prior smoking, diabetes, and hypertension.

At 20-year follow-up, the MIMA group had a statistically significant mean reduction in nonfatal myocardial infarction of 37%, and what Dr. Rankin called a “striking” 63% reduced incidence of redo coronary bypass—from 12.6% in the SIMA group to 4.6% in the MIMA group, which was highly significant. There were statistical trends toward fewer percutaneous coronary interventions (PCIs) and all-cause mortality in the MIMA group.

In the adjusted Cox model composite end point for SIMA versus MIMA, advanced age and a higher number of comorbidities were the most important determinants of long-term positive outcome, “but multiple IMA versus single IMA also was significant, with a 17% risk reduction over the 20 years,” said Dr. Rankin. “In further analyses, the average life expectancy was extended by almost 1 year in the multiple IMA patients, with a P value of .001.” There was no significant difference between the LAD configurations.

“Multiple IMA grafting can be performed in over 70% of patients with multivessel coronary artery disease. Operative mortality and sternal infections in our series were not increased, and the configuration is not critical as long as the two largest vessels are grafted,” he said.

In addition, multiple IMA grafting is applicable to the entire spectrum of coronary patients—including the elderly [and] diabetics—and in emergencies; results were just as good in these high-risk groups. The long-term incidence of all adverse cardiac outcomes—including nonfatal MI, PCI, redo coronary bypass, and all-cause death—are reduced, and overall composite outcome is significantly improved, statistically and clinically, over a full 20 years of follow-up,” Dr. Rankin said.

These findings should affect clinical practice, Dr. Rankin said in an interview. “From our viewpoint, with the exception of the extremely elderly, we probably ought to be doing MIMA grafts in most ages and in diabetics,” he said.

Furthermore, “even though women tend to have smaller vessels, as long as you really check out the [mammary arteries] so that you don't end up with one that's too small or doesn't have good enough flow, it's fine to use double [IMA grafts] in females,” he added.

The road to these conclusions has been a long one, beginning with the proposition and observation 2 decades ago that MIMA grafting had superior patency.

“When we originally presented our series from 1984 and showed no increase in infection rate, nobody believed it,” said Dr. Rankin, explaining that the Duke data did not turn positive until the second decade of follow-up.

“But there are all kinds of papers out now showing the advantages of MIMA grafting in patients” with severe coronary artery disease, he said.

'We probably ought to be doing MIMA grafts in most ages and in diabetics.' DR. RANKIN

CHICAGO — The long-term clinical benefits associated with multiple internal mammary artery bypass grafting in patients with multivessel coronary disease, compared with single internal mammary artery grafting, were confirmed in a 20-year follow-up study presented at the annual meeting of the Society of Thoracic Surgeons.

“Long-term rates of all adverse events are reduced with multiple internal mammary artery bypass, compared with single internal mammary artery bypass, as long as the grafts are placed to the two largest coronary systems,” said Dr. J. Scott Rankin, who said the procedure should be considered the “therapeutic standard.”

Investigators used the Duke University Cardiovascular Databank to assess 20-year outcomes and benefits of multiple internal mammary artery (MIMA) versus single internal mammary artery (SIMA) grafting and to evaluate possible differences in results between two multiple IMA configurations: left anterior descending (LAD) plus left circumflex grafts versus LAD plus right coronary grafts.

The series represents consecutive coronary bypass procedures by two surgeons working in the same practice at Duke University Medical Center, Durham, N.C., over a 3-year period beginning July 1, 1984.

One surgeon emphasized MIMA grafting for multivessel disease, and performed 654 procedures over the 3-year period. The other emphasized SIMA grafting, performing 413 procedures. “Both used primarily saphenous veins for adjunctive grafts,” said Dr. Rankin, who is now with Vanderbilt University in Nashville, Tenn.

In the final analysis, there were 490 patients in the SIMA cohort and 377 in the MIMA group. Two-thirds of the latter group underwent the LAD/left circumflex combination.

“In general, the philosophy was to use the IMAs for the two largest vessels. The LAD/circumflex patients had primarily pedicled right IMA grafts to the LAD and left IMAs to the circumflex,” he said.

End points for the data analysis were all-cause death, nonfatal MI, percutaneous coronary intervention, and redo coronary bypass; all four were combined as a composite end point. There were no statistically significant differences between the mostly male groups with respect to median ejection fractions, sternal infections, hospital mortality, or the 4-year requirement for redo bypass. There were small, statistically significant differences in rates of prior smoking, diabetes, and hypertension.

At 20-year follow-up, the MIMA group had a statistically significant mean reduction in nonfatal myocardial infarction of 37%, and what Dr. Rankin called a “striking” 63% reduced incidence of redo coronary bypass—from 12.6% in the SIMA group to 4.6% in the MIMA group, which was highly significant. There were statistical trends toward fewer percutaneous coronary interventions (PCIs) and all-cause mortality in the MIMA group.

In the adjusted Cox model composite end point for SIMA versus MIMA, advanced age and a higher number of comorbidities were the most important determinants of long-term positive outcome, “but multiple IMA versus single IMA also was significant, with a 17% risk reduction over the 20 years,” said Dr. Rankin. “In further analyses, the average life expectancy was extended by almost 1 year in the multiple IMA patients, with a P value of .001.” There was no significant difference between the LAD configurations.

“Multiple IMA grafting can be performed in over 70% of patients with multivessel coronary artery disease. Operative mortality and sternal infections in our series were not increased, and the configuration is not critical as long as the two largest vessels are grafted,” he said.

In addition, multiple IMA grafting is applicable to the entire spectrum of coronary patients—including the elderly [and] diabetics—and in emergencies; results were just as good in these high-risk groups. The long-term incidence of all adverse cardiac outcomes—including nonfatal MI, PCI, redo coronary bypass, and all-cause death—are reduced, and overall composite outcome is significantly improved, statistically and clinically, over a full 20 years of follow-up,” Dr. Rankin said.

These findings should affect clinical practice, Dr. Rankin said in an interview. “From our viewpoint, with the exception of the extremely elderly, we probably ought to be doing MIMA grafts in most ages and in diabetics,” he said.

Furthermore, “even though women tend to have smaller vessels, as long as you really check out the [mammary arteries] so that you don't end up with one that's too small or doesn't have good enough flow, it's fine to use double [IMA grafts] in females,” he added.

The road to these conclusions has been a long one, beginning with the proposition and observation 2 decades ago that MIMA grafting had superior patency.

“When we originally presented our series from 1984 and showed no increase in infection rate, nobody believed it,” said Dr. Rankin, explaining that the Duke data did not turn positive until the second decade of follow-up.

“But there are all kinds of papers out now showing the advantages of MIMA grafting in patients” with severe coronary artery disease, he said.

'We probably ought to be doing MIMA grafts in most ages and in diabetics.' DR. RANKIN

CHICAGO — The long-term clinical benefits associated with multiple internal mammary artery bypass grafting in patients with multivessel coronary disease, compared with single internal mammary artery grafting, were confirmed in a 20-year follow-up study presented at the annual meeting of the Society of Thoracic Surgeons.

“Long-term rates of all adverse events are reduced with multiple internal mammary artery bypass, compared with single internal mammary artery bypass, as long as the grafts are placed to the two largest coronary systems,” said Dr. J. Scott Rankin, who said the procedure should be considered the “therapeutic standard.”

Investigators used the Duke University Cardiovascular Databank to assess 20-year outcomes and benefits of multiple internal mammary artery (MIMA) versus single internal mammary artery (SIMA) grafting and to evaluate possible differences in results between two multiple IMA configurations: left anterior descending (LAD) plus left circumflex grafts versus LAD plus right coronary grafts.

The series represents consecutive coronary bypass procedures by two surgeons working in the same practice at Duke University Medical Center, Durham, N.C., over a 3-year period beginning July 1, 1984.

One surgeon emphasized MIMA grafting for multivessel disease, and performed 654 procedures over the 3-year period. The other emphasized SIMA grafting, performing 413 procedures. “Both used primarily saphenous veins for adjunctive grafts,” said Dr. Rankin, who is now with Vanderbilt University in Nashville, Tenn.

In the final analysis, there were 490 patients in the SIMA cohort and 377 in the MIMA group. Two-thirds of the latter group underwent the LAD/left circumflex combination.

“In general, the philosophy was to use the IMAs for the two largest vessels. The LAD/circumflex patients had primarily pedicled right IMA grafts to the LAD and left IMAs to the circumflex,” he said.

End points for the data analysis were all-cause death, nonfatal MI, percutaneous coronary intervention, and redo coronary bypass; all four were combined as a composite end point. There were no statistically significant differences between the mostly male groups with respect to median ejection fractions, sternal infections, hospital mortality, or the 4-year requirement for redo bypass. There were small, statistically significant differences in rates of prior smoking, diabetes, and hypertension.

At 20-year follow-up, the MIMA group had a statistically significant mean reduction in nonfatal myocardial infarction of 37%, and what Dr. Rankin called a “striking” 63% reduced incidence of redo coronary bypass—from 12.6% in the SIMA group to 4.6% in the MIMA group, which was highly significant. There were statistical trends toward fewer percutaneous coronary interventions (PCIs) and all-cause mortality in the MIMA group.

In the adjusted Cox model composite end point for SIMA versus MIMA, advanced age and a higher number of comorbidities were the most important determinants of long-term positive outcome, “but multiple IMA versus single IMA also was significant, with a 17% risk reduction over the 20 years,” said Dr. Rankin. “In further analyses, the average life expectancy was extended by almost 1 year in the multiple IMA patients, with a P value of .001.” There was no significant difference between the LAD configurations.

“Multiple IMA grafting can be performed in over 70% of patients with multivessel coronary artery disease. Operative mortality and sternal infections in our series were not increased, and the configuration is not critical as long as the two largest vessels are grafted,” he said.

In addition, multiple IMA grafting is applicable to the entire spectrum of coronary patients—including the elderly [and] diabetics—and in emergencies; results were just as good in these high-risk groups. The long-term incidence of all adverse cardiac outcomes—including nonfatal MI, PCI, redo coronary bypass, and all-cause death—are reduced, and overall composite outcome is significantly improved, statistically and clinically, over a full 20 years of follow-up,” Dr. Rankin said.

These findings should affect clinical practice, Dr. Rankin said in an interview. “From our viewpoint, with the exception of the extremely elderly, we probably ought to be doing MIMA grafts in most ages and in diabetics,” he said.

Furthermore, “even though women tend to have smaller vessels, as long as you really check out the [mammary arteries] so that you don't end up with one that's too small or doesn't have good enough flow, it's fine to use double [IMA grafts] in females,” he added.

The road to these conclusions has been a long one, beginning with the proposition and observation 2 decades ago that MIMA grafting had superior patency.

“When we originally presented our series from 1984 and showed no increase in infection rate, nobody believed it,” said Dr. Rankin, explaining that the Duke data did not turn positive until the second decade of follow-up.

“But there are all kinds of papers out now showing the advantages of MIMA grafting in patients” with severe coronary artery disease, he said.

'We probably ought to be doing MIMA grafts in most ages and in diabetics.' DR. RANKIN

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. They include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It's not necessary to go right to a diagnostic test, Dr. Fortin said, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

'It should not be assumed that patients with an elevated right ventricular systolic pressure by echo' have PAH. DR. FORTIN

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. They include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It's not necessary to go right to a diagnostic test, Dr. Fortin said, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

'It should not be assumed that patients with an elevated right ventricular systolic pressure by echo' have PAH. DR. FORTIN

MONTREAL — Obese patients often have a constellation of physiological problems that together can lead to a mistaken diagnosis of pulmonary artery hypertension, according to researchers at Duke University Medical Center in Durham, N.C.

The presence of exertional dyspnea in these patients often leads to an echocardiogram and a finding of elevated right ventricular systolic pressure.

“Often the pressure is just mildly elevated, and these patients don't really have pulmonary arterial hypertension but are referred for evaluation anyway,” Dr. Terry A. Fortin said at the annual meeting of the American College of Chest Physicians.

To assess diagnostic strategies for pulmonary arterial hypertension (PAH) in this often very symptomatic population, Dr. Fortin and her colleagues at Duke University retrospectively assessed consecutive cardiac catheterization data on patients referred for suspected PAH.

Suspected PAH was defined as mean pulmonary arterial pressure (mPAP) greater than 25 mm/Hg, pulmonary capillary wedge pressure (PCWP) less than 15 mm/Hg, and pulmonary vascular resistance (PVR) greater than 3 Wood units. Patients with left ventricular systolic dysfunction, PAH clearly associated with a known syndrome, or significant valve or lung disease of sufficient severity to explain PH were excluded. That left 78 obese patients with mild pulmonary hypertension (PH) with mPAP greater than 25 mm/Hg and PVR less than 5 Wood units, said Dr. Fortin of Duke University Medical Center.

Of those 78 patients, 40 had baseline syndromes or conditions that the investigators believed adequately explained the patients' PH after workup. Those conditions included connective tissue disease, congenital heart disease, chronic thromboembolic disease, portopulmonary disease, severe lung disease, high-output arteriovenous shunts, and left-sided valve disease.

Eliminating these patients left 38 patients with elevated mPAP associated with a constellation of factors that together resulted in PH, although maybe not PAH, Dr. Fortin said.

Most were women with a mean age of 60 years. All were hypertensive, and virtually all had a body mass index greater than 30; half had a body mass index (BMI) greater than 40. Nearly two-thirds had diabetes and/or a sleep disorder.

“The precatheterization diagnostic tests often showed elevated right ventricular systolic pressures on referral cardiac echo, and that was typically the reason that the patients were sent to us,” Dr. Fortin explained. Many of the patients did have increased artery sizes, and their right atrium size or decreased contractility in the right ventricle was of concern. About half the patients were hypoxemic, and some were hypercarbic, “which is not necessarily what we would expect in pulmonary hypertension,” she added.

Low lung volume was common, and many patients had reduced diffusion capacity of carbon monoxide (DLCO). Two patients had only increased right ventricular systolic pressures.

“Looking at the cardiac cath data, PVRs were not quite 3 [Wood units] in most patients, and if you break them down into those with enlarged and normal right ventricles, they're slightly different, but not statistically so,” Dr. Fortin said. The investigators also found a slight but statistically nonsignificant difference in mean pulmonary pressures, with a predominance of elevated pressures—as expected in bigger right ventricles. Overall, the patients had normal cardiac indices and were not very sick.

Only one patient had pulmonary arterial hypertension based upon a PCWP less than 15 mm/Hg and a PVR greater than 3, Dr. Fortin said. Hypoxemia, hypercarbia, low total lung capacity, and DLCO were all related to obesity, hypoventilation, and sleep disorders, she added.

“Lest you think that obese people do not ever have pulmonary hypertension, I was quickly able to glean 13 patients … who were morbidly obese with BMIs greater than 40 who were seen in our clinic,” Dr. Fortin said. “All had mPAPs greater than 25 with elevated pulmonary vascular resistances. In fact, their average pulmonary artery pressure was 60, and their PVR was 12, while their cardiac indices were very low; these were very sick patients.”

The study's researchers concluded that a number of factors can contribute to a mistaken diagnosis of PAH. They include systemic hypertension, obesity, sleep-disordered breathing and hypoventilation, and elevated pulmonary capillary wedge pressure.

“It should not be assumed that patients with an elevated right ventricular systolic pressure by echo have pulmonary arterial hypertension,” Dr. Fortin cautioned. “Pulmonary capillary wedge pressure and diastolic dysfunction may be causative.”

Aggressive management of weight, sleep disorders, hypertension, hypoxemia, and diabetes may limit the development of diastolic dysfunction and secondary pulmonary hypertension, though that's easier said than done, she added.

“Patients with this complex of disorders often have findings similar to those in full-blown PAH, and thus cardiac catheterization is necessary to help sort this out,” Dr. Fortin said. “I think that diagnostic testing also should definitely include sleep studies, as 70% of these patients had sleep disorders that were not necessarily diagnosed at the time of presentation.”

It's not necessary to go right to a diagnostic test, Dr. Fortin said, “as long as you're following the patient carefully; try to fix these other factors first before going to cardiac catheterization.”

'It should not be assumed that patients with an elevated right ventricular systolic pressure by echo' have PAH. DR. FORTIN

CHICAGO — Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were placed in the left carotid in 18 patients. All of the patients were asymptomatic and right handed. Therefore, speech-related functions were primarily left-brain functions in these patients, she explained.

Perfusion and diffusion-weighted magnetic resonance imaging was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis, or the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit.

Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

“Perfusion of the brain may be what improves cognitive function,” Dr. Grunwald said in an interview. “If that's the case, other means may be taken to improve blood flow. For example, we are also doing studies with sildenafil, which can also improve blood perfusion in the brain and, it appears, improve cognitive functioning afterwards. Further studies with different time intervals and more refined testing are needed to confirm our findings.”

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Carotid stent placement in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald

CHICAGO — Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were placed in the left carotid in 18 patients. All of the patients were asymptomatic and right handed. Therefore, speech-related functions were primarily left-brain functions in these patients, she explained.

Perfusion and diffusion-weighted magnetic resonance imaging was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis, or the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit.

Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

“Perfusion of the brain may be what improves cognitive function,” Dr. Grunwald said in an interview. “If that's the case, other means may be taken to improve blood flow. For example, we are also doing studies with sildenafil, which can also improve blood perfusion in the brain and, it appears, improve cognitive functioning afterwards. Further studies with different time intervals and more refined testing are needed to confirm our findings.”

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Carotid stent placement in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald

CHICAGO — Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were placed in the left carotid in 18 patients. All of the patients were asymptomatic and right handed. Therefore, speech-related functions were primarily left-brain functions in these patients, she explained.

Perfusion and diffusion-weighted magnetic resonance imaging was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis, or the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit.

Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

“Perfusion of the brain may be what improves cognitive function,” Dr. Grunwald said in an interview. “If that's the case, other means may be taken to improve blood flow. For example, we are also doing studies with sildenafil, which can also improve blood perfusion in the brain and, it appears, improve cognitive functioning afterwards. Further studies with different time intervals and more refined testing are needed to confirm our findings.”

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Carotid stent placement in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruction and significant mitral regurgitation, as well as those who died following medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The research team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome variable. The goal was to assess the effectiveness of different types of treatment for CAD. The data were further broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified based on disease severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease).

Patients remained in their initial treatment groups regardless of subsequent crossover to alternate therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said.

“PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease,” he added.

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts.

“Thus, revascularization with either PCI or bypass grafting provided improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, physicians praised Dr. Smith and his team for clarifying an issue that goes to the heart of clinical practice. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues, other physician groups, patients, the press, and the government on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Physicians have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of relatively low-risk patient subsets that tend to inflate PCI survival rates, he added.

“I believe there is compelling evidence now that coronary bypass is superior to percutaneous intervention for patients with multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple vessel disease, including the proximal left anterior descending. But the [physicians] responded, 'now we have stents,' and they told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. [Physicians] responded, 'now we have drug-eluting stents,'” Dr. Guyton said from the floor, adding that coronary occlusion, not restenosis, delivers the fatal blow and CABG protects against coronary occlusion by revascularizing the distal vessels.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians and our patients?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruction and significant mitral regurgitation, as well as those who died following medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The research team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome variable. The goal was to assess the effectiveness of different types of treatment for CAD. The data were further broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified based on disease severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease).

Patients remained in their initial treatment groups regardless of subsequent crossover to alternate therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said.

“PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease,” he added.

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts.

“Thus, revascularization with either PCI or bypass grafting provided improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, physicians praised Dr. Smith and his team for clarifying an issue that goes to the heart of clinical practice. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues, other physician groups, patients, the press, and the government on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Physicians have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of relatively low-risk patient subsets that tend to inflate PCI survival rates, he added.

“I believe there is compelling evidence now that coronary bypass is superior to percutaneous intervention for patients with multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple vessel disease, including the proximal left anterior descending. But the [physicians] responded, 'now we have stents,' and they told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. [Physicians] responded, 'now we have drug-eluting stents,'” Dr. Guyton said from the floor, adding that coronary occlusion, not restenosis, delivers the fatal blow and CABG protects against coronary occlusion by revascularizing the distal vessels.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians and our patients?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”

CHICAGO — Bypass grafting is superior to percutaneous intervention for the treatment of severe coronary artery disease, according to a large retrospective study presented at the annual meeting of the Society of Thoracic Surgeons.

The study, prompted in part by what the authors called “limitations in the ability of randomized trials to represent typical [coronary artery disease] patients seen in clinical practice,” also found that:

▸ The treatment of coronary artery disease (CAD) has improved over time as measured by mortality outcome.

▸ Both coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) are superior to medical therapy for all degrees of CAD.

▸ Contrary to conventional wisdom, the advantage of CABG over PCI increased in the bare stent era.

The observational data analysis of 18,481 patients with significant coronary disease (greater than 75% stenosis of at least one coronary artery) was carried out between 1986 and 2000 with subsequent follow-up at Duke University Medical Center in Durham, N.C., and the Miriam Hospital Cardiac Center in Providence, R.I. Patients with significant left main obstruction and significant mitral regurgitation, as well as those who died following medical treatment within 5 days of index cardiac catheterization (median time to surgery), were excluded from the analysis.

The research team, led by Dr. Peter K. Smith at Duke, targeted all-cause mortality as the primary outcome variable. The goal was to assess the effectiveness of different types of treatment for CAD. The data were further broken down into three “eras” of treatment selection: 1986–1990, 1991–1995, and 1996–2000.

Each group was further stratified based on disease severity: low (predominantly one-vessel disease), intermediate (predominantly two-vessel disease), and high (primarily three-vessel disease).

Patients remained in their initial treatment groups regardless of subsequent crossover to alternate therapy. The Multivariable Cox Proportional Hazard Model was used to adjust for cardiovascular risk factors and to correct for propensity of treatment selection.

In the low- and intermediate-disease groups, CABG and PCI appeared to contribute equally to the survival advantage, but in high-severity disease, CABG conferred a mean survival advantage of about 8 months. When examined by era in terms of absolute survival advantage in months per 7 years' follow-up, the data showed that CABG:

▸ Conferred an additional survival trend compared with PCI, especially for high-severity disease, in the 1986–1990 era.

▸ Provided a statistically significant absolute survival advantage over PCI for high-severity disease, with no difference in less severe disease, during the 1991–1995 era.

▸ Provided an additional 5 months of life per 7 years of follow-up in high-severity disease during the 1996–2000 era, which was characterized by the general availability of bare metal stents.

“Compared to the bypass and medical therapy groups, the PCI group had a higher ejection fraction and a higher likelihood of prior myocardial infarction but a lower incidence of congestive heart failure, diabetes, cerebral vascular disease, peripheral vascular disease, and chronic renal disease. Medical therapy and CABG patients shared similar risk factors,” Dr. Smith said.

“PCI patients were more likely to have one- or two-vessel disease, and bypass grafting most often was performed for two- or three-vessel disease,” he added.

The inherent risk of cardiovascular death increased throughout the study period for all patients, though PCI patients had a generally lower risk over time than did the other two cohorts.

“Thus, revascularization with either PCI or bypass grafting provided improved survival, although the overall survival at 17 years' follow-up was less than 45%,” Dr. Smith explained. The survival advantage provided by revascularization varied significantly with disease severity; less than 30% of high-severity disease patients survived to 17 years, regardless of initial therapy.

During the discussion period, physicians praised Dr. Smith and his team for clarifying an issue that goes to the heart of clinical practice. “For the last 30 years we have been engaged in a series of dialogues with our cardiology colleagues, other physician groups, patients, the press, and the government on the relative merits of the percutaneous treatment of coronary disease relative to bypass surgery,” said Dr. Bruce W. Lytle of the Cleveland Clinic Foundation. Physicians have seized upon randomized, prospective trials which have shown little or no difference in survival between PCI and surgery, he said. Because those trials were biased at the point of patient inclusion, they tend to be made up of relatively low-risk patient subsets that tend to inflate PCI survival rates, he added.

“I believe there is compelling evidence now that coronary bypass is superior to percutaneous intervention for patients with multivessel disease,” said Dr. Robert A. Guyton of the Emory Clinic in Atlanta. “The New York State Registry reported in 2000 that in the prestent era, there was a highly significant survival advantage for coronary bypass at 3 years and a 43% relative survival advantage for triple vessel disease, including the proximal left anterior descending. But the [physicians] responded, 'now we have stents,' and they told their patients there was no mortality difference between stenting and coronary bypass. Last year, the data from New York were presented for the stent era, and there still was a highly significant survival advantage—46%—for coronary bypass. [Physicians] responded, 'now we have drug-eluting stents,'” Dr. Guyton said from the floor, adding that coronary occlusion, not restenosis, delivers the fatal blow and CABG protects against coronary occlusion by revascularizing the distal vessels.

“With these new data, can we continue to passively let the interventionalists present their position … to multivessel disease patients?” Dr. Guyton asked Dr. Smith. “With the data you presented and the data from New York, is there not now an ethical imperative to confront cardiologists with these data and to educate primary care physicians and our patients?”

Following extended applause, Dr. Smith replied, “The short answer is 'yes.'”