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Biomedical subjects

E R Bates

Publications and source records attributed to E R Bates.

At least 73 records · Page 4Linked to original sources
PubMed1992

Cardiogenic shock complicating acute myocardial infarction: the use of coronary angioplasty and the integration of the new support devices into patient management.

Conventional therapy for cardiogenic shock complicating acute myocardial infarction continues to be associated with a high in-hospital mortality rate. Hemodynamic support with new mechanical devices and emergency coronary revascularization may alter the long-term prognosis for patients with this complication. Between July 1985 and March 1990, 68 patients presented to the University of Michigan with acute myocardial infarction and cardiogenic shock. Interventions performed included thrombolytic therapy (46%), intraaortic balloon pump counterpulsation (70%), cardiac catheterization (86%), coronary angioplasty (73%), emergency coronary artery bypass grafting/ventricular septal defect repair (15%), Hemopump insertion (11%), percutaneous cardiopulmonary support (4%) and ventricular assist device (3%). The 30-day survival rate was significantly better in patients who had successful angioplasty of the infarct-related artery than in patients with failed angioplasty (61% vs. 7%, p = 0.002) or no attempt at angioplasty (61% vs. 14%, p = 0.003). This difference was maintained over the 1-year follow-up period. The only clinical variable that predicted survival was age less than 65 years. The early use of the new support devices in 10 patients was associated with death in 8 (80%), but this poor outcome may reflect a selection bias for an especially high risk population. Collectively, these recent data continue to suggest that emergency revascularization with angioplasty may reduce the mortality rate, but further study is required to define optimal utilization and integration of new support devices.

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PubMed1992

Treatment of acute myocardial infarction: a cardiologist's perspective.

The treatment of acute myocardial infarction can generally be organized along three pathways. First, interventions directed toward alleviating acute myocardial ischemia include oxygen, sublingual nitroglycerin, morphine, aspirin, heparin, and intravenous nitroglycerin. Appropriate patients may also benefit from beta-adrenergic blockers, thrombolytic agents, intra-aortic balloon counterpulsation, and revascularization with either coronary angioplasty or bypass graft surgery. Second, interventions directed toward assessing and treating acute left ventricular dysfunction include invasive hemodynamic monitoring and echocardiography; maximizing preload; correcting blood gas, serum electrolyte, acid-base, or hemoglobin abnormalities; controlling heart rate; and maintaining AV conduction. Pharmacological agents to consider include diuretics, nitroglycerin, nitroprusside, dobutamine, dopamine, norepinephrine, and amrinone. Support devices, coronary angioplasty, and cardiac surgery are also occasionally needed. Third, interventions directed toward preventing or treating arrhythmias and conduction disturbances include atropine, isoproterenol, beta-blockers, verapamil, digitalis, adenosine, lidocaine, procainamide, bretylium, amiodarone, countershock, and cardiac pacing. All of the above information has been drawn from studies in nonsurgical patients. Unfortunately, there is little in the cardiology literature about treatment of patients with perioperative MI [17]. It is of interest to note that most perioperative MI occurs in the postsurgical period, not intraoperatively, and is often painless. As discussed throughout this volume, controlling postoperative stresses--including surgical complications, pulmonary complications, fluid and electrolyte abnormalities, and heart rate and blood pressure responses--is probably important. Serial cardiac enzymes and electrocardiograms improve the diagnostic yield. Treatment options are limited by the fact that many events are non-Q wave infarctions. Also, the increased risk of bleeding from the operative site precludes use of antiplatelet, anticoagulation, and thrombolytic agents. Hemodynamically or electrically unstable patients should be referred for emergency cardiac catheterization and probable coronary angioplasty. Patients at risk for large Q wave MI, heralded by ST-segment elevation in several electrocardiographic leads, should also be considered for invasive treatment. Further clinical investigation of the natural history, diagnosis, and treatment of perioperative MI is sorely needed.

Angioplasty, Balloon↗
PubMed1992

Evaluation and treatment of acute myocardial infarction complicating systemic lupus erythematosus.

Coronary artery disease has emerged as an important cause of death in young patients with SLE. We report three cases of acute myocardial infarction in young lupus patients who underwent emergent coronary angiography. One patient had a large coronary aneurysm and died five months later from myocarditis. The other two patients underwent coronary angioplasty. The difficulty in distinguishing coronary arteritis from premature atherosclerosis and its relevance to methods of treatment is discussed.

Adult↗
PubMed1992

Is survival in acute myocardial infarction related to thrombolytic efficacy or the open-artery hypothesis? A controversy to be investigated with GUSTO.

The reduction in morbidity and mortality associated with thrombolytic therapy in patients with acute myocardial infarction was initially attributed to early restoration of arterial patency, salvage of ischemic myocardium, and preservation of left ventricular function. Recombinant tissue plasminogen activator (rt-PA) was initially the favored thrombolytic agent because of selected studies showing superior early patency rates. Interestingly, averaged results of studies using conventional dosing regimens show 90-min patency rates for streptokinase, rt-PA, and anisoylated plasminogen streptokinase activator complex (APSAC) to be 53%, 68%, and 72%, respectively, suggesting that previous claims exaggerated differences in early patency. More recently, it was found that administering the full 100-mg dose of rt-PA within 90 min increased 90-min patency rates to approximately 85% and that infusing rt-PA plus urokinase or streptokinase halved reocclusion rates. These results again suggest the unrealized potential of rt-PA to offer a unique clinical benefit. However, three important recent trials have challenged the concept that early patency conveys a survival benefit by showing no difference in mortality in patients treated with different thrombolytic agents. Other trials have shown survival benefit in patients in whom patency of the infarct artery was achieved in a time frame beyond that in which myocardial salvage could be expected. The "open-artery hypothesis" suggests that survival may be more dependent on improved left ventricular remodeling and healing, increased electrical stability, and better myocardial perfusion than on infarct size reduction. In an attempt to determine whether 90-min patency or 24-h patency is more predictive of survival, the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial will randomize approximately 40,000 patients to (1) streptokinase and subcutaneous heparin; (2) streptokinase and intravenous heparin; (3) front-loaded, weight-adjusted rt-PA and intravenous heparin; or (4) the combination of streptokinase and rt-PA and intravenous heparin.

Anistreplase↗
PubMed1991

Treatment of recurrent ischemia after thrombolysis and successful reperfusion for acute myocardial infarction: effect on in-hospital mortality and left ventricular function.

To determine the effect of treatment of recurrent ischemia after reperfusion for acute myocardial infarction on in-hospital mortality and left ventricular function recovery and to identify patients at highest risk of serious consequences in the event of recurrent ischemia in this setting, 405 consecutively treated patients were studied retrospectively. All patients received intravenous thrombolytic therapy within 6 h of ST segment elevation-documented infarction and had angiographic confirmation of their reperfusion status performed within 120 min of treatment. Three hundred three patients had successful reperfusion with or without rescue angioplasty and had no recurrent ischemia (group 1), 74 patients had initially successful reperfusion but subsequent recurrent ischemia (group 2) and 28 patients had failed reperfusion (group 3). The in-hospital mortality in groups 1 to 3 was 2.0%, 14.9% and 32.1%, respectively (p less than 0.001) and the change from baseline to prehospital discharge left ventricular ejection fraction was 1.2 +/- 9.3%, -0.8 +/- 8.7% and -4.3 +/- 5.3%, respectively (p = NS). Within the recurrent ischemia group (group 2), multiple regression analysis found absence of cardiogenic shock at presentation (p = 0.002) and successful treatment initiated within 90 min of recurrent ischemia (p = 0.045) to be the only variables independently correlated with in-hospital survival. Later successful reperfusion was not associated with improved hospital survival. The timing and success of treatment did not affect recovery of global or regional left ventricular function in the patients with paired angiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1991

Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. TAMI Study Group.

Previous studies report larger myocardial infarcts and increased in-hospital mortality rates in patients with inferior wall acute myocardial infarction (AMI) and complete atrioventricular block (AV), but the clinical implications of these complications in patients treated with reperfusion therapy have not been addressed. The clinical course of 373 patients--50 (13%) of whom developed complete AV block--admitted with inferior wall AMI and given thrombolytic therapy within 6 hours of symptom onset was studied. Acute patency rates of the infarct artery after thrombolytic therapy were similar in patients with or without AV block. Ventricular function measured at baseline and before discharge in patients with complete AV block showed a decrement in median ejection fraction (-3.5 vs -0.4%, p = 0.03) and in median regional wall motion (-0.14 vs +0.24 standard deviations/chord, p = 0.05). The reocclusion rate was higher in patients with complete AV block (29 vs 16%, p = 0.03). Patients with complete AV block had more episodes of ventricular fibrillation or tachycardia (36 vs 14%, p less than 0.001), sustained hypotension (36 vs 10%, p less than 0.001), pulmonary edema (12 vs 4%, p = 0.02) and a higher in-hospital mortality rate (20 vs 4%, p less than 0.001), although the mortality rate after hospital discharge was identical (2%) in the 2 groups. Multivariable logistic regression analysis revealed that complete AV block was a strong independent predictor of in-hospital mortality (p = 0.0006). Thus, despite initial successful reperfusion, patients with inferior wall AMI and complete AV block have higher rates of in-hospital complications and mortality.

Aged↗
PubMed1991

Subacute bilateral coronary ostial stenoses following cardiac catheterization and PTCA.

Accelerated coronary ostial stenosis is an infrequent late complication of coronary artery catheter instrumentation during aortic valve surgery, PTCA, or coronary angiography. We report the first case of bilateral coronary artery ostial stenoses developing after cardiac catheterization and right coronary artery PTCA. In patients with worsening angina following cardiac catheterization or PTCA, accelerated ostial stenoses should not be over-looked in the differential diagnosis.

Angioplasty, Balloon, Coronary↗
PubMed1991

Limitations of thrombolytic therapy for acute myocardial infarction complicated by congestive heart failure and cardiogenic shock.

As many as one quarter of patients treated with thrombolytic therapy present with congestive heart failure or cardiogenic shock. Although thrombolytic therapy has been shown to limit infarct size, preserve left ventricular ejection fraction and decrease mortality in most subgroups of patients, no apparent benefit has been demonstrated in patients with clinical left ventricular dysfunction. The lack of correlation between ejection fraction and other measurements of left ventricular dysfunction such as exercise time, cardiac output, filling pressures, activation of the neurohumoral system and regional perfusion bed abnormalities may partly explain this paradox. Alternatively, lower perfusion rates, higher reocclusion rates, associated mechanical complications or completed infarction may explain these findings. Preliminary data indicate that emergency coronary angioplasty or bypass graft surgery improves survival in selected patients with cardiogenic shock. Because these findings suggest that restoration of infarct artery patency is especially important in patients with clinical left ventricular dysfunction, additional studies are needed in these patients to investigate the potential benefit that new thrombolytic strategies, inotropic or vasodilator agents or intraaortic balloon counterpulsation might offer by augmenting coronary blood flow and improving reperfusion rates. Currently, acute mechanical revascularization should be considered for patients who present with congestive heart failure associated with hypotension or tachycardia and for patients with cardiogenic shock.

Angioplasty, Balloon, Coronary↗
PubMed1991

Prospects for the use of antagonists to the platelet glycoprotein IIb/IIIa receptor to prevent post-angioplasty restenosis and thrombosis.

Despite many advances since its inception in humans in 1977, coronary angioplasty continues to be limited by the problems of abrupt arterial closure and late restenosis. Excessive platelet deposition at the site of angioplasty undoubtedly plays an important role in the pathophysiology of both of these problems. Monoclonal antibodies and snake venom-derived or synthetic peptides directed against a common protein recognition sequence on the platelet glycoprotein IIb/IIIa receptor are currently in the early stages of preclinical and clinical testing and hold promise of preventing abrupt closure and restenosis by inhibiting platelet function. Whether any of these agents will eventually be commonly used in clinical practice will depend on their effects on the complex pathophysiology of these problems and on their safety profile when administered to patients who are likely to receive other antithrombotic medications and who are instrumented for coronary angioplasty.

Angioplasty, Balloon, Coronary↗
PubMed1991

A randomized placebo-controlled trial of combined early intravenous captopril and recombinant tissue-type plasminogen activator therapy in acute myocardial infarction.

The adjunctive use of intravenous captopril with tissue plasminogen activator early during acute myocardial infarction offers theoretic advantages of diminishing left ventricular volume, preventing ventricular dilation and improving patient survival. To test the safety and efficacy of combined early administration of intravenous captopril and recombinant tissue-type plasminogen activator (rt-PA), 38 patients treated with rt-PA 3 +/- 0.3 h (mean +/- SE) after the onset of myocardial infarction were randomized to intravenous followed by oral captopril or placebo therapy. They underwent cardiac catheterization with measurement of hemodynamic variables and left ventricular function and determination of serum renin, angiotensin and aldosterone levels on days 1 and 7. Oral administration of the selected agent was continued for 3 months along with other antianginal medications, including nonangiotensin-converting enzyme inhibitor vasodilators. Repeat measurements of left ventricular function were obtained before hospital discharge and at 3 months. There were no significant differences in baseline clinical characteristics between groups. One patient in the captopril-treated group became hypotensive during intravenous therapy, requiring discontinuation of treatment. Compared with the placebo-treated group, the captopril-treated group had significant reductions at day 7 in left ventricular end-diastolic pressure (22.5 +/- 1.5 versus 16.3 +/- 1.6 mm Hg, p less than 0.01) and mean systemic arterial pressure (93.6 +/- 3.3 versus 86.2 +/- 2.7 mm Hg, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Captopril↗
PubMed1991

Racial differences in responses to thrombolytic therapy with recombinant tissue-type plasminogen activator. Increased fibrin(ogen)olysis in blacks. The Thrombolysis and Angioplasty in Myocardial Infarction Study Group.

To determine whether there are differences in responses to thrombolytic therapy in certain populations, the data for the Thrombolysis and Angioplasty in Myocardial Infarction (phase 1) study were analyzed for black and white patients. Baseline variables including risk factors and extent of coronary artery disease were similar in the 352 white and 24 black patients. The time from onset of chest pain to recombinant tissue-type plasminogen activator (rt-PA) therapy and rt-PA dosing regimens were the same in the two groups. The patency rate of the infarct-related artery at 90 minutes was 91% for blacks and was 72% for whites (p = 0.051). Blacks displayed significantly lower nadir fibrinogen levels (0.57 +/- 0.62 versus 1.3 +/- 0.76 g/l, p less than 0.0001), greater delta fibrinogen (baseline-nadir) (2.7 +/- 1.1 versus 1.7 +/- 1.1 g/l, p less than 0.0001), and increased peak levels of fibrin(ogen) degradation products (837 +/- 865 versus 245 +/- 475 micrograms/ml, p less than 0.0001). rt-PA antigen levels tended to be higher in blacks than in whites (2.8 +/- 2.2 versus 2.2 +/- 3.2 micrograms/ml [p = 0.10] at the peak and 1.6 +/- 1.3 versus 0.99 +/- 1.4 micrograms/ml [p = 0.06] at the end of the maintenance infusion). Major clinical outcomes including survival until time of hospital discharge (92% black versus 93% white, p = 0.68) were not significantly different. However, despite undergoing fewer angioplasty procedures (25% versus 46.3%, p = 0.047), blacks received more transfusions (58.8% versus 19.5% were administered greater than or equal to 2 units packed erythrocytes, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Black People↗
PubMed1991

A monoclonal antibody against the platelet glycoprotein IIb/IIIa receptor complex prevents platelet aggregation and thrombosis in a canine model of coronary angioplasty.

BACKGROUND: The comparative effects of aspirin and F(ab')2 fragments of monoclonal antibody 7E3 against the platelet glycoprotein IIb/IIIa receptor on ex vivo platelet aggregation and in vivo thrombosis were studied in a canine coronary balloon angioplasty model. METHODS AND RESULTS: Three groups were studied. Group 1 (n = 8) was pretreated with saline placebo, group 2 (n = 8) was pretreated with 325 mg aspirin, and group 3 (n = 8) was pretreated with 0.8 mg/kg 7E3 F(ab')2. Coronary angioplasty was performed in the left anterior descending coronary artery of open-chest dogs under fluoroscopic control; serial measurements of basal and hyperemic coronary blood flows were then made for 2 hours after application of an external stenosis that decreased hyperemic flow by 50%. There were no significant differences in platelet counts or hemodynamic measurements during the experiments. Platelet aggregation was decreased by treatment: group 1, 64 +/- 13% versus 50 +/- 13% (p = NS); group 2, 57 +/- 4% versus 25 +/- 4% (p less than 0.001); and group 3, 77 +/- 5% versus 10 +/- 6% (p less than 0.0002). Compared with initial measurements, the 7E3 antibody was superior to aspirin in maintaining hyperemic coronary blood flow after release of the external stenosis: group 1, 177 +/- 14 versus 21 +/- 14 ml/min (p less than 0.0003); group 2, 189 +/- 9 versus 110 +/- 28 ml/min (p less than 0.008); and group 3, 194 +/- 12 versus 181 +/- 15 ml/min (p less than 0.02). In group 1, arterial occlusion developed in five dogs, and nonocclusive thrombus was seen in three dogs. In group 2, arterial occlusion developed in one dog, and nonocclusive thrombus was seen in five dogs. No thrombotic material was visualized in group 3 dogs treated with 7E3 F(ab')2. CONCLUSIONS: In this animal model, the 7E3 antiplatelet antibody is superior to aspirin in inhibiting platelet aggregation, thrombosis, and acute closure after deep arterial injury caused by coronary balloon angioplasty.

Angioplasty, Balloon, Coronary↗
PubMed1990

Precordial ST segment depression predicts a worse prognosis in inferior infarction despite reperfusion therapy. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group.

The impact of associated precordial ST segment depression in inferior myocardial infarction on angiographic and clinical outcomes after thrombolytic therapy and selective coronary angioplasty was studied in 583 patients with acute myocardial infarction. Anterior infarction (Group I), inferior infarction with precordial ST segment depression (Group II) and inferior infarction without precordial ST segment depression (Group III) were present in 289, 135 and 159 patients, respectively. Precordial ST segment depression was more frequent in circumflex than right coronary infarct-related arteries (44 [71%] of 62 versus 91 [40%] of 230; p = 0.000). Although acute patency rates were not statistically different, there was a trend toward different patency rates at day 7 (Group I 88%, Group II 84%, Group III 80%; p = 0.089) partly because of insignificantly higher reocclusion rates in inferior infarction without precordial ST segment depression (Group I 11%, Group II 10%, Group III 18%, p = 0.104). Infarct zone regional wall motion (standard deviations/chord) in inferior infarction was lower with precordial ST segment depression, both acutely (Group I -2.8 +/- 0.9, Group II -2.5 +/- 1.2, Group III 2.0 +/- 1.1; p = 0.000) and at day 7 (Group I -2.2 +/- 1.1, Group II -2.3 +/- 1.1, Group III -1.9 +/- 1.3; p = 0.011). Precordial ST segment depression was associated with a lower ejection fraction in inferior infarction both acutely (Group I 47 +/- 11%, Group II 53 +/- 11%, Group III 58 +/- 9%; p = 0.000) and at day 7 (Group I 49 +/- 12%, Group II 53 +/- 10%, Group III 58 +/- 8%; p = 0.000). Complication rates tended to be higher in inferior infarction when precordial ST segment depression was present. Mortality rates for Groups I, II and III were 8%, 6% and 5%, respectively. These results suggest that precordial ST segment depression in inferior infarction predicts a worse ventriculographic and clinical outcome despite reperfusion therapy.

Angioplasty, Balloon, Coronary↗
PubMed1989

Emergency percutaneous transluminal coronary angioplasty during acute myocardial infarction for patients more than 70 years of age.

Thirty-five patients greater than 70 years of age with acute myocardial infarction (AMI) were treated with emergency percutaneous transluminal coronary angioplasty (PTCA). Seventeen (49%) patients received previous thrombolytic therapy: streptokinase (10 patients), tissue plasminogen activator (6) and combined tissue plasminogen activator and urokinase (1). Infarct-related artery patency was achieved in 26 patients (74%) after PTCA. Total in-hospital mortality was 34%. Univariate analysis showed a higher in-hospital mortality in patients with an occluded vessel after PTCA (78%) than in those patients with a patient infarct-related artery (19%) (p = 0.003). Symptomatic coronary reocclusion occurred in 3 patients (15%) during the hospital stay. Compared with emergency PTCA in 200 consecutively treated patients less than 70 years of age, the in-hospital mortality was increased (34 vs 6%, p less than 0.001), and the primary success rate was reduced (66 vs 90%, p less than 0.001). At a mean follow-up of 28 months, there has been a 13% out-of-hospital mortality rate in the elderly patients (3 patients died). Of the 20 surviving patients, 14 are asymptomatic and 6 have class II angina. In conclusion, emergency PTCA for AMI in elderly patients is associated with a decreased success rate and a higher mortality rate. However, the in-hospital mortality rate is not dissimilar to that in elderly AMI patients treated with conventional therapy or thrombolytic therapy alone, and the postdischarge mortality rates are low.

Age Factors↗
PubMed1989

Incidence and predictors of early recurrent ischemia after successful percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Two hundred forty consecutive patients with acute myocardial infarction treated within 48 hours by successful percutaneous transluminal coronary angioplasty (PTCA) were analyzed to determine the incidence and predictors of recurrent ischemic events during hospitalization. Thirty-nine patients had recurrent ischemia: 20 patients had chest pain or electrocardiographic changes requiring repeat PTCA or bypass surgery, or resulting in a second creatine kinase elevation suggestive of myocardial infarction; 12 had total occlusion of the dilated artery on follow-up angiography; and 7 had exercise-induced ischemia and greater than or equal to 70% diameter stenosis that required PTCA or bypass surgery before hospital discharge. In-hospital mortality was 15% in the recurrent ischemia group, compared to 1% in the group without recurrent myocardial ischemia (p less than 0.001). Angiographic follow-up before hospital discharge was obtained in 198 patients, including 38 of the 39 patients with ischemic events. Thus, the true incidence of recurrent ischemic events was between 39 of 199 and 39 of 240, or 16 and 20%. In multivariate analyses, recurrent ischemia was predicted by translesional gradient greater than 25 mm Hg (p = 0.001), dissection (p = 0.01) and post-PTCA Thrombolysis in Myocardial Infarction 2 flow pattern (p = 0.016). However, even in the absence of these risk factors recurrent ischemic events occurred in 13% of patients. Post-PTCA percent diameter stenosis (whether assessed by objective or visual assessment), degree of the early systemic fibrinolytic state, post-PTCA residual minimal diameter and concomitant use of thrombolytic agents were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon↗
PubMed1989

Coronary angioplasty as primary therapy for acute myocardial infarction 6 to 48 hours after symptom onset: report of an initial experience.

Recent randomized trials in acute myocardial infarction suggest that infarct size reduction need not be achieved for intravenous streptokinase to improve patient survival. If this is the case, attempts to achieve late revascularization may be justified. To assess the results of late primary coronary angioplasty performed in the setting of acute myocardial infarction, the clinical and angiographic data as well as hospital outcome of 139 consecutive patients treated with coronary angioplasty without prior thrombolytic therapy 6 to 48 h after the onset of chest pain (late group) were compared with those of 117 patients treated with primary angioplasty less than 6 h after the onset of chest pain (early group); time to angioplasty was assessed as a covariate of survival. In the 139 patients treated greater than or equal to 6 h after the onset of chest pain, the mean age (+/- SD) was 57 +/- 12 years and the median time to angioplasty was 15 h; 61% had multivessel disease, 14% were in cardiogenic shock and the mean left ventricular ejection fraction was 44 +/- 12%. Angioplasty was successful (final diameter stenosis less than 70% and Thrombolysis in Myocardial Infarction [TIMI] flow grade greater than or equal to 2) in 78% of patients. Successful angioplasty was associated with a 5.5% in-hospital mortality rate, whereas unsuccessful angioplasty was associated with a 43% hospital mortality rate (p less than 0.001). Multivariate testing in all patients identified four independent predictors of in-hospital death: cardiogenic shock (p less than 0.001), unsuccessful angioplasty (p = 0.001), ejection fraction less than or equal to 30% (p = 0.002) and patient age (p = 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)

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