Search PubMed⌕ Search

Biomedical subjects

M van den Brand

Publications and source records attributed to M van den Brand.

At least 19 recordsLinked to original sources
PubMed1999

Continuous ST-segment monitoring associated with infarct size and left ventricular function in the GUSTO-I trial.

BACKGROUND: The aim of this study was to evaluate whether in patients with myocardial infarction, the intensity and duration of myocardial ischemia as measured by continuous ST monitoring are associated with infarct size and residual left ventricular function. METHODS AND RESULTS: The analyses included patients with myocardial infarction, receiving thrombolytic therapy, who were enrolled in the electrocardiographic substudy of GUSTO-I, monitored by a vector-derived 12-lead electrocardiographic recording system, and in whom either infarct size (defined as cumulative release of alpha-hydroxybutyrate dehydrogenase activity per liter of plasma over a 72-hour period [Q(72)]) or left ventricular ejection fraction (LVEF) was determined. With the use of linear regression analysis, we investigated the association of various ST-trend characteristics with Q(72) (206 patients) and with LVEF (180 patients). A higher area under the ST trend since thrombolysis until 50% ST recovery and a higher area under recurrent ischemic episodes (ST reelevations) were significantly associated with a higher Q(72), whereas only a higher area under recurrent ischemic episodes was significantly associated with a lower LVEF. These associations remained after adjusting for other patient characteristics such as age, sex, infarct location, and time to treatment. CONCLUSIONS: These findings support the physiologic hypothesis that both the intensity and duration of myocardial ischemia (both reflected by the estimated areas under the ST-trend curve) determine myocardial damage and thus are associated with infarct size and ejection fraction in patients with acute myocardial infarction who receive thrombolytic therapy.

Aged↗
PubMed1999

A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction. The (Swiss) Multicenter Trial of Angioplasty for Shock-(S)MASH.

AIM: To test whether emergency revascularization improves survival in patients with acute myocardial infarction and shock. METHODS AND RESULTS: Patients with acute myocardial infarction and early shock were randomized either to undergo emergency angiography, followed immediately by revascularization when indicated, or to receive initial medical management. In five of the nine participating centres, patients with shock but not randomized were entered in a registry. Only 55 patients could be randomized. Of the 32 patients in the invasive group, 30 (94%) underwent early angiography, 27 (84%) PTCA, and one (4%) CABG. Twenty-two (69%) died within 30 days in the invasive group vs 18/23 (78%) in the medically managed group (ns, RR=0.88, 95% confidence interval 0.6-1.2). Among the registry patients, 24/51 were excluded from randomization solely because of patient or physician preference for the invasive approach: 23 (96%) of them underwent emergency angiography, 21 (88%) PTCA, and 12 (50%) died within 30 days. Among the remaining registry patients (n=27) only nine (33%) underwent early angiography, nine (33%) PTCA and 20 (74%) died. CONCLUSION: We failed to demonstrate that emergency PTCA significantly improves survival in patients with acute myocardial infarction and early cardiogenic shock. Because the study was stopped prematurely, due to an insufficient patient inclusion rate, a clinically meaningful benefit of early reperfusion may have been missed.

Aged↗
PubMed1999

Minimal myocardial damage during coronary intervention is associated with impaired outcome.

AIMS: Studies on the glycoprotein IIb-IIIa receptor blocker abciximab in patients undergoing percutaneous coronary intervention consistently show a reduction in procedure-related myocardial infarction. Some such infarcts are characterized by elevated creatine kinase or creatine kinase-MB, without apparent clinical symptoms. The clinical relevance of such 'creatine kinase leaks' has been questioned. Therefore we investigated the relationship between post-procedural creatine kinase-MB elevation and outcome at the 6 month follow-up. METHODS AND RESULTS: Creatine kinase-MB, or total creatine kinase values were analysed in 5025 out of 6156 patients enrolled in the CAPTURE, EPIC and EPILOG studies. A consistent gradual increase in 6 month mortality was observed as creatine kinase-MB or creatine kinase levels increased: 1.1%, 2.1%, 1.8%, 3. 6% and 6.7% for creatine-MB or creatine ratios (relative to upper limit of normal) <1, 1-3, 3-5, 5-10 and >/=10, respectively. Also the incidence of death or (recurrent) myocardial infarction was related to creatine kinase-MB or creatine kinase ratios. Subsequent revascularization was not related to periprocedural myocardial infarction. By multivariable analysis, correcting for clinical and angiographic characteristics, mortality at 6 months was related to the enzyme (creatine kinase, creatine kinase-MB) ratio, a history of heart failure and age. The combined end-point of death and myocardial infarction was also related to these factors, as well as to a history of bypass surgery and unstable angina. CONCLUSION: Modest elevation of cardiac enzymes (creatine kinase-MB, creatine kinase) after percutaneous coronary intervention is associated with an increased risk of mortality and reinfarction during the 6 month follow-up. Measures to reduce such periprocedural infarcts are warranted.

Abciximab↗
PubMed1999

Assessment of coronary angiograms prior to and after treatment with abciximab, and the outcome of angioplasty in refractory unstable angina patients. Angiographic results from the CAPTURE trial.

BACKGROUND: The CAPTURE study (c 7E3 A nti P latelet T herapy in U nstable Re fractory angina) was designed to assess outcome in patients with refractory angina undergoing angioplasty, receiving either abciximab or placebo. METHODS: One thousand two hundred and sixty-five patients with refractory unstable angina, defined as recurrent myocardial ischaemia despite medical treatment including heparin and nitrates were enrolled. After angiography, patients received an infusion of abciximab or placebo over 18-24 h preceding angioplasty, continuing until 1 h after the procedure. In 1197 patients undergoing angioplasty the angiographic committee centrally reviewed the baseline as well as the procedural angiograms. Coronary flow and lesion characteristics were assessed in the baseline angiogram as well as before intervention. Angiographic outcome, reason for failure as well as complications were assessed after angioplasty. RESULTS: At 30 days follow-up, patients receiving abciximab (n=595) compared with placebo (n=602) had a 30% reduction in the composite primary end-point death, myocardial infarction or urgent (re)intervention: 10.8% vs 15.4% (P=0.017). Baseline demographics were identical in the angiogram available group compared with the total study group. At 30 days, the non-angiogram available patients showed a higher incidence of events compared to those in whom the angiogram was reviewed: 19.4 vs 13.1% (P=ns). Lesion characteristics and coronary flow were not different at baseline between the placebo and abciximab groups. A primary end-point was reached in 9.6% of both placebo and abciximab patients with type A or B(1)lesions, in 17.0% vs 12.0% with type B(2)lesions, and in 19.1% vs 11.5% with type >B(2)or C lesions. Sixty-one percent of placebo and abciximab patients had TIMI 3 flow at baseline angiography. Pre-angioplasty TIMI 3 flow was observed in 69% and 72% respectively. The thrombus was resolved between the angiograms in 22% and 43% respectively, in the placebo and abciximab groups (P=0. 033). Angiographic success of the procedure was achieved in 88% and 94% in the placebo and abciximab patients, respectively (P<0.001). Stents were implanted in the ischaemia-related artery in 56 and 60 patients, respectively. However, failure of the stent procedure was more frequent in the placebo group than in the abciximab group, nine vs no patients (P=0.003). CONCLUSION: More frequent thrombus resolution was observed and a higher angiographic success rate was achieved in patients treated with abciximab before and during angioplasty compared with placebo. Patients with complex lesions as the underlying pathology reached fewer end-points if treated with abciximab before and during angioplasty.

Abciximab↗
PubMed1999

Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients.

OBJECTIVE: To describe the long term clinical outcome (up to 11 years) after coronary stenting. DESIGN: A single centre observational study encompassing 1000 consecutive patients with a first stent implantation (1560 stents) between 1986 and 1996, who were followed for at least one year with a median follow up of 29 months (range 12-132 months). RESULTS: Up to July 1997 the cumulative incidence of the major adverse cardiac events (MACE) of death, non-fatal acute myocardial infarction, coronary artery bypass grafting, and repeat percutaneous transluminal coronary angioplasty was 8.2%, 12.8%, 13.1%, and 22.4%, respectively. Survival at one, three, and five years was 95%, 91%, and 86%, respectively. Comparison of MACE incidence during the "anticoagulant era" and the "ticlopidine era" revealed significantly improved event free survival with ticlopidine (27% v 13%; p < 0.005). Multivariable analyses showed that ejection fraction < 50% (relative risk (RR) 4. 1), multivessel disease (RR 3.0), diabetes (RR 2.9), implantation in saphenous vein graft (RR 2.1), indication for unstable angina (RR 1. 9), and female sex (RR 1.7) were independent predictors of increased mortality after stenting. Independent predictors of any MACE were multivessel stenting (RR 2.0), implantation in saphenous bypass graft (RR 1.6), diabetes (RR 1.5), anticoagulant treatment (versus ticlopidine and aspirin) (RR 1.5), bailout stenting (RR 1.5), multivessel disease (RR 1.4), and multiple stent implantation (RR 1. 5). CONCLUSIONS: Long term survival and infarct free survival was good, particularly in non-diabetic men with single vessel disease and good ventricular function, who had a single stent implanted in a native coronary artery. A dramatic improvement was observed in event free survival, both early and late, with the replacement of anticoagulation by ticlopidine. This, of course, cannot be separated from improved stent implantation techniques between 1986 and 1995. Ultimately, almost 40% of the patients experienced an adverse cardiac event (mainly repeat intervention) in the long term. New advances in restenosis treatments and in secondary prevention must be directed at this aspect of patient management after stenting.

Adult↗
PubMed1998

Rescue angioplasty after failed thrombolysis: technical and clinical outcomes in a large thrombolysis trial. GUSTO-1 Angiographic Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries.

OBJECTIVES: We sought to assess the angiographic outcome, complication rates and clinical features of percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. BACKGROUND: "Rescue angioplasty" refers to mechanical reopening of an occluded infarct-related artery (IRA) after failed intravenous thrombolysis. Although the procedure is commonly performed, data describing its technical and clinical outcome are sparse. Early reports suggested that rescue PTCA is less often successful and produces more complications than primary PTCA. Other reports have described beneficial effects of successful rescue PTCA but adverse outcomes when PTCA is unsuccessful. METHODS: Using data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) angiographic substudy, we compared clinical and angiographic outcomes of 198 patients selected for a rescue PTCA attempt with those of 266 patients with failed thrombolysis but managed conservatively and, for reference, with those of 1,058 patients with successful thrombolysis. RESULTS: Patients offered rescue PTCA had more impaired left ventricular function than those in whom closed vessels were managed conservatively. Rescue successfully opened 88.4% of closed arteries, with 68% attaining Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. The interventions did not increase catheterization laboratory or postprocedural complication rates. Multivariate analysis identified severe heart failure to be a determinant of a failed rescue attempt. Successful rescue PTCA resulted in superior left ventricular function and 30-day mortality outcomes, comparable to outcomes in patients with closed IRAs managed conservatively, but less favorable than in patients in whom thrombolytic therapy was initially successful. The mortality rate after a failed rescue attempt was 30.4%; however, five of the seven patients who died after failed rescue PTCA were in cardiogenic shock before the procedure. CONCLUSIONS: Rescue PTCA tends to be selected for patients with clinical predictors of a poor outcome. It is effective in restoring patency. Patients who die after a failed rescue attempt are often already in extremis before the angioplasty attempt.

Aged↗
PubMed1998

Interventional cardiology in Europe 1994. Working Group Coronary Circulation of the European Society of Cardiology.

The working group Coronary Circulation of the European Society of Cardiology conducts an annual survey of cardiac interventions in Europe with the support of the national societies of cardiology. A detailed questionnaire about cardiac interventions performed during 1994 was mailed to all members of the European Society of Cardiology. Incomplete or absent data from eight national members precluded their inclusion in the final analysis. Thus, this report summarizes the cardiac interventions performed during 1994 in 29 of 37 members of the European Society of Cardiology, representing a total population of approximately 490 million inhabitants. CORONARY ANGIOGRAPHY: A total of 922,687 coronary angiograms were reported during 1994, representing an increase of 22% compared with 1993 and of 35% compared with 1992. The mean incidence of coronary angiograms was 1881/10(6) inhabitants, ranging from 4417/10(6) inhabitants in Germany to 35/10(6) inhabitants in Romania, Germany, France, Great Britain, and Italy with 50% of the European population performed 73% of all cardiac interventions. CORONARY ANGIOPLASTY: During 1994, a total of 224,722 coronary angioplasty (PTCA) procedures were reported in Europe, an increase of 22% compared with 1993 and of 52% compared with 1992. Adjusted per capita, the mean incidence of coronary angioplasty was 458/10(6) inhabitants, ranging from 1091/10(6) inhabitants in Germany to 6/10(6) inhabitants in Romania. On average, the ratio PTCA per coronary angiogram was 0.24, ranging from 0.37 in the Netherlands to 0.06 in Cyprus. Ad hoc PTCA accounted for 22% of all PTCA cases. The majority (81%) of PTCAs were restricted to a single vessel. Major complications were reported in 2% of patients undergoing PTCA, including death (0.3%), myocardial infarction (1.0%) and need for emergency coronary artery bypass grafting (0.7%). CORONARY STENTING: Coronary stents were utilized in 21,599 coronary interventions during 1994, an increase of 235% compared with 1993 and thus representing the fastest growth in interventional cardiology. The number of European countries employing stents during coronary angioplasty grew from 14 during 1993 to 24 during 1994. Elective use (38%) became the most frequent indication for coronary stenting during 1994, replacing bail-out stenting as the primary indication during 1993. OTHER NEW DEVICES: Other new interventional therapeutic devices were employed in 8827 cases. Only the Rotablator was used more frequently during 1994 as compared with 1993. All other new therapeutic devices showed a decline. Coronary ultrasound was utilized in 3032 interventions and coronary angioscopy in 304 cases during 1994. NON-CORONARY INTERVENTIONS: Valvuloplasty remained the most frequent non-coronary intervention in Europe during 1994 with a total of 2622 mitral. 609 pulmonary and 506 aortic valvuloplasties. CATHETERIZATION FACILITIES: The number of facilities per 10(6) inhabitants performing invasive cardiac procedures in Europe during 1994 ranged from 7.7 in Iceland to 0.2 in Romania (European mean 2.9). The number of trained operators per 10(6) inhabitants ranged from 24 in Germany to 0.4 in Romania (European mean 10). During 1994, a mean of 701 coronary angiograms and 170 PTCAs were performed per catheterization facility in Europe (range: 1052 coronary angiograms and 293 PTCAs per facility in Norway to 218 coronary angiograms and 37 PTCAs per facility in Romania). CONCLUSIONS: The number of both coronary angiograms and coronary angioplasties continues to grow at an annual rate of approximately 20% in Europe. There is a wide range in the amount of revascularization procedures performed between western and eastern European countries. However, countries with the lowest numbers of coronary angiograms and coronary angioplasties, e.g. Romania, also show the fastest annual growth. About one quarter of all patients undergoing coronary angiography are subsequently revascularized by coronary angioplasty. (ABSTRACT TRUN

Angioplasty, Balloon, Coronary↗
PubMed1996

Repeat interventions as a long-term treatment strategy in the management of progressive coronary artery disease.

OBJECTIVES: This study investigates whether repeat coronary interventions, applied over an extended time period, can successfully curtail the progression of ischemic symptoms and angiographic lumen narrowing. BACKGROUND: Coronary artery disease is a chronic and generally progressive disorder, and potential treatment strategies should be examined and compared with this chronicity in mind. Percutaneous interventional revascularization procedures could theoretically be useful in controlling progression of the disease through repeated use as new coronary lesions arise. However, the outcome of this long-term management concept has not previously been subjected to detailed investigation. METHODS: From a consecutive series of 4,357 interventional cardiac procedures, 544 patients were identified who received two or more interventions during the 13-year study period. These patients were categorized into one of three groups: restenosis (repeat interventions limited to the same target segment, n = 261), new stenosis (all repeat interventions directed to stenoses not previously treated, n = 155) or both (repeat interventions directed both to the same and to different target lesions, n = 128). RESULTS: Two to five procedures were performed per patient; the time period (mean +/- SD) separating each procedure was significantly less (p < 0.0001) for the restenosis group (4.2 +/- 2.3 months) than for the new stenosis (24.2 +/- 23.5 months) or the "both" groups (11.4 +/- 11.0 months). Despite the need for repeat procedures, the severity of angina (mean New York Heart Association functional class 1.6 +/- 0.9) after 6.2 +/- 2.3 years of follow-up was substantially better than before the initial procedure (mean functional class 3.2 +/- 0.8), with a similar magnitude of change found in all three groups. This long-term functional improvement was mirrored by a corresponding anatomic improvement, with the mean number of diseased vessels remaining constant at the time of each procedure (1.5 +/- 0.7, 1.5 +/- 0.7 and 1.6 +/- 0.7, respectively, for the first, second and third procedures, p = NS). The restenosis and the new stenosis groups also demonstrated statistically similar annual rates of mortality (1.9% vs. 1.8%) and coronary surgery (2.3% vs. 2.6%), although the restenosis group had a lower rate of infarction (1.4% vs. 3.2%, p = 0.002). CONCLUSIONS: Repeat interventional treatment of newly acquired stenoses provides a rational approach for the long-term management of chronic coronary artery disease. In addition to yielding a favorable late outcome, the use of this strategy can result in sustained functional improvement and can check the progression of clinically significant stenoses.

Angioplasty, Balloon, Coronary↗
PubMed1996

Interventional cardiology in Europe 1993. Working Group on Coronary Circulation of the European Society of Cardiology.

An annual survey on cardiac interventions in Europe is performed by the working group on Coronary Circulation of the European Society of Cardiology with the help of the national societies of cardiology. A questionnaire about cardiac interventions in 1993 was mailed to a representative of the national societies of 35 members of the European Society of Cardiology. The data collection of coronary interventions was delayed by slow backreporting and from 10 of the 35 national members data were missing or grossly incomplete. They were excluded from the analysis. CORONARY ANGIOGRAPHY: A total of 756,822 coronary angiograms were reported resulting in an incidence of 1146 +/- 1024 per 10(6) inhabitants, ranging from 24 (Romania) to 3499 (Germany). This represents an increase of 12% compared to 1992. Germany (279,882 cases), France (157,237), the United Kingdom (77,000), Italy (44,934) and Spain (37,591) registered 79% of all the coronary angiograms performed. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY: A total of 183,728 percutaneous transluminal coronary angioplasty cases were reported in 1993, 24% more than in 1992. On average, they accounted for 18 +/- 7% (range 8 (Romania) to 35% (Sweden) of the coronary angiograms. Most of these percutaneous transluminal coronary angioplasties (82%) were confined to a single vessel. In 13% only, percutaneous transluminal coronary angioplasty took place immediately after the diagnostic study. Adjusted per capita. Germany ranks first with 873 percutaneous transluminal coronary angioplasties per 10(6) inhabitants, followed by France (737), Holland (725), Belgium (713), and Switzerland (665). The European mean of percutaneous transluminal coronary angioplasties per 10(6) inhabitants was 270 +/- 279, representing an increase of 14% compared with 1992. A major in-hospital complication was reported in 3.8% of the patients undergoing percutaneous transluminal coronary angioplasty: 0.6% hospital deaths, 1.5% emergency coronary artery bypass grafting, and 1.7% myocardial infarctions. NEW DEVICES: In 1993 stents were implanted in 6444 patients (3.5% of all percutaneous transluminal coronary angioplasty patients), equally distributed between bail-out situations (53%) and elective procedures. The 14 stent implanting countries showed a mean increase in incidence of coronary stenting of 53% compared with 1992. Other interventional devices were applied in 7045 cases, 3.8% of all percutaneous transluminal coronary angioplasty cases. Coronary ultrasound (2194 cases) and coronary angioscopy (380 cases) were performed infrequently. NON-CORONARY INTERVENTIONS: Valvuloplasties were most frequently performed non-coronary interventions European countries performed more than 300 valvuloplasties each in 1993. Most of them were mitral valvuloplasties in southern countries. CONCLUSIONS: Although partial backreporting might conclusions, several findings of this survey are noteworthy for the participating countries: The number of percutaneous taneous transluminal coronary angioplasties is universally increasing. There is an extremely wide range of coronary angiography and percutaneous translumina, coronary angioplasties performed per population. The most common additional procedure is a stent implantation while other new devices are only rarely applied. Mitral valvuloplasty is the most frequently performed non-coronary intervention.

Angioplasty, Balloon, Coronary↗
PubMed1996

Cost effectiveness of stent implantation versus PTCA: the BENESTENT experience.

The aim of this paper is to assess the costs and effects of stent implantation versus percutaneous transluminal coronary angioplasty (PTCA). Data have been taken from both the BENESTENT-I and BENESTENT-II pilot study. Effects are expressed in terms of event-free survival and costs include those of the initial hospitalization and those during follow-up. The costs per additional event-free survivor after 7 months are estimated at Dfl 88,315, Dfl 28,127 and Dfl 6747 using respectively the results from the BENSTENT-I study, the BENESTENT-II pilot study and phase IV of the BENESTENT-II pilot study. Significant decreases in complications and ischaemic events have made stent implantation not only the most favourable in terms of event-free survival but also in terms of cost effectiveness.

Angioplasty, Balloon, Coronary↗
PubMed1995

Vectorcardiographic monitoring to assess early vessel patency after reperfusion therapy for acute myocardial infarction.

Reperfusion therapy has lowered mortality in patients suffering from acute myocardial infarction. Failure to reperfuse is associated with an increased short- and long-term mortality. In a prospective study we used dynamic vectorcardiography to monitor 96 patients with acute myocardial infarction treated with reperfusion therapy to non-invasively assess coronary patency. The results from continuous monitoring were compared to those obtained from angiography. By using trend-analysis of QRS vector difference and ST vector magnitude, we were able to correctly identify 58 of the 70 patients (83%) with a reperfused infarct-related artery, and 19 of the 26 patients (73%) with a persistently occluded artery demonstrated at an early angiogram (diagnostic accuracy 80%). In patients with high-grade collateral flow to the infarct-related area, the results of the vectorcardiographic monitoring and of angiography showed the largest disagreement, whereas the accuracy of vectorcardiographic monitoring was high: 88% among patients without collaterals. The present results suggest that QRS complex and ST segment vectorcardiographic monitoring is a useful tool for assessing early coronary artery patency, and that dynamic vectorcardiography may help in identifying candidates for emergency coronary angiography.

Acute Disease↗
PubMed1995

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less.

OBJECTIVE: To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less. DESIGN: Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians. SETTING: A tertiary referral cardiac centre. PATIENTS: 57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient. RESULTS: The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival. CONCLUSIONS: In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.

Adult↗
PubMed1994

Early angiography cannot predict postthrombolytic coronary reocclusion: observations from the GUSTO angiographic study. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries.

OBJECTIVES: The purpose of this study was to determine whether early qualitative or quantitative angiographic features can predict reocclusion after initially successful coronary thrombolysis. BACKGROUND: Although both the benefits of early reperfusion and the consequences of subsequent reocclusion after thrombolysis for acute myocardial infarction have been well described, efforts to describe angiographic markers of lesions at high risk for reocclusion have produced conflicting results. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient cohort studied to date. METHODS: We studied 559 patients undergoing follow-up angiography at 90 min and 5 to 7 days after thrombolysis in the GUSTO trial. Patients received one of four thrombolytic regimens: 1) streptokinase with intravenous heparin; 2) streptokinase with subcutaneous heparin; 3) accelerated-dose recombinant tissue-type plasminogen activator (rt-PA) with intravenous heparin; or 4) a combination of streptokinase and conventionally dosed rt-PA with intravenous heparin. Qualitative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) flow grade, visible thrombus and lesion morphology. Quantitative variables included percent diameter stenosis, percent area stenosis, minimal lumen diameter and lesion length. The study contained a power > 0.85 to detect clinically important differences in percent diameter stenosis, percent area stenosis and minimal lumen diameter between the groups with subsequent reocclusion and sustained patency at the p = 0.05 level. RESULTS: At follow-up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group with reocclusion was compared with the group with continued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, percent area stenosis, minimal lumen diameter or lesion length. CONCLUSIONS: Our findings demonstrate that neither qualitative nor quantitative angiographic variables at 90 min after initiation of thrombolytic therapy can be used to predict subsequent coronary reocclusion.

Aged↗
PubMed1994

Acute and long-term outcome of directional coronary atherectomy for stable and unstable angina.

The clinical efficacy and safety of directional coronary atherectomy for the treatment of stable and unstable angina were assessed in 82 patients with stable and 68 patients with unstable angina. Therefore, clinical and angiographic follow-up was obtained in a prospectively collected consecutive series of 150 atherectomy procedures. Restenosis was assessed clinically and by quantitative angiography. The overall clinical success rate of atherectomy for patients with unstable and stable angina was 88% and 91%, respectively. No significant differences were found for in-hospital event rates between the unstable and stable angina groups: death (1.5% vs 0%), myocardial infarction (10% vs 6%), and emergency bypass operation (3% vs 2%). These clinical events were related to the occurrence of abrupt occlusions (8.8% in patients with stable and 6.1% in those with unstable angina; p = NS). Clinical follow-up was achieved in 100% of the patients with stable and unstable angina at a mean interval of 923 and 903 days, respectively. Two-year survival rates were 96% and 97% in the populations with unstable and stable angina, respectively. There were no significant differences with respect to bypass surgery and angioplasty, but event-free survival at 2 years was significantly lower in the unstable (54%) than the stable (69%) angina group. Quantitative coronary angiography did not detect any difference in luminal renarrowing during the 6-month angiographic follow-up period. Although directional coronary atherectomy can be performed effectively in patients with unstable and stable angina, the long-term clinical outcome was less favorable in the unstable angina group.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Predictive value of reactive hyperemic response on reperfusion on recovery of regional myocardial function after coronary angioplasty in acute myocardial infarction.

BACKGROUND: The objective of the study was to determine the coronary vasodilatory reserve in reperfused myocardium in patients with acute myocardial infarction and its relation to regional myocardial function. METHODS AND RESULTS: The study population consisted of 22 patients with acute myocardial infarction who underwent successful coronary angioplasty. The vasodilatory reserve in the reperfused myocardium was assessed quantitatively using computer-assisted digital subtraction cine-angiography immediately after angioplasty and at follow-up angiography before hospital discharge. Myocardial contrast medium appearance time and density were determined before and after pharmacological hyperemia induced by an intracoronary injection of 12.5 mg papaverine. Global and regional left ventricular functions were determined from contrast angiography. After papaverine, the mean contrast medium appearance time decreased significantly from 3.5 +/- 0.7 to 2.7 +/- 0.7 cardiac cycles (P < .000005) immediately after successful coronary angioplasty and from 3.8 +/- 0.7 to 2.7 +/- 0.9 cardiac cycles (P < .000005) at angiography before hospital discharge. The mean contrast medium density increased significantly from 48.7 +/- 13.8 to 61.0 +/- 19.0 pixels (P < .003) and from 49.6 +/- 19.7 to 80.3 +/- 29.6 pixels (P < .000005), respectively. As a consequence, the calculated coronary flow reserve increased significantly from 1.8 +/- 0.7 to 2.6 +/- 1.0 (P < .0008). The global ejection fraction increased significantly from 52 +/- 12% to 58 +/- 14% (P < .03), primarily because of a significant improvement in the regional myocardial function of the infarct zone from 20.8 +/- 9.0% to 26.0 +/- 10.5% (P < .001). Coronary flow reserve correlated well with regional myocardial function both during the acute phase (R = .79, P < .002) and at follow-up angiography (R = .82, P < .000004). Interestingly, coronary flow reserve measurement on reperfusion, immediately after angioplasty, correlated significantly with regional myocardial function at follow-up angiography (R = .81, P < .00003). CONCLUSIONS: The results indicate that there is a pharmacologically inducible vasodilatory reserve in reperfused ischemic myocardium after successful coronary angioplasty in patients with acute myocardial infarction and that this is increased at 10-day follow-up angiography. More important, the degree of reactive hyperemic response on reperfusion has a predictive value regarding the ultimate degree of recovery of regional myocardial function. Quantitative assessment of reperfusion may be useful in investigating the role of coronary reperfusion and salvage of myocardial function.

Angiography, Digital Subtraction↗