tailieunhanh - VASCULAR COMPLICATIONS OF DIABETES - PART 4

Revascularization khẩn cấp thường được thực hiện trong đau thắt ngực không ổn định vật liệu chịu lửa không giải quyết mặc dù điều trị nội khoa tối ưu. Trong điều trị y tế 90-95% ổn định tình hình. | CHAPTER 7 EVIDENCE-BASED INTERVENTIONS 65 Fig. Effects of ramipril on cardiovascular outcomes in people with diabetes -MiCrO-HOPE. Lancet 2000 355 253-259. 66 SECTION I MICRO- AND MACROVASCULAR COMPLICATIONS OF DIABETES Revascularization Urgent revascularization is usually undertaken in refractory unstable angina that fails to settle despite optimum medical therapy. In 90-95 medical therapy stabilizes the situation. However early intervention with angiography and angioplasty where appropriate has now been shown to be superior to medical treatment alone. One study compared thrombolysis within 30 minutes of admission with primary angioplasty within 90 minutes. After six months of follow-up patients in the angioplasty group fared better on all measures the mortality rate was compared with for TPA the rate of recurrent ACS was compared with for TPA and the stroke rate was compared with 4 for TPA. Length of time in hospital also was shorter for the angioplasty group days compared with 6 days for those who received TPA. These differences though small represent significant improvements in outcome. When available and performed by experienced operators at high-volume centers primary percutaneous coronary intervention PPCI saves 20 lives and results in 60 fewer events for every 1 000 patients treated. Time is muscle and most hospitals do not have these facilities so unless transfer and urgent PPCI can be achieved within 90 minutes thrombolysis remains the treatment of choice. Surgery and angioplasty have similar results - vein grafting only improves prognosis in patients with triple vessel disease or LV dysfunction. There is no evidence that diabetics need an alternative strategy except that the Bypass Angioplasty Revascularization Investigation BARI study suggested that people with diabetes did less well with angioplasty - this remains to be confirmed. The BARI 2 Diabetes BARI 2D trial has not yet reported but will compare whether attenuation of