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PubMed1991

[Coronary disease in patient following heart transplantation].

Coronary artery disease is a common and particularly severe complication of cardiac transplantation because it may cause progressive destruction of the graft by acute or chronic ischemia. The ischemia is usually silent because of cardiac denervation. Cardiac failure related to graft dysfunction, asymptomatic infarction on the ECG, or sudden death, are sometimes the only signs of severe coronary disease. The prevalence of coronary lesions has been evaluated by coronary angiography at nearly 25% at 2 years and 50% at 5 years. The distribution and morphology of the lesions are characteristic: diffuse concentric, irregular and occlusive, predominantly distal stenoses, without a distal and usually without a collateral circulation. The histological features are variable: the association of medial necrosis, severe endothelial lesions and intense parietal inflammation are suggestive of acute arteriolitis, often present during acute rejection, may be related to a common pathological process. Diffuse obliterative arteriolar lesions with concentric proliferation of medial smooth muscle are the usual appearances in transplant patients who have died or been retransplanted. There is no non-invasive diagnostic method sufficiently sensitive of specific which justifies the practice of many groups of systematic annual coronary angiography in transplanted patients. The pathogenesis is poorly understood and probably multifactorial: disorders of lipid metabolism, immunological factors, the atherogenic role of Cytomegalovirus infection. The absence of an identifiable risk factor makes preventive measures difficult. The evolutive risk justifies retransplantation in selected patients, the results of which are less satisfactory but which reduces the risk of acute coronary events and sudden death.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Angiography↗
PubMed1999

Delayed systolic blood pressure recovery after graded exercise: an independent correlate of angiographic coronary disease.

OBJECTIVE: This study was performed to determine whether a delayed decline in systolic blood pressure (SBP) after graded exercise is an independent correlate of angiographic coronary disease. BACKGROUND: The predictive importance of the rate of SBP decline after exercise relative to blood pressure changes during exercise has not been well explored. METHODS: Among adults who underwent symptom-limited exercise treadmill testing and who underwent coronary angiography within 90 days, a delayed decline in SBP during recovery was defined as a ratio of SBPs at 3 min of recovery to SBP at 1 min of recovery >1.0. Severe angiographic coronary artery disease was defined as left main disease, three-vessel disease or two-vessel disease with involvement of the proximal left anterior descending artery. RESULTS: There were 493 subjects eligible for analyses (age 59 +/- 11 years, 78% male). Severe angiographic coronary disease was noted in 102 (21%). There were associations noted between a delayed decline in SBP during recovery and severe angiographic coronary disease (34% vs. 17%, odds ratio [OR] 2.59, confidence interval [CI] 1.58 to 4.25, p = 0.001). In multivariate logistic regression analyses adjusting for SBP changes during exercise and other potential confounders, a delayed decline in SBP during recovery remained predictive of severe angiographic coronary disease (adjusted OR 2.22, 95% CI 1.27 to 3.87, p = 0.005). CONCLUSIONS: A delayed decline in SBP during recovery is associated with a greater likelihood of severe angiographic coronary disease even after accounting for the change in SBP during exercise.

Aged↗
PubMed1996

[Prevention of coronary diseases in daily clinical practice].

Coronary heart disease mortality has declined in a number of European countries, included Belgium, but has remained unchanged or increased in others. In all these countries, coronary heart disease mortality remains the leading cause of mortality in men over 45 years and women over 65 years. The progress, when present, is related both with a better understanding of the physiopathological mechanisms, a better pharmacological and interventional approach and with a better application of prevention. Enthusiasms are nevertheless less important in application of prevention measures than in technical progresses. We present here the recommendations for prevention of coronary heart disease proposed by the European Society of Cardiology in clinical practice.

Aged↗
PubMed1980

Arteriography of coronary disease at clinical onset.

The coronary arteriographic anatomic findings in 491 male patients clinically symptomatic for less than six months are described. Single and multiple vessel disease was noted, respectively, in 40 and 60 percent with 6.5 percent also manifesting left main coronary disease. Our findings indicate that severe coronary artery disease is present early in the symptomatic phase and that patients presenting with initial inferior myocardial infarctions may represent a select group having an excessive frequency of severe coronary disease suitable for early angiographic detection and surgical bypass therapy.

Adult↗
PubMedDate not supplied

Dyslipidemia as a risk factor for coronary disease in patients with diabetes.

OBJECTIVE: To highlight the frequency of lipid abnormalities in patients with diabetes and the need for appropriate treatment strategies for coronary disease. METHODS: The epidemiologic features of coronary artery disease in the diabetic population are reviewed, and the pathogenesis of atherosclerotic disease is discussed. Various risk factors for predicting coronary artery disease and guidelines for therapeutic intervention are presented. RESULTS: The American Diabetes Association has estimated that 60% of all adults will die of coronary artery disease and that 80% of patients with diabetes will ultimately have atherosclerosis. The accelerated rate of atherosclerosis in patients with diabetes may be attributable to several factors, including hyperglycemia and insulin resistance. Abnormalities in lipid metabolism have a major role in the development of coronary disease. Because the National Cholesterol Education Program guidelines for treatment were established for less complicated hyperlipidemias, The American Diabetes Association recommends more aggressive lipid-lowering therapy at a lower level of low-density lipoproteins (130 mg/dL or 3.36 mmol/L) to produce an equivalent reduction in risk of coronary disease in patients with diabetes. CONCLUSION: In patients with diabetes, lipid levels should be aggressively reduced to decrease the possibility of coronary artery disease.

Journal Article↗
PubMed1999

[Coronary disease and type 2 diabetes].

Coronary heart disease is the leading cause of premature deaths in type 2 diabetic patients. Atypical in its clinical presentation or silent coronary heart disease in this population is to be detected early in those patients at high risk of cardiovascular disease. Males with peripheral artery disease, albuminuria and those with (or) the combination of tobacco use, hypertension and dyslipidemias. Exercise test is the non-invasive investigation to be used as a first line examination. A coronary angiography is to be performed in the patients with a positive exercise test. A significant stenosis of the left main coronary artery or a triple vessel disease, common conditions in diabetic patients, should lead to myocardial revascularisation which reduces cardiovascular mortality and morbidity. The diagnosis of coronary heart disease in type 2 diabetic patients, should induce in all cases a medical treatment including cardiological and metabolic therapies, unfortunately very poorly performed in too many patients.

Cause of Death↗
PubMed1997

Coronary risk factors and plaque morphology in men with coronary disease who died suddenly.

BACKGROUND: Cigarette smoking and abnormal serum cholesterol concentrations are risk factors for acute coronary syndromes, but the underlying mechanisms are poorly understood. We studied whether cigarette smoking and abnormal cholesterol values may precipitate acute coronary thrombosis and sudden death resulting from either rupture of vulnerable coronary plaques or erosion of plaques. METHODS: We examined the hearts of 113 men with coronary disease who had died suddenly and also analyzed their coronary risk factors. We found an acute coronary thrombus in each of 59 men, and severe narrowing of the coronary artery by an atherosclerotic plaque without acute thrombosis (stable plaque) in 54. Cases of acute thrombosis were divided into two groups: 41 resulting from rupture of a vulnerable plaque (a thin fibrous cap overlying a lipid-rich core), and 18 resulting from the erosion of a fibrous plaque rich in smooth-muscle cells and proteoglycans. Vulnerable plaques that had not ruptured were counted in each heart. RESULTS: Cigarette smoking was a risk factor in 44 (75 percent) of the men with acute thrombosis, as compared with 22 (41 percent) of the men with stable plaques (P<0.001). The mean (+/-SD) ratio of serum total cholesterol to high-density lipoprotein (HDL) cholesterol was markedly elevated in the men who died of acute thrombosis with plaque rupture (mean, 8.5+/-4.0) but only mildly elevated in the men without acute thrombosis (5.5+/-2.4; P<0.001) and in the men with thrombi overlying eroded plaques (5.0+/-1.8; P<0.001). Multivariate analysis showed an association between an elevated ratio of serum total cholesterol to HDL cholesterol and the presence of vulnerable plaques (P<0.001). CONCLUSIONS: Among men with coronary disease who die suddenly, abnormal serum cholesterol concentrations - particularly elevated ratios of total cholesterol to HDL cholesterol - predispose patients to rupture of vulnerable plaques, whereas cigarette smoking predisposes patients to acute thrombosis.

Acute Disease↗
PubMed2001

Mild hyperhomocysteinemia is not associated with cardiac allograft coronary disease.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor for coronary disease and elevated plasma homocysteine levels have been documented in heart transplant recipients. The aim of this study was to test the hypothesis that homocysteine levels are associated with presence or absence of transplant coronary artery disease. METHODS: Forty-three non-smoking adults were recruited, all of whom had received a heart transplant between 2 and 7 yr previously. All 43 had blood drawn for fasting homocysteine level on the day of presentation. All patients had undergone diagnostic coronary angiography within the past 6 months. RESULTS: For all patients, the average fasting plasma homocysteine level was 17.0+/-SD 6.6 micromol/L with a range from 6.0 to 36.9 micromol/L. Twenty-six patients (60%) had fasting plasma homocysteine levels above 15.0 micromol/L. On the basis of arteriography, patients were categorized as those with angiographically normal (n=22) or abnormal (n=21) coronary arteries. There was no difference in the mean plasma homocysteine level comparing patients with angiographically normal (17.2+/-SD 7.0 micromol/L) to those with abnormal (16.8+/-SD 6.2 micromol/L) coronary arteries. Plasma homocysteine levels increased with increasing plasma creatinine levels (r=0.63, p<0.0001) and with decreasing vitamin B6 levels (r=-0.56, p<0.0001). CONCLUSIONS: Mild hyperhomocysteinemia is a consistent finding among heart transplant recipients. This finding was not associated with transplant coronary artery disease in our patients. The combination of renal dysfunction and vitamin B6 deficiency may explain the unusual prevalence of hyperhomocysteinemia in heart transplant recipients.

Adult↗
PubMedDate not supplied

Depression and self-reported physical health in patients with coronary disease: mediating and moderating factors.

OBJECTIVES: The purpose of this study was to define how the relation between depression and self-reported physical health in patients with coronary disease is modified by other patient-centered factors. METHODS: We conducted a prospective cohort study of 111 patients (members of a health maintenance organization) with angiographically documented coronary disease, examining factors (physical symptoms, psychological states and traits, and spousal support) modifying the relation between depression and patient-reported physical health 5 years later using multiple hierarchical regression models. RESULTS: Five regression models (all including demographic and disease severity covariates) were constructed to predict physical health from depression only (R2 = 0.22); depression plus angina and fatigue (R2 = 0.53); depression plus positive affect and novelty seeking and their interaction (R2 = 0.48); depression plus spousal support (R2 = 0.27); and depression, angina, fatigue, positive affect, and novelty seeking (overall model) (R2 = 0.65). Depression remained significant in each model, but the proportion of variance it predicted was diminished in the presence of the other variables (bivariate r = 0.39, partial r = 0.37-0.13). CONCLUSIONS: The effect of depression on self-reported physical health is significantly mediated by physical symptoms (angina and fatigue), personality states and traits (positive affect and novelty seeking), and spousal support. Positive affect and novelty seeking had more marked effects on physical health in the presence of more depression. Thus, a broad range of factors beyond the severity of coronary disease itself affect the perceived physical health of patients with coronary heart disease.

Affect↗