Reversal of refractory hypotension with intracoronary epinephrine during coronary angioplasty.
Explore the source record for details and available documents.
Aged↗
Biomedical subjects
J K Kahn
Publications and source records attributed to J K Kahn.
Failed direct coronary angioplasty for acute myocardial infarction: in-hospital outcome and predictors of death.
OBJECTIVES: The purpose of this study was to compare the mechanisms, predictors and outcome of patients with failed direct coronary angioplasty of the infarct-related artery with those in patients with successful direct angioplasty. BACKGROUND: Direct coronary angioplasty of the infarct-related artery, without antecedent thrombolytic therapy, is an effective treatment for patients with acute myocardial infarction. Concern has been expressed over high mortality rates in patients with failed direct infarct angioplasty. METHODS: All patients treated by angioplasty were prospectively entered into a computer data base. The characteristics and outcome of all patients with failed direct angioplasty were reviewed and compared with those of patients with successful direct angioplasty. RESULTS: Direct angioplasty was successful in 705 (94%) of 750 patients and unsuccessful in 45 (6%). Patients in the failure group were more likely to be in cardiogenic shock (22% vs. 7%, p < 0.003), to have had a previous myocardial infarction (44% vs. 28%, p < 0.03) and to have three-vessel coronary artery disease (44% vs. 23%, p < 0.003). Age, gender, ejection fraction, previous bypass surgery and diabetes mellitus were similar in both groups. Only the presence of multivessel coronary artery disease (p < 0.004) and cardiogenic shock (p < 0.025) were independent predictors of failed direct angioplasty. In-hospital death (31% vs. 4.8%, p < 0.001) and the need for emergency coronary artery bypass surgery (27% vs. 0.5%, p < 0.0001) were more frequent in patients with unsuccessful than in patients with successful direct angioplasty. Patients with failed direct angioplasty and in-hospital death usually had multiple high risk characteristics, including cardiogenic shock (50%), previous myocardial infarction (43%) and multivessel coronary artery disease (93%). CONCLUSIONS: Direct coronary angioplasty is an effective method for establishing reperfusion in acute myocardial infarction. Procedural failure is infrequent, usually occurring in patients with high risk baseline characteristics.
Adult↗
Caring for patients after coronary bypass surgery. Follow-up tips for primary care physicians.
Primary care physicians are often faced with follow-up care of patients who have had coronary artery bypass graft surgery. Familiarity with possible cardiac, pulmonary, neurologic, and infectious complications is important, and an open line of communication with the consulting cardiologist and the cardiac surgeon is essential. Modification of coronary risk factors is one of the greatest challenges after bypass surgery. The primary care physician plays the major role in directing and monitoring life-style changes that reduce the risk of progressive coronary atherosclerosis. Recurrent myocardial ischemia after bypass surgery should be evaluated fully and is often responsive to nonsurgical therapies, including percutaneous transluminal coronary angioplasty.
Activities of Daily Living↗
Aggressive treatment of acute myocardial infarction. Management options for various settings.
Multiple lifesaving options are currently available for treatment of acute myocardial infarction as a medical emergency. Serial electrocardiography and continuous ST-segment monitoring, urgent echocardiography, rapid enzyme analysis, and cardiac catheterization may all assist in the accurate and early diagnosis of acute myocardial infarction. Both intravenous thrombolytic therapy and direct infarct percutaneous transluminal coronary angioplasty are of benefit in early treatment. The choice of therapy depends on the individual patient and the hospital capabilities. Adjunctive pharmacologic therapies can be easily administered in the community hospital setting and should be considered for every patient with suspected acute myocardial infarction. The risk of serious morbidity and hospital death in these patients has not been eliminated, and a more aggressive approach to diagnosis and treatment is sorely needed.
Angioplasty, Balloon, Coronary↗
Slow coronary flow complicating elective balloon angioplasty in postthrombolytic patients.
BACKGROUND: Coronary blood flow after percutaneous transluminal coronary angioplasty (PTCA), as judged by the clearance of contrast media from the arterial bed, is usually brisk. Reduced coronary blood flow after PTCA in the absence of arterial dissection, air embolism, and large vessel spasm is unusual and the mechanism that causes it is incompletely understood. METHODS: All cases of reduced coronary blood flow after PTCA during a 12-month period were identified from a prospective database. Clinical, procedural, and angiographic findings were reviewed. RESULTS: Four patients demonstrated reduced coronary flow after PTCA in the absence of intimal dissection, air embolism, or large vessel spasm. All of the patients had been treated several days earlier with thrombolytic agents for acute myocardial infarction. The reduced coronary flow developed despite pretreatment with aspirin, heparin, and vasodilators. Symptoms of myocardial ischemia developed in each patient, including myocardial necrosis in three patients, complete heart block in one, and delayed cardiac rupture in one. This syndrome was not rapidly reversed with intracoronary nitroglycerin and thrombolytic agents. CONCLUSIONS: Percutaneous transluminal coronary angioplasty of recently lysed or freshly thrombotic coronary arteries may predispose to the activation of potent vasoconstrictors or distal embolization of microparticulate atherothrombotic debris, leading to slow coronary flow and myocardial ischemia.
Aged↗
Reversing coronary atherosclerosis. How to put findings of recent trials to practical use.
The value of aggressively modifying lipid levels in patients who have established coronary artery disease has been clarified by recent studies. Diet or drug programs that lower low-density lipoprotein (LDL) cholesterol levels to 100 mg/dL or less may halt disease progression and reverse preexisting arterial plaques. The safety of these programs has been demonstrated, and trends toward improved survival time have been observed in the larger studies. Improvement in anginal control and clinical stability, with fewer required coronary revascularization procedures, are also noted with this therapy. All patients with established coronary artery disease should undergo fasting lipid profiles, including measurements of LDL and high-density lipoprotein cholesterol fractions. Dietary and drug therapy if necessary should be offered to achieve the target LDL cholesterol level. Ongoing studies will further clarify the role of newer lipid-lowering agents and potential benefits of noninvasive monitoring techniques in patients with atherosclerosis.
Anticholesteremic Agents↗
The equivalence of antithrombolytic agents.
Explore the source record for details and available documents.
Drug Costs↗
Anticoagulant therapy for atrial fibrillation. Recommendations from major studies.
The role of antithrombotic therapy in reducing thromboembolic complications in patients with chronic atrial fibrillation has been clarified by the results of four major randomized and placebo-controlled trials. Patients with rheumatic heart disease complicated by atrial fibrillation should receive long-term warfarin therapy to reduce the risk of stroke unless an absolute contraindication exists. Patients with nonrheumatic atrial fibrillation should also be treated with low-dose warfarin therapy, especially if high-risk features for thromboembolism exist. In patients who have contraindications to warfarin therapy and in young patients with lone atrial fibrillation or paroxysmal atrial fibrillation, therapy with 325 mg of aspirin a day is preferred. Ongoing trials directly comparing aspirin and warfarin will provide additional insight into the optimal role of these antithrombotic agents in patients with atrial fibrillation.
Acute Disease↗
Comparison of procedural results and risks of coronary angioplasty in men and women for conditions other than acute myocardial infarction.
Explore the source record for details and available documents.
Aged↗
Balloon catheter requirements during contemporary percutaneous transluminal coronary angioplasty.
In order to examine the outcome of utilizing multiple balloon catheters during the percutaneous transluminal coronary angioplasty (PTCA), 300 consecutive PTCAs were analyzed. PTCA was performed in a single lesion in 163 patients (54%), in multiple lesions in 52 patients (18%), and in multiple vessels in 85 patients (28%). A total of 488 balloon catheters were used (1.6/case, range 1-9) and in 112 cases (37%) > or = 2 catheters were used. Multiple balloon catheters were needed in 27 single lesion (17%), 24 multilesion (48%), and 61 multivessel (72%) cases (p < .05). There was no difference in the angiographic success rate in cases completed with 1 balloon catheter (238/251, 95%) compared to those requiring > or = 2 catheters (260/274, 95%). Emergency bypass was required in 5 patients (1.7%) and there were 2 deaths (0.6%). Thus, although contemporary PTCA frequently requires multiple balloon catheters for completion, success rates remain high and appear to offset the increased procedural expenses.
Adult↗
Percutaneous balloon angioplasty through an anomalous left main coronary artery.
Explore the source record for details and available documents.
Aged↗
Caring for patients after coronary intervention. Follow-up tips for primary care physicians.
Primary care physicians may be faced with assessing patients after their return home from percutaneous transluminal coronary angioplasty (PTCA) or other coronary intervention. Familiarity with possible vascular, renal, and hematologic complications is important, and an open line of communication with the cardiologist who performed the procedure is essential. Restenosis can usually be identified by the return of symptoms or with exercise imaging studies. When restenosis is suspected, referral for consideration of a second PTCA is appropriate. Most patients enjoy an excellent long-term result after PTCA and can return to an active life-style. Primary care physicians play an important role in instituting and reinforcing plans for life-style changes that promote reduction in coronary atherosclerosis.
Anemia↗
Safety and efficacy of percutaneous transluminal coronary angioplasty in patients with left ventricular dysfunction.
The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.
Adolescent↗
Progressive congestive heart failure. Ways to approach office management.
Treatment of congestive heart failure depends on the cause, precipitating factors, and symptoms of the disease in each patient. Dr Kahn outlines the use of the three main types of pharmacologic agents given for heart failure--diuretics, vasodilators, and digoxin. He describes a stepwise regimen, whereby agents are added as needed to improve symptoms and prolong life.
Ambulatory Care↗
Evidence for dynamic coronary vasoconstriction in the early minutes of acute myocardial infarction.
Explore the source record for details and available documents.
Aged↗
Spontaneous alterations in coronary blood flow velocity before and after coronary angioplasty in patients with severe angina.
Cyclic coronary artery flow variations with a spontaneous decline in coronary blood flow to very low levels have been documented in stenosed canine coronary arteries with endothelial injury. These flow variations are associated with transient platelet aggregation and dislodgment and the release of selected mediators, including thromboxane A2 and serotonin. However, cyclic or spontaneous flow variations have not been demonstrated in stenosed coronary arteries in humans. In this study, the hypothesis was tested that spontaneous coronary blood flow velocity variations occur in some patients with stenosed coronary arteries before or after coronary artery angioplasty. Thus, 13 patients with severe and limiting angina underwent intracoronary pulsed Doppler velocimetry of their dilated artery immediately before and after percutaneous transluminal coronary angioplasty, whereas 9 control patients underwent velocimetry of an angiographically normal coronary artery. A 3F catheter with a 20 MHz Doppler crystal was positioned to achieve a maximal stable signal, and the flow velocity signal was recorded continuously for 20 min. Spontaneous flow velocity variations (greater than or equal to 38% change in Doppler frequency shift with wide morphologic changes) were present in 3 of the 13 patients tested. Spontaneous flow velocity variations occurred before angioplasty in one patient, after angioplasty in another and both before and after angioplasty in a third. In addition, 2 of the 13 patients, 1 with spontaneous coronary artery flow velocity variations before angioplasty, had frank vasospasm in an adjacent area just distal to the area of coronary dilation immediately after balloon inflation. These data establish that spontaneous coronary artery flow velocity variations occur in some patients with severe and limiting angina before and after coronary angioplasty. These variations may be related to platelet aggregation or coronary vasoconstriction, or both, at sites of endothelial injury resulting from plaque fissuring or ulceration and endothelial and medial injury occurring during coronary angioplasty.
Angina Pectoris↗
Advances in noninvasive detection of CAD.
Advances in the noninvasive detection of myocardial ischemia are increasing our ability to diagnose coronary artery disease (CAD). Tomographic (SPECT) thallium imaging provides better identification of coronary arteries with atherosclerotic narrowing. Increased lung thallium uptake and transient ischemic dilatation of the heart are additional markers of severe CAD. Late thallium imaging, as well as reinjection imaging, provides more accurate identification of myocardial ischemia. Finally, new myocardial ischemia. Finally, new myocardial imaging agents, such as technetium Tc 99m sestamibi (Cardiolite), should improve detection of CAD by noninvasive methods.
Coronary Disease↗
Timing and mechanism of in-hospital and late death after primary coronary angioplasty during acute myocardial infarction.
The effect of early myocardial reperfusion on patterns of death after acute myocardial infarction (AMI) is unknown. Thus, the mechanism and timing of in-hospital and late deaths among a group of 614 patients treated with coronary angioplasty without antecedent thrombolytic therapy for AMI were determined. Death occurred in 49 patients (8%) before hospital discharge. Four patients died in the catheterization laboratory. Death was due to cardiogenic shock in 22 patients, acute vessel reclosure in 5 patients, was sudden in 8 patients and followed elective coronary artery bypass surgery in 8 patients. Cardiac rupture was observed in only 2 patients after failed infarct angioplasty, and did not occur among the 574 patients with successful infarct reperfusion. Intracranial hemorrhage did not occur. Multivariate predictors of in-hospital death included failed infarct angioplasty, cardiogenic shock, 3-vessel coronary artery disease and age greater than or equal to 70 years. During a follow-up period of 32 +/- 21 months (range 1 to 87), 55 patients died. The cause of death was cardiac in 36 patients, including an arrhythmic death in 23 patients and was due to circulatory failure in 13 others. One patient died of reinfarction due to late reclosure of the infarct artery. Actuarial survival curves demonstrated overall survival after hospital discharge of 95 and 87% at 1 and 4 years, respectively. Freedom from cardiac death at 1 and 4 years was 96 and 92%. Multivariate predictors of late death included 3-vessel disease, a baseline ejection fraction of less than or equal to 40%, age greater than 70 years and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗