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PubMed1963

[Coronary disease].

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Coronary Disease↗
PubMed2004

Treatment of inoperable coronary disease and refractory angina: spinal stimulators, epidurals, gene therapy, transmyocardial laser, and counterpulsation.

Intractable angina from refractory coronary disease is a severe form of myocardial ischemia for which revascularization provides no prognostic benefit. Inoperable coronary disease is also accompanied by a "vicious cycle" of myocardial dystrophy from a chronic alteration of the cardiac sympathetic tone and sensitization of damaged cardiac tissues. Several adjunctive treatments have demonstrated efficacy when revascularization is either unsuccessful or contraindicated. Spinal cord stimulation modifies the neurologic input and output of the heart by delivering a very low dose of electrical current to the dorsal columns of the high thoracic spinal cord. Neural fibers then release CGRP and other endogenous peptides to the coronary circulation reducing myocardial oxygen demand and enhancing vasodilation of collaterals to improve the myocardial blood flow of the most diseased regions of the heart. Randomized study has shown the survival data at five years is comparable to bypass for high-risk patients. Transmyocardial laser revascularization creates small channels into ischemic myocardium in an effort to enhance flow though studies have shown no improvement in prognosis over medical therapy alone. Enhanced external counterpulsation uses noninvasive pneumatic compression of the legs to improve diastolic filling of the coronary vessels and promote development of collateral flow. The compressor regimen requires thirty-five hours of therapy over a seven-week treatment period. Therapeutic angiogenesis requires injection of cytokines to promote neovascularization and improve myocardial perfusion into the regions affected by chronic ischemia. Phase 3 trials are pending. High thoracic epidural blockade produces a rapid and potent sympatholysis, coronary vasodilation and reduced myocardial oxygen demand in refractory coronary disease. This technique can be used as an adjunct to bypass surgery or medical therapy in chronic or acute unstable angina. Epidurals are easy to perform and often available for outpatient or inpatient use. The rapid anti-ischemic effect may complement therapeutic angiogenesis or other interventions with delayed onset to clinical benefit. A new era for interventional and implant cardiology is beginning to emerge as more clinicians, including cardiologists, gradually learn new procedures to safely provide more therapeutic options for patients suffering refractory angina.

Anesthesia, Epidural↗
PubMed2001

Psychiatric morbidity and the presence and absence of angiographic coronary disease in patients with chest pain.

OBJECTIVE: To assess psychiatric morbidity in coronary angiogram patients. METHOD: A psychiatric assessment of 200 consecutive chest-pain patients was performed the day before coronary angiography in a double-blind study design. The sample included 132 men (mean age 57.2 years, SD 9.5) and 68 women (mean age 59.8 years, SD 8.9). A Structured Clinical Interview for DSM-III-R was used to obtain psychiatric diagnosis. The 21-item Beck Depression Inventory, the 20-item Toronto Alexithymia Scale and a four-item Life Satisfaction Scale were used to assess mental symptoms. A coronary angiography with obstruction of a coronary artery by more than 50% was considered to indicate angiographic coronary disease. RESULTS: Mental disorders were found in 28% (95% CI 14-41) of the patients with normal angiographic findings (n=47) and in 24% (95% CI 17 - 30) of the patients with angiographic coronary disease (n=153). Furthermore, no difference was found between these two groups in other rating scales assessing mental symptoms even when adjusted for the New York Heart Association class, duration of chest-pain symptoms or exercise capacity. CONCLUSION: Psychiatric morbidity may not be associated with angiographic findings in patients with chest pain.

Adult↗
PubMed1979

Beta- and pre-beta-lipoproteins in coronary disease and hyperlipoproteinaemia.

A very high percentage of male patients with proven coronary disease and/or raised lipid levels had a pre-beta-hyperlipoproteinaemia (class P [6] or Fredrickson [3] type IV) and relatively few had a beta-hyperlipoproteinaemia (class B or Fredrickson type IIA). Mixed hyperlipoproteinaemia was found in a large number of male patients but these again had predominantly raised triglyceride. More female patients over 40 years had beta-hyperlipoproteinaemia. Our retrospective study shows that raised triglyceride levels are more often found in patients with coronary disease than raised cholesterol levels.

Adult↗
PubMed1984

Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon.

Patients with chest pain and minimal or no coronary disease have a good prognosis for survival, yet many continue to have pain. In our experience with 821 medically treated patients there were three cardiac deaths (0.3%) and two nonfatal myocardial infarctions (0.2%) in the first year after angiography, which had revealed insignificant (less than 75% narrowing of the luminal diameter) or no coronary artery stenosis. In a subset of 548 patients selected with no apparent systematic difference from the inception cohort of 821 patients, there was complete absence of chest pain in 178 (33%) patients but 155 (28%) had similar or worse pain. From an analysis of clinical history and catheterization data entered in a stepwise logistic regression function, unimproved chest pain was significantly associated with female sex (p = 0.01) and an index of five chest pain descriptors (p = 0.0005). After adding selected behavioral variables available for a representative sample of 217 patients, a high hypochondriasis score (scale I from the Minnesota Multiphasic Personality Inventory) became the strongest determinant of continued pain (p less than 0.0001). In our experience, an exaggerated preoccupation with personal health is prospectively associated with continued chest pain in patients with minimal or no coronary disease.

Adolescent↗
PubMedDate not supplied

Disparate effects of out-patient cardiac and pulmonary rehabilitation programs on work efficiency and peak aerobic capacity in patients with coronary disease or severe obstructive pulmonary disease.

BACKGROUND: Exercise intolerance is an integral component of chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD) and is caused by several mechanisms that ultimately impact overall functional capacity. We assessed various components of exercise function in patients with CHD and COPD during the course of cardiac and pulmonary rehabilitation to evaluate changes unique to each condition. METHODS: Work efficiency (WEf, defined as delta watts/delta VO2) and peak VO2 were measured and compared at baseline and after 3 months (36 sessions) of outpatient cardiac and pulmonary rehabilitation programs in 25 patients (mean age = 66 +/- 7 years) with severe COPD (mean FEV1.0 = 0.90 +/- 0.35 L) and in 25 patients (mean age = 65 +/- 8 years) with CHD. RESULTS: At baseline, patients with COPD had significantly reduced values of WEf (2.04 +/- 0.86 versus 3.23 +/- 1.38 watts/mL/kg/min; P = 0.004) and peak VO2 (13.2 +/- 3.9 versus 17.1 +/- 3.9 mL/kg/min; P = 0.005) compared with patients with CHD. After rehabilitation, patients with CHD increased peak VO2 by 12% (17.1 +/- 3.9 to 19.1 +/- 4.9 mL/kg/min; P = 0.01) with no change in WEf (3.23 +/- 1.38 to 3.32 +/- 1.43 watts/mL/kg/min; P = not significant). In contrast, patients with COPD increased peak VO2 by only 5% (13.2 +/- 3.9 to 13.9 +/- 3.8 mL/kg/min; P = 0.0008), but WEf increased by 36% (2.04 +/- 0.86 to 2.78 +/- 0.84 watts/mL/kg/min; P = 0.0002). Subjective measures of functional status improved similarly in both groups. CONCLUSIONS: In contrast to patients with CHD, work inefficiency contributes significantly to exercise intolerance in patients with severe COPD. Outpatient rehabilitation programs enhance functional status in patients with CHD and COPD by differing mechanisms, depending on the underlying disease. These data show the disparate effects of out-patient rehabilitation on peak VO2 and WEf in cardiac and pulmonary patients.

Activities of Daily Living↗
PubMedDate not supplied

Left ventricular function in coronary disease: serial studies in the absence of myocardial infarction or coronary artery surgery.

Fifteen patients with coronary artery disease underwent repeat cardiac catheterization (R) 7-45 months (mean 19.4) after the initial study (I) because of increasing angina. No patient sustained a myocardial infarction between I and R or underwent coronary artery surgery. Left ventricular function exhibited variability between the two studies with 6 patients demonstrating deterioration in ejection fractions (I = 65.6 = +/- 14.0 vs R = 50.5 +/- 15.4 p less than 0.01); 5 patients had a slight increase and the remainder showed no change. Changes in left ventricular volumes were not significant. Eight patients demonstrated progression of their coronary artery disease. The remaining 7 patients did not demonstrate progression. All 8 patients with progression and 5 of 7 patients without coronary artery progression demonstrated left ventricular asynergy. There was no difference in left ventricular function in the group of patients with coronary progression vs. those without progression. We conclude that changes in LV function are variable in patients with coronary artery disease in the absence of myocardial infarction or coronary surgery, and the relationship to progression of coronary artery disease or increasing angina is unclear.

Cardiac Catheterization↗
PubMed1995

Relation of high-density lipoprotein subfractions and apolipoprotein E isoforms to coronary disease.

Although a variety of methods have become available for the determination of high-density lipoprotein (HDL) subfractions in plasma, a review of published data from nine studies of coronary disease outcomes and 10 investigations of coronary artery disease severity do no suggest that measurement of HDL2-cholesterol (C) and HDL3-C offer any advantage in the prediction of coronary disease over the determination of total HDL-C alone. Apolipoprotein E is typically present in plasma as one of six isoforms, the six being encoded by three common alleles, epsilon 2, epsilon 3, and epsilon 4. The epsilon 3 allele is the most common, the epsilon 4 allele has been reported to be associated with higher cholesterol concentrations, and the epsilon 2 and epsilon 4 alleles are both associated with higher triglyceride concentrations. Clinical and arteriographic studies of coronary disease suggest that vascular disease risk is increased among persons with the epsilon 4 allele.

Apolipoproteins E↗
PubMed1979

A Roentgen-anatomic study of the relationships between conduction defects and coronary disease.

Intraventricular conduction defects of various types were correlated to the extent of coronary disease and to the parameters reflecting the function of the left ventricle in 125 patients who had been subjected to coronary arteriography. In the patients with conduction disturbances, coronary disease was found to be more extensive and the proportion of abnormal parameters of left ventricular function higher than in those with normal conduction. The relationship of the various conduction defects with the lesions of the individual coronary branches and with the parameters of left ventricular function are discussed in detail.

Adult↗