-Chronic/Degenerative meniscal tear with or without OA (i.e. chronic injury)- surgery vs conservative management + sham surgery found no benefit for surgery.
-Acute traumatic meniscal tear-- go to surgery, evidence that surgery within 3 months leads to better outcomes
2. Shoulder pathology
-Painful arc test: LR +3.7 for rotator cuff disease
-External rotation lag gest LR+7.2, internal rotation lag test LR +5
Frozen shoulder
-occurs when people stop moving arm (i.e pain)
-pain near deltoid insertion (can't sleep on that side)
-Xrays normal
3. Baseline workup/initial management for newly diagnosed stable angina:
-EKG
-Lipids
-BMP
-TSH
-CBC
-Sublingual nitroglycerin PRN (put one under tongue, feel fizz, if still have pain after 5 minutes, take another, if after 3 you still have pain go to ER)
-B-blocker if they are also hypertensive
-Aspirin (data shows that it helps in people with high CRPs
4. ER management of unstable angina:
-DDx can't-miss: STEMI, Aortic dissection,
-O2, EKG, nitroglycerin, beta blocker, IV heparin (questionable whether you have to rule out dissection before giving heparin)
5. Stress tests
-EKG stress test: you look at EKG before and after stress, and you look for ischemic changes so if their baseline EKG is not normal, it won't really help. Sens & spec ~75%, good for low prettest probability, normal baseline ekg, low suspicion.
-Echos are very specific, because you have to have enough coronary disease to see a change in anterior wall motion
-Thallium is sensitive, but not specific (higher false postiive). At maximum level of exertion, inject with tracer, rest them to let the tracer redistribut to get a rest image.
6. CABG vs PCI
- Low risk patients - (one or two vessel non complex dx) no difference in mortality between medical management only and stent. Stents have better symptom control, but lead to more procedures
- Moderate risk - (more complex multivessel dx but normal EF), PCI approximately equal to CABG, both are better than medical therapy, PCI leads to more procedures
- High risk- left main disease, 3 vessel dx or 2 vessel dx with proximal LAD involvement, low EF, CABG has better outcomes than PCI in diabetics, although stenting can have similar outcomes to surgery in selected patients.
7. CABG vs PCI: RCT Data from 1966 to 2006 {Ann Intern Med, 2007}
Ann Intern Med. 2007 Nov 20;147(10):703-16. Epub 2007 Oct 15.
Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery.
DATA SOURCES:
MEDLINE, EMBASE, and Cochrane databases (1966-2006); conference proceedings; and bibliographies of retrieved articles.
STUDY SELECTION:
Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies.
DATA EXTRACTION:
Information was extracted on study design, sample characteristics, interventions, and clinical outcomes.
DATA SYNTHESIS:
The authors identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedure-related strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG-PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease.
LIMITATIONS:
The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents.
CONCLUSION:
Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.
JAMA. 2013 Nov 20;310(19):2086-95. doi: 10.1001/jama.2013.281718.
Coronary artery bypass graft surgery vs percutaneous interventions in coronary revascularization: a systematic review.
FINDINGS:
Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies.
CONCLUSIONS AND RELEVANCE:
Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.
9. CABG vs PCI in complex patients (left main/three vessel disease/diabetes): the SYNTAX trial {Eur J Cardiothoracic Surg, 2013}
Eur J Cardiothorac Surg. 2013 May;43(5):1006-13. doi: 10.1093/ejcts/ezt017. Epub 2013 Feb 14.
Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial.
METHODS:
Patients (n = 1800) with LM and/or 3VD were randomized to receive either PCI with TAXUS Express paclitaxel-eluting stents or CABG. Five-year outcomes in subgroups with (n = 452) or without (n = 1348) diabetes were examined: major adverse cardiac or cerebrovascular events (MACCE), the composite safety end-point of all-cause death/stroke/myocardial infarction (MI) and individual MACCE components death, stroke, MI and repeat revascularization. Event rates were estimated with Kaplan-Meier analyses.
RESULTS:
In diabetic patients, 5-year rates were significantly higher for PCI vs CABG for MACCE (PCI: 46.5% vs CABG: 29.0%; P < 0.001) and repeat revascularization (PCI: 35.3% vs CABG: 14.6%; P < 0.001). There was no difference in the composite of all-cause death/stroke/MI (PCI: 23.9% vs CABG: 19.1%; P = 0.26) or individual components all-cause death (PCI: 19.5% vs CABG: 12.9%; P = 0.065), stroke (PCI: 3.0% vs CABG: 4.7%; P = 0.34) or MI (PCI: 9.0% vs CABG: 5.4%; P = 0.20). In non-diabetic patients, rates with PCI were also higher for MACCE (PCI: 34.1% vs CABG: 26.3%; P = 0.002) and repeat revascularization (PCI: 22.8% vs CABG: 13.4%; P < 0.001), but not for the composite end-point of all-cause death/stroke/MI (PCI: 19.8% vs CABG: 15.9%; P = 0.069). There were no differences in all-cause death (PCI: 12.0% vs CABG: 10.9%; P = 0.48) or stroke (PCI: 2.2% vs CABG: 3.5%; P = 0.15), but rates of MI (PCI: 9.9% vs CABG: 3.4%; P < 0.001) were significantly increased in the PCI arm in non-diabetic patients.
CONCLUSIONS:
In both diabetic and non-diabetic patients, PCI resulted in higher rates of MACCE and repeat revascularization at 5 years. Although PCI is a potential treatment option in patients with less-complex lesions, CABG should be the revascularization option of choice for patients with more-complex anatomic disease, especially with concurrent diabetes.
My conclusions:
-Diabetics: no difference in mortality, stroke, MI. Stents are ~50% likely to need repeat procedure at 5 years (50% vs 30%)
-Non-diabetics: no difference in mortality, stroke. Stents have ~3x higher risk of MI (10% vs 3%).
-Choose: A few extra trips to the cath lab VS thoracotomy/ICU stay. Which would you pick?
My conclusions:
-Diabetics: no difference in mortality, stroke, MI. Stents are ~50% likely to need repeat procedure at 5 years (50% vs 30%)
-Non-diabetics: no difference in mortality, stroke. Stents have ~3x higher risk of MI (10% vs 3%).
-Choose: A few extra trips to the cath lab VS thoracotomy/ICU stay. Which would you pick?
10. COURAGE trial:
N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26.
Optimal medical therapy with or without PCI for stable coronary disease.
BACKGROUND:
In patients with stable coronary artery disease, it remains unclear whether an initial management strategy of percutaneous coronary intervention (PCI) with intensive pharmacologic therapy and lifestyle intervention (optimal medical therapy) is superior to optimal medical therapy alone in reducing the risk of cardiovascular events.
METHODS:
We conducted a randomized trial involving 2287 patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centers. Between 1999 and 2004, we assigned 1149 patients to undergo PCI with optimal medical therapy (PCI group) and 1138 to receive optimal medical therapy alone (medical-therapy group). The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median, 4.6).
RESULTS:
There were 211 primary events in the PCI group and 202 events in the medical-therapy group. The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (hazard ratio for the PCI group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P=0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P=0.62); hospitalization for acute coronary syndrome (12.4% vs. 11.8%; hazard ratio, 1.07; 95% CI, 0.84 to 1.37; P=0.56); or myocardial infarction (13.2% vs. 12.3%; hazard ratio, 1.13; 95% CI, 0.89 to 1.43; P=0.33).
CONCLUSIONS:
As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number, NCT00007657 [ClinicalTrials.gov].).
