Biomedical subjects
Publications and source records attributed to Duane S Pinto.
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We evaluated a combination therapy using glycoprotein IIb/IIIa receptor antagonism and direct thrombin inhibition in nine patients with heparin-induced thrombocytopenia (HIT) undergoing 10 percutaneous coronary interventions (PCIs). In selected patients with HIT, the combination of a direct thrombin inhibitor, lepirudin, and abciximab, tirofiban, or eptifibatide appears to be a safe and effective anticoagulation strategy for PCI.
We report the time course to the restoration of normal platelet aggregation in three patients who were treated with eptifibatide in the setting of severe renal failure. There was prolonged platelet inhibition in the first patient who developed acute renal failure. The second patient with acute on chronic renal failure developed an intracerebral hemorrhage. Normal platelet aggregation was restored after acute hemodialysis. In a third patient with end-stage renal disease, platelet function returned to the normal range following hemodialysis. There is a prolonged time course to the restoration of normal platelet aggregation in patients with severe renal dysfunction who are treated with eptifibatide. Acute renal hemodialysis may reverse the inhibitory effect of eptifibatide on platelet aggregation in these patients.
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Lyme disease is a vector-borne illness that can affect numerous organ systems during the early disseminated phase, including the heart. The clinical course of Lyme carditis is usually benign with most patients recovering completely. In rare instances, death from Lyme carditis has been reported. The cardinal manifestation of Lyme carditis is conduction system disease, which generally is self-limited. Heart block occurs usually at the level of the atrioventricular node but often is unresponsive to atropine sulfate. Temporary pacing may be necessary in more than 30% of patients, but permanent heart block rarely develops. Myocardial and pericardial involvement can occur but generally is mild and self-limited. Diagnosis is made by associating the clinical and historical features of borreliosis, such as previous tick bite, EM, or neurologic involvement, with electrocardiographic abnormalities and symptoms such as chest pain, palpitations, syncope, and dyspnea. Serologic studies and endomyocardial biopsy can support the diagnosis in the correct clinical setting, and MR imaging, echocardiography, and gallium scanning have utility in selected circumstances. No treatment has been shown clearly to attenuate or prevent the development of Lyme carditis, but mild carditis generally is treated with oral antibiotics and severe carditis with intravenous antibiotics in an effort to eradicate the infection and prevent late complications of Lyme disease. There is conflicting evidence regarding the role that B. burgdorferi plays in the development and progression of chronic congestive heart failure. Because of the significant false-positive ELISA rate in this population and the unclear benefit of antibiotic therapy, confirmatory Western blot analysis is recommended. Routine therapy and screening of patients with idiopathic dilated cardiomyopathy is of limited utility and should be reserved for patients with clear history of antecedent Lyme disease or tick bite.
Subacute stent thrombosis (SAT), while uncommon, continues to produce serious clinical consequences, including major myocardial infarction (MI) in 60 70% of cases, and short-term mortality rates of 20% or higher. A number of procedural and patient factors have been shown to predict the occurrence of SAT, including longer stent length, smaller minimum luminal diameter, persistent dissection, multivessel intervention, and possibly acute coronary syndrome (ACS) presentation. Despite substantial knowledge about the clinical and technical aspects of SAT, the economic impact of these events has not been previously reported. Methods. We retrospectively reviewed 26 cases of SAT that occurred at our institution from 1998-2000. Baseline clinical and procedural data, as well as clinical outcomes for the initial hospital admissions required to treat SAT, were obtained by record review. Direct health care costs for these admissions were calculated based on hospital billing data and measured resource utilization for catheterization laboratory procedures. Results. Most cases of SAT occurred in high-risk circumstances, including ACSs, multi-stent interventions, and treatment of 3.0 mm or smaller vessels. Most patients suffered significant MIs and were treated with repeat percutaneous coronary intervention. The median time to SAT was 3.5 days, with 58% of events occurring on an outpatient basis. Median total hospital costs were $11,100 per patient, with more than half of the costs generated by the catheterization laboratory and pharmacy. Conclusions. Despite its low overall frequency, the clinical and economic costs of SAT are substantial. Specific strategies at preventing its occurrence are warranted, particularly in high-risk situations.
BACKGROUND: We investigated the relationship of stress technetium 99m sestamibi lung uptake with rest thallium 201 lung uptake and with indices of left ventricular (LV) dysfunction and severity of coronary artery disease (CAD) in patients with known or suspected CAD undergoing stress testing and cardiac catheterization. Stress Tc-99m sestamibi lung uptake and both stress and rest Tl-201 lung uptake are associated with LV dysfunction and extent of CAD. Although the mechanism of lung uptake is thought to be similar for the two isotopes, their physiologic characteristics are different. No direct comparison of lung uptake for the two isotopes has been reported. METHODS AND RESULTS: We evaluated 192 consecutive patients who underwent dual-isotope myocardial perfusion imaging and cardiac catheterization within 30 days. We examined the relationship of stress Tc-99m sestamibi lung-to-heart ratio (LHR) with rest Tl-201 LHR, with indices of myocardial perfusion, and with invasive measures of the severity of LV dysfunction and CAD. Stress Tc-99m sestamibi LHR correlated with rest Tl-201 LHR (r = 0.548, P <.001). Stress Tc-99m sestamibi LHR was positively associated with LV filling pressures and extent of CAD and negatively associated with LV ejection fraction and arterial systolic blood pressure. However, after adjustment for multiple comparisons, stress Tc-99m sestamibi LHR was significantly associated only with LV end-diastolic pressure (r = 0.287, P =.002) and pulmonary capillary wedge pressure (r = 0.337, P <.001). CONCLUSIONS: Increased stress Tc-99m sestamibi LHR correlates with rest Tl-201 LHR in patients with known or suspected CAD. Stress Tc-99m sestamibi lung uptake is also associated with invasively measured LV filling pressures.
BACKGROUND: Stress lung thallium 201 uptake correlates with left ventricular (LV) dysfunction and extent of coronary artery disease (CAD). Although Tl-201 is used less commonly for stress imaging, dual-isotope stress and viability protocols continue to use Tl-201 for rest imaging. We sought to investigate the association between increased resting Tl-201 lung-to-heart ratio (LHR) and hemodynamic indices of LV dysfunction, indices of myocardial perfusion, and extent of CAD. METHODS AND RESULTS: Over a 1-year period, we identified 192 consecutive patients who underwent dual-isotope stress perfusion imaging and cardiac catheterization within 30 days, without interim events or revascularization. Resting LHR was measured, and its association with invasively measured hemodynamic parameters, extent of CAD, and indices of myocardial perfusion at rest and stress was examined. Increased resting Tl-201 LHR was weakly but significantly associated with lower LV ejection fraction (EF) (r = 0.209, P <.05), higher pulmonary capillary wedge pressure (r = 0.25, P <.005), and LV end-diastolic pressure (r = 0.215, P <.01) but not with pulmonary artery systolic pressure. Increased LHR was also weakly associated with rest perfusion abnormalities including the sum rest score (r = 0.271, P <.001) and number of abnormally perfused segments (r = 0.25, P <.001) bud did not correlate with stress perfusion indices or ischemic burden. The 76 patients (40%) with LHR greater than 0.5 were more likely to have LVEF lower than 40% and 3-vessel/left main CAD. CONCLUSIONS: Increased rest Tl-201 LHR is weakly associated with higher LV end-diastolic pressure and pulmonary capillary wedge pressure and lower LVEF. LHR is also associated with the extent of previously infarcted myocardium and may indicate the presence of 3-vessel/left main CAD.