Rewaskularyzacja wielonaczyniowa u chorych z cukrzycą – wyniki badania FREEDOM

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Wybór metody rewaskularyzacji tętnic wieńcowych u poszczególnych pacjentów zawsze był tematem dyskusji między kardiologami a kardiochirurgami. Jednak, jeśli chodzi o chorych z cukrzycą i chorobą wielonaczyniową, badania były do tej pory jednoznaczne. Najważniejsze z nich – badanie  BARI [1], pokazało  dobitnie, że korzystniejszą metodą jest operacja wszczepienia by-passów (CABG). Niemniej, od momentu jego opublikowania minęło 16 lat, a w tym czasie w dziedzinie rewaskularyzacji przezskórnej (PCI) dokonano znaczących postępów. Wprowadzenie do powszechnej praktyki stentów uwalniających lek antymitotyczny (DES) sprawiło, że pytanie o optymalną metodę rewaskularyzacji w tej grupie pacjentów znów stało się otwarte.

Odpowiedzi na nie postanowili dostarczyć amerykańscy naukowcy biorący udział w eksperymencie FREEDOM [2]. Jego celem było porównanie śmiertelności, częstości zawałów serca i udarów mózgu u pacjentów z cukrzycą i wielonaczyniową chorobą tętnic wieńcowych w zależności od sposobu zastosowanego leczenia. Szukając chorych spełniających założone kryteria włączenia do badania przeanalizowano 33 tyś. pacjentów, z których zakwalifikowano jedynie jedną dziesiątą. Część z nich nie wyraziła jednak  zgody na udział w eksperymencie, stąd ostateczna liczba osób poddanych obserwacji wyniosła 1900. Były to osoby z co najmniej 2 istotnymi (>70%) zwężeniami w dwóch różnych naczyniach wieńcowych, bez istotnego zwężenia pnia lewej tętnicy wieńcowej, będący potencjalnie dobrymi kandydatami zarówno do leczenia przezskórnego jak i operacyjnego. Wśród kryteriów wyłączenia znalazły się między innymi: niewydolność serca w III lub IV klasie wg. NYHA, ciężka choroba „pozasercowa” mogąca ograniczać przeżycie do poniżej 5 lat, przebyty udar mózgu w okresie ostatnich 6 miesięcy, przebyta wcześniej operacja kardiochirurgiczna, uczulenie na aspirynę lub klopidogrel oraz przebyte ciężkie krwawienie.

Pacjentów zakwalifikowanych do badania podzielono losowo na dwie grupy, z których jedną poddawano PCI z wszczepieniem co najmniej dwóch stentów powlekanych, a drugą zabiegowi wszczepienia by-passów. U wszystkich chorych stosowano także leczenie farmakologicznie zarówno cukrzycy jak i chorób sercowo-naczyniowych, postępując według aktualnych w danym czasie wytycznych. Zakładany okres obserwacji wynosił minimum 2 lata, przy czym ostatecznie, wśród osób, które przeżyły zabieg/operację, wyniósł on średnio 3,8 lat. W tym czasie śmiertelność całkowita u pacjentów z ramienia PCI wyniosła 16,3%, natomiast u chorych po CABG 10,9%. Różnica była istotna statystycznie (p=0,049). Na korzyść leczenia operacyjnego przemawia także odsetek zgonów sercowo naczyniowych (6,8% vs. 10,9% w grupie PCI) oraz częstość zawałów serca nie zakończonych  śmiercią pacjenta (6,0% vs. 13,9% w grupie PCI). Odwrotnie przedstawiała się natomiast częstość występowania udarów, która była znamiennie wyższa u chorych, którym wszczepiono by-passy (5,2% vs. 2,0% w grupie PCI). Biorąc pod uwagę, że zdecydowana większość z nich miała charakter niedokrwienny i występowała w pierwszych 30 dniach po operacji, należy sądzić, że był to efekt zastosowania krążenia zewnątrzustrojowego.

Wyniki badania wydają się potwierdzać wcześniejsze obserwacje – u pacjentów z cukrzycą rewaskularyzacja operacyjna poprawia rokowanie w stosunku do leczenia przezskórnego. Nie zmieniły tego osiągnięcia kardiologii interwencyjnej systematycznie poprawiające odległe efekty PCI. Jednocześnie należy pamiętać, że powyższe rezultaty odnoszą się jedynie do chorych spełniających kryteria włączenia do badania, którymi kierowali się jego autorzy. Niezwykle ważna pozostaje indywidualna ocena sytuacji klinicznej pacjenta, rozmowa z nim samym odnośnie oczekiwań związanych z leczeniem oraz jego ewentualna zgoda na operację.

1. BARI Investigators, Comparison of Coronary Bypass Surgery with Angioplasty in Patients with Multivessel Disease, N Engl J Med, 25 July 1996; 335:217-22

2. M. E. Farkouh et al., Strategies for Multivessel Revascularization in Patients with Diabetes, N Engl J Med, 20 Dec 2012; 367:2375-2384



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  20. Many of the advances in the life sciences have been greatly aided by the application of the techniques of physics and engineering to the study of living systems.Int J Radiat Oncol Biol Phys.Quick Hit torsades de pointes is a rapid polymorphic VT.He will carry out the treatment best if he knows beforehand from the present symptoms what will take place later. [url=http://sildenafilusforx.com]order viagra for women[/url] In Charnley began the first trial hip replacements with the metal ballandspike head for the femur and a UHMWP socket lining both cemented in place.It is caused by a wide variety of bacteria the most common being group A strep tococci or S.Update Date Updated by Shehzad Topiwala MD Chief Consultant Endocrinologist Premier Medical Associates The Villages FL.Hepatitis B Hepatitis B surface antigen HB s Ag Present in acute or chronic infection Detectable as early as to weeks after infection It persists in chronic hepatitis regardless of whether symptoms are present.Hopefully the first comprehensive highlevel biopsychosocial textbook is going to be released under the auspices of the American Psychosomatic Society in just a few years.Pain may be absent. [url=http://trirx.net]dapoxetine plus cialis[/url] She had a history of ovarian cancer so her physician recommended sentinel node biopsy pelvic ultrasonography colposcopyDysphagiaDysplasiaDysphasia Dont confuse dysphagia which is difculty in swallowing with dysplasia which is abnormal formation plaso formation or dysphasia which is abnormal speech phaso speech.AFAngiography is rarely performed because it carries aHeat removed [url=http://ziagen.net]vente de propecia forum[/url] MI is associated with a mortality rate half of the deaths are prehospital.MODERN MEDICINE The first openheart surgery was carried out with the aid of a mechanical cardiopulmonary bypass CPB device or heartlung machine see pp.Another of Vesaliuss innovations was to record what he saw with his own eyes in the form of detailed illustrations that were faithful to the specimens before him rather than relying on older renderings.The renal tubules cannot reabsorb all the sugar that lters out through the glomerular membrane.During these epi sodes the patient is incapacitated and must lie down in a dark room for several hours.Immunologicuremia inhibits cellular and humoral immunity. [url=http://buytadalafilgeneric.com]generic cialis tadalafil[/url] A.The work done in the deceleration is also mvmucous membraneYour mastery of this material and your analysis of the words in the section on Sufxes and Terminology will increase your medical language vocabulary.Tissue unperfused Felt and downBLOOD SYSTEM A B C FIGURE Bone marrow aspiration and biopsy.Macrolides a. [url=http://generic-onlineus.com]buy accutane 40 mg online[/url] Members of various medical faculties develop articles for Practical Therapeutics.Pulmonary angiography is the gold standard.

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  70. VISION AND THE NERVOUS SYSTEM Vision cannot be explained entirely by the physical optics of the eye.Furosemide Breastfeeding Warnings Furosemide is excreted into human milk and may inhibit lactation.Philadelphia Pa Saunders Elsevier chap [url=http://bedrugs.net]viagra[/url] Pronunciation Guide a as in a pe a as in a pple e as in e ven e as in e very i as in i ce i as in i nterest o as in o pen o as in p o t u as in u nit u as in u nder Vocabulary and Terminology TERM PRONUNCIATION MEANING adaptive immunity a D A Pt i v i M U n i t e adenoids A D e noydz anaphylaxis a n a f a L A Ks i s antibody A Nt i b o d e antigen A Nt i j e n asplenia a SPL E N e a autoimmune disease awt o i M U N d i Z E Z axillary nodes A KS i l a r e n o dz B cell B s e l cellmediated immunity s e l m e d e A t e d i M U N i t e cervical nodes S E Rv i kl n o dz complement system C O Mpl e m e nt S i St e m cytokines S I t o k i nz cytotoxic T cell s i t o T O Ks i k T s e l dendritic cell d e nDR I t i k s e l helper T cell H E Lp e r T s e l humoral immunity H U m e r a l i mM U N i t e hypersplenism h i p e rSPL E N i zm immunity i mM U N i t e immunoglobulins i m u n o GL O B u l i nz immunosuppression i m u n o s u PR E sh u n immunotherapy i m u n o TH E R a p e LYMPHATIC AND IMMUNE SYSTEMS TERM PRONUNCIATION MEANING inguinal node I NGgw i n a l n o d interferons i nt e rF E R o nz interleukins i nt e rLOOk i nz interstitial uid i nt e rST I SH a l FLOO i d lymph l i mf lymphadenitis l i mf a hd e N I t i s lymphadenopathy l i mf a d e N O P a hth e lymph capillaries l i mf K A P i l a r e z lymphedema l i mf e D E m a lymph node l i mf n o d lymphocytes L I Mf o s i tz lymphocytosis l i mf o s i T O s i s lymphocytopenia l i mf o s i t o P E n e a lymphoid organs L I Mfoid O Rg a nz lymphopoiesis l i mf o poy E s i s lymph vessel l i mf V E S e l macrophage M A Kr o f a j mediastinal nodes m e d e a sT I n a l n o dz mesenteric nodes m e s e nT E R i k n o dz monoclonal antibody m o n o KL O n a l A Nt i b o d e natural immunity N A t u r a l i mM U n i t e paraaortic nodes p a r a a O Rt i k n o dz plasma cell PL A Zm a s e l right lymphatic duct r i t l i mF A t i k d u kt spleen spl e n splenectomy spl e N E Kt o m e splenomegaly spl e n o M E G a l e suppressor T cell s u PR E s o r T s e l T cell T s e l thoracic duct th o R A s i k d u kt thymectomy th i M E Kt o m e thymus gland TH I m u s gl a nd tolerance T O L e r a ntz tonsils T O Ns i lz LYMPHATIC AND IMMUNE SYSTEMS TERM PRONUNCIATION MEANING toxic T O Ks i k toxin T O Ks i n vaccination v a ks i N A sh u n vaccine v a kS E N Pathology and Laboratory Tests TERM PRONUNCIATION MEANING acquired immunodeciency syndrome a KW I RD i m u n o d e F I SH e ns e S I Ndr o m allergen A L e rj e n allergy A L e rj e atopy A T o p e CD cell CD P O S i t i v s e l ELISA e L I z a Hodgkin disease H O Jk i n d i Z E Z human immunodeciency virus H U m a n i m u n o d e F I SH e ns e V I r u s immunoelectrophoresis i m u n o e l e ktr o ph o r E s i s Kaposi sarcoma K A p o s e or k a P O Ss e s a rK O m a lymphoma l i mF O m a multiple myeloma M U LT i pl m i e L O m a nonHodgkin lymphoma n o nH O Jk i n l i mF O ma opportunistic infections o pp o rt u N I St i k i nF E Ksh u nz protease inhibitors PR O t e a s i nH I B i t o rz reverse transcriptase inhibitors severe combined immunodeciency disease r e V E RS tr a nsSCR I PT a z i nH I B i t o rz s e V E R k o mB I ND i m u n o d e F I SH e ns e d i Z E Z thymoma th i M O m a viral load test v i r a l l o d t e st wasting syndrome W A ST i ng S I Ndr o m Western blot W E St e rn bl o t LYMPHATIC AND IMMUNE SYSTEMS REVIEW SHEET Write the meaning of the word parts in the spaces provided.The ciliary body adjusts the lens rounding it and the pupil constricts.nih.They also may attach directly to foreign cells and destroy them.m reduces her sleep by hrday and spends this extra time reading while sitting upright.M. [url=http://antabusefast.com]purchase antabuse[/url] QT intervalthe normal QT interval should be less than half of the RR intervalp.MICROBE A tiny lifeform visible only under a microscope.The first time I took mg and I had headache.Airway hyperresponsiveness c.Also reviewed by David Zieve MD MHA Medical Director A. [url=http://edrxnewmedfor.com]buy levitra[/url] Diabetic neuropathy see Figure a.With nasal positive pressure air coming from a compressor opens the oropharynx and nasopharynx preventing obstructive sleep apnea.Metaanalyses have found evidence that acupuncture is effective for pain relief for lower back pain and is much better than sham acupuncture or no additional treatment.It is caused by a parvovirus. [url=http://armadol.com]buy zoloft on line[/url] inspiration inhalationwhite [url=http://buymisoprostoltabletsonline.com]misoprostol venta[/url] c.There are many misconceptions about contraindications to vaccination.g.

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o T E m e a bacteriuria b a kt e r e U r e a calciferol c a lS I f e r o l caliceal k a l i S E a l caliectasis k a l e E Kt a s i s calyx calix plural calyces K A l i ks K A l i s e z calices catheter K A th e t e r cortex K O Rt e ks cortical K O Rt i k a l creatinine kr e A T i n e n creatinine clearance kr e A T i n e n KL E R a ns CT urography CT u R O Gr a f e cystectomy s i sT E Kt o m e cystitis s i sT I t i s cystoscopy s i sT O Sk o p e cystostomy s i sT O St o m e diabetes insipidus d i a B E t e z i nS I P i d u s diabetes mellitus d i a B E t e z M E L i t u s URINARY SYSTEM TERM PRONUNCIATION MEANING diuresis d i u rR E s i s dysuria d i s U r e a edema e D E m a electrolyte e L E Ktr o l i t enuresis e n u R E s i s erythropoietin e r i thr o P OY e t i n essential hypertension e S E Nsh u l h i p e rT E Nsh u n ltration f i lTR A sh u n glomerular capsule gl o M E R u l a r K A Ps u l glomerulonephritis gl o m e r u l o n e FR I t i s glomerulus plural glomeruli gl o M E R u l u s gl o M E R u l i glycosuria gl i k o s U r e a hematuria h e m a T U r e a hemodialysis h e m o d i A L i s i s hilum H I l u m hydronephrosis h i dr o n e FR O s i s hyperkalemia h i p e rk a L E m e a hyponatremia h i p o n a TR E m e a interstitial nephritis i nt e rST I sh u l n e FR I t i s intravesical i ntr a V E S i k a l ketonuria k e t o n U r e a ketosis k e T O s i s kidney K I Dn e lithotripsy L I TH o tr i ps e meatal stenosis m e A t a l st e N O s i s meatus m e A t u s medulla m e D U L a or m e D U L a medullary M E D u l a r e MRI urography MRI u R O Gr a f e nephrolithiasis n e fr o l i TH I a s i s URINARY SYSTEM TERM PRONUNCIATION MEANING nephrolithotomy n e fr o l i TH O T o m e nephron N E Fr o n nephropathy n e FR O p a th e nephroptosis n e fr o pT O s i s nephrostomy n e FR O St o m e nephrotic syndrome n e FR O T i k S I Ndr o m nitrogenous waste n i TR O J e n u s w a st nocturia n o kT U r e a oliguria o l i G U r e a parenchyma p a r E Nk i m a paranephric p a r a N E Fr i k peritoneal dialysis p e r i t o N E a l d i A L i s i s phenylketonuria f e n i lk e t o n U R e a polycystic kidney disease p o l e S I St i k K I Dn e d i Z E Z polydipsia p o l e D I Ps e a polyuria p o l e U r e a potassium p o T A s e u m pyelolithotomy p i e l o l i TH O T o m e pyelonephritis p i e l o n e fR I t i s pyuria p i U r e a reabsorption r e a bS O RPsh u n renal angiography R E n a l a nj e O Gr a f e renal angioplasty R E n a l A Nj e o pl a st e renal artery R E n a l A Rt e r e renal calculi R E n a l K A Lk u l i renal cell carcinoma R E n a l s e l k a rs i N O m a renal colic R E n a l K O L i k renal failure R E n a l F A L u r renal hypertension R E n a l h i p e rT E Nsh u n renal ischemia R E n a l i sK E m e a renal pelvis R E n a l P E Lv i s URINARY SYSTEM TERM PRONUNCIATION MEANING renal transplantation R E n a l tr a nspl a nT A sh u n renal tubule R E n a l T oo b u l renal vein R E n a l v a n renin R E n i n retrograde pyelogram R E tr o gr a d P I e l o gr a m secondary hypertension S E k o nd a r e h i p e rT E Nsh u n sodium S O d e u m stricture STR I Ksh u r trigone TR I g o n trigonitis tr i g o N I t i s urea u R E a uremia u R E m e a ureter u R E t e r or U R e t e r ureteroileostomy u r e t e r o i l e O St o m e ureteroneocystostomy u r e t e r o n e o s i sT O St o m e ureteroplasty u r e t e r o PL A St e urethra u R E thr a urethral stricture u R E thr a l STR I Ksh u r urethritis u r e THR I t i s urethroplasty u r e thr o PL A St e uric acid U r i k A S i d urinalysis u r i n A L i s i s urinary bladder U R i n a r e BL A d e r urinary catheterization U R i n a r e k a th e t e r i Z A sh u n urinary incontinence U R i n a r e i nK O Nt i n e ns urinary retention U R i n a r e r e T E Nsh u n urination u r i N A sh u n vesicoureteral reux v e s i k o u R E t e r a l R E u ks voiding VOYd i ng voiding cystourethrogram VOYd i ng s i st o u R E thr o gr a m Wilms tumor w i lmz T oo m u r URINARY SYSTEM REVIEW SHEET Write the meanings of the combining forms sufxes and prexes in the spaces provided.

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