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PubMed1994

[Complications shortly after transluminal angioplasty or following coronary surgery in 183 comparable patients with multi-vessel coronary disease].

OBJECTIVE: Description of the differences in complications within 30 days after percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery (CABG) in patients suffering from multiple vessel coronary disease. DESIGN: Prospective, randomised. SETTING: 3 hospitals in the Netherlands. METHOD: Between 1988 and 1992, 183 Dutch patients took part in the European Coronary angioplasty versus bypass revascularisation investigation (CABRI) and were randomly treated with PTCA or CABG. Apart from the clinical result, all complications and cardiac events from time of randomisation until 30 days after the intervention were registered. RESULTS: The CABG group consisted of 88 patients with a total of 255 vascular obstructions, the PTCA group of 95 patients with 294 vascular lesions. In this short period of observation the clinical results of the two treatments were the same. The death rates were 1.1% and 2.1%, for CABG and PTCA respectively. The proportion of transmural, non-fatal myocardial infarctions was 2.3% in the CABG group versus 3.1% in the PTCA group. The proportion of reinterventions was higher in the PTCA group, 11.4% versus 1.1%. CONCLUSION: The differences in death rate and myocardial infarctions are not significant, in contrast to the difference in the numbers of reinterventions. These results appear to be in accordance with those of other randomised studies. Although long-term evaluation is needed, treatment of multiple vessel coronary disease by means of PTCA seems a reasonable alternative to coronary surgery.

Aged↗
PubMed1998

[Calcium channel blockers in the treatment of hypertension and ischemic coronary disease. Conflicts in their evaluation].

Calcium channel blockers represent a pharmacologically non homogenic group. Verapamil and diltiazem have myocardial component of their effect, which acts against activated sympathicus. Short acting dihydropyridines (nifedipin) appear to be harmful by patients after myocardial infarction which is caused by the reflex sympathetic response to the predominant vasodilation. In the treatment of cardiovascular disease (e.g. hypertension, coronary vascular disease) are short acting dihydropyridines not recommended. Dihydropyridines of the new generation (amlodipin, felodipin, isradipin, lacidipin, nicardipin, nimodipin, nisoldipin, nitrendipin) induce less tachycardia due to their favorable kinetic features. If the slow movement in blood or at the receptor site is not a result of molecule features there is necessary to use retarded preparations of active substance. Nevertheless, commonly used retarded preparations fulfil this requirement only incompletely. The desirable quality is provided by modern form of retardation. (e.g. GITS) only.

Calcium Channel Blockers↗
PubMed2001

Screening family members at high risk for coronary disease. Why isn't it done?

BACKGROUND: The National Cholesterol Education Program strongly recommends screening family members of patients with early cardiovascular disease (CVD) for coronary risk factors, but the physician and patient compliance with this recommendation has not been extensively studied. The American College of Cardiology Evaluation of Preventive Therapeutics (ACCEPT) study, a national survey conducted in 1996-1997, determined if physicians were screening first-degree relatives of patients with early CVD. SETTING/PARTICIPANTS: The ACCEPT study included 5553 patients with either their first bypass surgery, first angioplasty, an acute myocardial infarction, or myocardia ischemia, admitted to 53 hospitals throughout the United States. MAIN OUTCOME MEASURE: Self-reported screening of first-degree relatives obtained by interview follow-up 6 months after event. RESULTS: Less than 1% of inpatient medical records contained a discharge plan by the physician recommending screening family members of patients younger than age 55. Only 17.8% of these patients had their family screened within 6 months of their cardiovascular event, while only 19.6% with a recognized family history of premature coronary artery disease had their family screened. The only factors that were significant (p<0. 05) predictors of successful family screening were education (19.4%), having high cholesterol (16.4%), being widowed (18.1%), not smoking (16.4%), and being black (20.5%). CONCLUSIONS: U.S. physicians do not appear to follow national recommendations for the screening of family members of their high-risk patients. These data also suggest that physicians are not ready to use and exploit known genetic factors in treating CVD even as the human genome data become available for clinical use.

Adult↗
PubMed1979

Use of treadmill score to quantify ischemic response and predict extent of coronary disease.

In this study we assessed whether various responses to exercise testing could be quantified in order to derive the probabilities of presence of coronary disease, and if present, to assess its severity. A treadmill score based on the exercise response was determined in 405 patients who had both treadmill tests and coronary angiograms. The score was derived using discriminant function analysis, by weighting and combining depth and configuration of ST depression (downsloping, horizontal or slowly upsloping), timing onset and duration of ischemia, grading ventricular arrhythmias, heart rate and blood pressure change, coexistence of exercise-induced chest pain and sex. The treadmill score was effective in detecting coronary disease (lesions with an greater than or equal to 50% narrowing), with a predictive accuracy (PA) (probability that a subject manifesting a positive test has disease) of 87%, a true negative rate (TNR) (probability of a subject with a negative test having no disease) of 80%, and sensitivity of 94%. The treadmill score also detected severe disease (triple-vessel, main left and/or greater than 90% proximal occlusion of the left anterior descending artery), with a PA of 73%, TNR of 79% and sensitivity of 82%. We conclude that the exercise response, expressed numerically as a treadmill score, permits analysis of most of the relevant data from exercise testing, increases test accuracy by 10-15% compared with standard criteria for treatmill test interpretation, and enables the derivation of probability statements for presence and severity of coronary disease. The validity of any prediction on the basis of exercise performance may thus be quantitatively judged.

Analysis of Variance↗
PubMed1987

[Exploratory hierarchy and surgical indications for carotid surgery in patients with coronary disease].

The major cause of death from carotid artery surgery (1.2% in 1984 in this series) is still coronary disease and myocardial infarct. A series of 50 patients were randomly selected for detailed study of post-operative cardiologic complications and the following sequelae were noted: mortality = 1 myocardial infarct; morbidity = 1 myocardial infarct, 3 documented anginal pains, 8 repolarization disorders, 4 benign ventricular arrhythmias. Analysis of these complications and a literature review demonstrated: the high frequency of combined carotid artery and coronary artery stenosis even in asymptomatic patients (25 to 40% of cases); the elevated percentage of complications in patients with symptomatic coronary disease (mortality risk multiplied by ten), hypertension or arterial disease; the low effect of age taken alone as risk factor. Pre-operative explorations to detect angina, particularly when latent and asymptomatic, should include a questionnaire, strict patient clinical examination and detailed reading of electrocardiogram tracings. An effort test should be performed as a function of results and patients' medical history and when positive should lead to coronarography in patients under 70 in good general condition, and when doubt persists after the effort tests. The indication for surgical treatment is dependent on results of these explorations: Carotid artery surgery (stenosis with high cerebral risk) should be performed under pre- and post-operative myocardial protection in patients with coronary artery disease who are too old or inoperable for cardiac reasons. Simultaneous myocardial and cerebral revascularization in the presence of severe lesions and at equivalent risk of progression. First intention carotid artery surgery for bilateral stable lesions with subsequent simultaneous myocardial and cerebral revascularization. First intention carotid artery surgery in case of cerebral ischemia with coronary artery shunt surgery at a later stage. Improved exploration of patients and close cooperation between cardiologists, anaesthetists and surgeons should allow patients at high risk to be operated upon under improved conditions of safety.

Aged↗
PubMed2005

Evaluation of glucose metabolism profile in coronary disease. Prospective study in hospitalized patients.

BACKGROUND: In 1995, it was estimated that 4% of the adult population had a diagnosis of diabetes mellitus. The trend is for growing prevalence, with a prediction of 300 million individuals with diabetes diagnosed in 2025. There seems to be a large number of asymptomatic individuals with undiagnosed disorders of glucose metabolism. These disorders, whether diabetes mellitus or conditions considered as prediabetic, including impaired glucose tolerance or impaired fasting glucose, represent an important risk factor for coronary disease and worsen the prognosis of established disease. The aim of this study was to evaluate the prevalence of glucose metabolism disorders in individuals admitted to hospital with coronary disease and to determine whether a significant number of these patients had previously undiagnosed diabetes or prediabetic conditions. METHODS: We conducted a prospective study of 44 consecutive patients admitted to the Cardiology Department with a diagnosis of coronary disease, whether previously established or established at the time of admission. We measured morning plasma glucose in all patients, after at least eight hours fasting, and all except those with a previous diagnosis of diabetes underwent an oral glucose tolerance test with 75 g of glucose before hospital discharge. For classification of glucometabolic state, we used the values defined by the World Health Organization (1999). RESULTS: The mean age of our cohort was 64.2+/-13.6 years. The most prevalent disorder was diabetes, with 19 patients (43.2%). Of these, 12 patients (27.3%) had a previous diagnosis of diabetes and 7 patients (15.9%) were unaware that they had the disease. We identified isolated impaired glucose tolerance in 11 patients (25%), isolated impaired fasting glucose in one patient (2.3%) and combined impaired glucose tolerance and impaired fasting glucose in another (2.3%). The remaining 12 patients (27.3%) revealed normal glycemia values. CONCLUSIONS: Glucose metabolism disorders including diabetes and impaired glucose tolerance have a high prevalence in coronary patients. This population includes a significant number of asymptomatic patients with undiagnosed diabetes or undetected prediabetic conditions. A systematic evaluation of the glucometabolic state of individuals with coronary disease during hospitalization, using an oral glucose tolerance test, may enable earlier identification of these disorders and implementation of measures to reduce their future impact.

Coronary Disease↗
PubMed1998

Erythrocyte passive potassium flux is increased in patients with ischemic coronary disease (ICD) and in subjects with family history of ICD.

BACKGROUND: It has been proposed that ischemic coronary disease (ICD) associated potassium loss could be due to modifications of potassium permeability. We investigated whether a positive family history of ICD can influence this parameter. We have compared potassium permeability in erythrocytes from ICD patients and from positive family history subjects (FICD) with control subjects. METHODS: All patients and subjects were carefully selected for the absence of hypertension and dysmetabolic pathologies. ICD group: 24 patients (19 males, 5 females; ages 43 to 69) all affected by ischemic coronary disease, under no drug treatment; FICD group: 18 subjects (all males, ages 27 to 42) with a verified positive ICD family history, without hypertensive family history and cardiovascular pathology; control group: 16 subjects (11 males, 5 females; ages 28 to 48) without positive family history of ICD. Passive potassium efflux (PPE) was spectrophotometrically measured in K-free medium containing ouabain and bumetanide. The kinetic constant was calculated by dividing PPE by the erythrocyte potassium concentration. RESULTS: No statistically significant differences were noted between the intracellular potassium content of the three groups. However, (1) the passive potassium permeability of the ICD group was significantly higher (kK=0.055 +/- 0.021 h(-1), n=24) than that of the control group (kK=0.023 +/- 0.008 h(-1), n= 16; p<0.00001), (2) the FICD group was higher (kK=0.036 +/- 0.012 h(-1), n=18) than the control group (p<0.001), and (3) the ICD group was higher than the FICD group (p<0.001). CONCLUSIONS: Our results suggest an inheritability of ICD, paralleling the familial aggregation of the pathology. Erythrocyte potassium permeability could represent an early marker of ischemic coronary disease and be used as a prophylactic tool.

Adult↗
PubMed1998

Angiotensin-converting enzyme and angiotensin II receptor 1 polymorphisms: association with early coronary disease.

OBJECTIVE: To examine the association between coronary artery disease and polymorphisms at the angiotensin-converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) genes. METHODS: A total of 181 patients younger than 50 years and 240 controls from the same homogeneous Caucasian population (Asturias, Northern Spain) were genotyped (using polymerase chain reaction) for the ACE insertion/deletion (ACE-I/D) and the AT1R A/C transversion (AT1R-A/C) (3-untranslated region) polymorphisms. RESULTS: The DD-genotype was at a non-significant higher frequency among patients (50%) than in controls (41%). No difference between the two groups was found for the AT1R-genotypes. Distribution of ACE-genotypes according to AT1R-genotypes showed a significant association between ACE-DD and AT1R-CC and early coronary disease. Among the CC patients 58% were DD, compared to 21% among the controls (p = 0.02; OR = 5.32, 95% CI = 1.45, 19.51). We determined the distribution of these genotypes among the hypertensive and non-hypertensive patients. Frequencies of ACE- or AT1R-genotypes did not differ between the two groups. However, we found an interaction between the DD- and CC-genotypes in the group of normotensives. Among the CC patients, 13% of the hypertensives and 75% of the normotensives were DD (p = 0.014). CONCLUSIONS: Our results indicate a synergistic contribution of ACE and AT1R polymorphisms to the risk of coronary artery disease. This gene-gene interaction could have clinical implications. Approximately 2% of individuals in our population are CC + DD, and the genotyping of both polymorphisms could identify those with a high relative risk for coronary artery disease.

Adult↗
PubMed2005

Optimizing revascularization strategies in patients with multivessel coronary disease: impact of intracoronary pressure measurements.

OBJECTIVES: In patients with multivessel coronary disease, the functional significance of each lesion is often unclear, and preinterventional stress tests may be inconclusive. In this setting, intracoronary pressure measurements may be helpful to define the optimal revascularization strategy. METHODS: Twenty-five consecutive patients (aged 64 +/- 11 years) with multivessel disease, inconclusive stress tests or not performed stress tests, and an angiographically intermediate coronary artery stenosis in at least 1 major vessel underwent intracoronary pressure measurements. Myocardial fractional flow reserve was measured for the intermediate lesions under the condition of maximum hyperemia induced by intravenous adenosine (140 microg x kg(-1) x min(-1). Revascularization strategies based on angiographic information alone were compared with treatment strategies based on fractional flow reserve results. RESULTS: The original recommendation of the revascularization procedure of choice (bypass operation or angioplasty) was changed in 9 patients (36%) on the basis of the results of fractional flow reserve measurements. In 6 more patients, pressure measurements led to a change in the recommended number of anastomoses to be aimed for during the operation. Within diffusely diseased vessels, fractional flow reserve provided an exact segmental resolution of pathologic vessel resistance for optimal graft placement. Significant left main disease was confirmed in 3 of 6 patients and was detected in 3 angiographically unsuspected cases. CONCLUSIONS: In patients with multivessel disease, coronary pressure-derived fractional flow reserve is a valuable tool to guide clinical decision making and support cardiologists and cardiovascular surgeons in the composition of optimal revascularization strategies.

Adenosine↗
PubMed2004

Polymorphism of the ACE gene is associated with extent and severity of coronary disease.

BACKGROUND: The progression and extent of coronary heart disease (CHD) are extremely variable and in many instances independent of conventional risk factors. The differences may be partly explained by less favorable genetic polymorphisms that are associated with them. The polymorphisms of the angiotensin I converting enzyme (ACE) gene have been thoroughly evaluated, but the connection between them and the extent of CHD is unknown. AIMS: Our study is aimed at determining whether any or all of the polymorphisms of the ACE gene are markers of the extent and severity of CHD. METHODS: This was a descriptive study of 296 patients with a history of myocardial infarction or with coronary disease confirmed by coronary angiography. The severity of CHD was quantified according to Leaman's score (based on the number of arteries with more than 75% reduction in diameter and the number of affected coronary segments). The ACE genotypes were determined by specific polymerase chain reaction amplification and the segments were subjected to polyacrylamide gel electrophoresis. The mean coronary score and standard deviation of the three polymorphisms were calculated and the values statistically compared using the Student's t test for independent samples. RESULTS: 296 patients with a mean age of 55.103 years, 234 male, were evaluated. CONCLUSION: The study clearly shows that the DD genotype is linked to the extent of CHD, with a high level of significance. If this is confirmed, careful secondary prevention is indicated in patients with this genotype.

Coronary Disease↗
PubMed1980

[Comparative clinical and radiocardiographic studies in coronary disease].

A clinical-functional characteristics was carried out of 124 patients with coronary disease (104 patients with a past history of myocardial infarction in a post-convalescent stage and 20 patients with atherosclerotic myocardiosclerosis). The patients were distributed into three groups depending on the functional state of the cardiovascular system. Manifestations of decompensation were found only in one of the groups--postinfarction states. A comparison was made of the changes in the central hemodynamics, assessed radiocardiographically. In all the three groups, a decrease of the minute and stroke volumes was radiocardiographically established as well as stasis in the pulmonary circulation, confirmed by the changes in the pulmonary volume of blood and velocity of blood within the pulmonary circulation, a manifestation of left-ventricular insufficiency. Left ventricular insufficiency is found in the patients with coronary disease in the absence of clinical manifestations of cardiac insufficiency.

Adult↗
PubMed1996

Relations of changes in coronary disease rates and changes in risk factor levels: methodological issues and a practical example.

One of the main hypotheses of the World Health Organization (WHO) MONICA Project is that trends in the major coronary disease risk factors are related to trends in rates of fatal and non-fatal coronary disease events. The units of study are populations rather than individuals. The WHO MONICA Project involves continuous monitoring of all coronary disease events in the populations over a 10-year period and periodic risk factor surveys in random samples of the same populations. Estimation of associations between average annual changes in mortality and risk factor levels is illustrated with the use of data from a subset of MONICA centers. Crude estimates of regression coefficients are compared with estimates obtained by weighting for standard errors in both the outcome and explanatory variables. The results show that the strength of association may be either underestimated or overestimated if these errors are not taken into account.

Adult↗
PubMedDate not supplied

Collateral arteries in the presence of obstructive coronary disease.

BACKGROUND: The clinical importance of coronary collaterals in the presence of obstructive coronary artery disease is not clearly defined. METHODS: We retrospectively analysed the clinical and angiographic features of 100 patients with > or = 90% luminal diameter stenosis involving at least one major coronary artery. Coronary collaterals were graded 0 to 4 (Nitzberg's classification) and studied to determine their influence on clinical parameters. RESULTS: Thirty patients had no collaterals (group I) and 70 showed collaterals (group II). There were no significant differences between groups I and II in age and sex distribution, prevalence of risk factors of coronary artery disease (hypertension, diabetes, smoking, hypercholesterolaemia), duration of symptoms of coronary artery disease and prior myocardial infarction. Groups I and II had similar types (left anterior descending 73% v. 71%; left circumflex 50% v. 50% and right coronary 37% v. 56%) and numbers of arteries involved (one 47% v. 41%; two 47% v. 40%; three 7% v. 19%). Group II had a significantly lower prevalence of rest angina (14% v. 47%, p = 0.002). This difference was also evident when the patients were re-classified according to the extent of flow through the collaterals. Those with good collateralization (Nitzberg grades 3 and 4) had a lower prevalence of rest angina (13%) compared to those with poor collateralization (Nitzberg grades 0 to 2; 35%, p = 0.02). CONCLUSION: Coronary artery collaterals may reduce the incidence of rest angina in patients with obstructive coronary artery disease.

Angina Pectoris↗
PubMed2002

[Chronic Chlamydia pneumoniae infection in patients with coronary disease. Relation with increased fibrinogen values].

BACKGROUND: A number of studies have suggested that infection with Chlamydia pneumoniae can play a role in development of atherosclerosis. The goal of this study was to know the prevalence of chronic C. pneumoniae infection, evaluated with IgG antibodies seropositivity, in Spanish patients with coronary disease and its association with inflammatory markers and cardiovascular risk factors. PATIENTS AND METHOD: In 176 patients with coronary disease IgG and IgM antibodies to C. pneumoniae were determined by enzyme immunoassay. In addition, fibrinogen and C-reactive protein values were measured as inflammatory markers. Controls were 55 healthy subjects whose age was not different from patients. Seropositivity for C. pneumoniae was considered when indices of IgG and/or IgM antibodies were higher than mean plus two standard deviations of control values. Three patients with seropositivity for IgM were excluded. RESULTS: In 126 patients and 2 controls a seropositivity against C. pneumoniae was proved (72.8% vs 4.2%; p < 0.001). Cardiovascular risk factors were not different in seropositive and seronegative groups of patients. Prevalence of hyperfibrinogenemia was higher in the former group (38.8% vs 19.1%; p = 0.01). The number of the patients with increased values of C-reactive protein was similar in both groups, although these values could be modified by treatment with statins. In multivariate analysis an association between seropositivity for C. pneumoniae and hyperfibrinogenemia was found (odds ratio [OR] = 2.42; 95% confidence interval, 1.07-5.48; p = 0.03) after adjusting for age, gender, smoking, hypertension, hypercholesterolemia and diabetes. CONCLUSIONS: Chronic infection with C. pneumoniae in patients with coronary disease is very prevalent, and it is associated with increased fibrinogen values.

Antibodies, Bacterial↗
PubMed1990

[Factors associated with generalized forms of arteriosclerosis in patients with coronary disease].

We studied the lipidic metabolism and the atherogenic risk factors non related to lipidic metabolism in two groups of patients: group 1 with only coronary disease and group 2 with coronary disease and atherosclerosis in the cerebral and/or peripheric artery territories. Patients of group 2 showed a cholesterol, cLDL, and B-apoprotein titers significantly higher than group 1. Systolic and diastolic blood pressure were higher in group two. Also the incidence of diabetes mellitus in group 2 was higher than in group 1. In a stepwise discriminating analysis the diastolic arterial pressure and cholesterol titers were the parameters with a greatest predictive potential for the presence of localized or generalized ischemic disease. B-apoprotein was the lipidic parameter with the greatest predictive potential. All together these data suggest that in coronary patients, a discrete increase in plasma cholesterol can imply a risk of suffering ischemia in some other arterial territories. Diastolic blood pressure, cholesterol and diabetes mellitus are the factors with the highest predictive potential for the generalization of arteriosclerosis.

Arteriosclerosis↗
PubMed1977

Multifactor evaluation of the determinants of ischemic electrocardiographic response to maximal treadmill testing in coronary disease.

Despite widespread use of treadmill stress in the detection of coronary disease, detailed information relating the important features of coronary pathoanatomy to the ischemic response noted on the electrocardiogram is lacking. Accordingly, 91 consecutive patients undergoing graded maximal exercise tests (MEXT) who were found to have clinical stenosis (larger than or equal to 75 per cent luminal narrowing) of at least one of the three major coronary arteries on coronary arteriography were evaluated. Positive MEXT was defined as larger than or equal to 0.1 mV horizontal or downsloping S-T segment depression larger than or equal to 0.08 second beyond J point. Over-all sensitivity of positive MEXT was 59 of 91 (65 per cent) patients; 11 of 26 (42 per cent) with single vessel stenosis, 20 of 30 (66 per cent) with two vessel disease and 28 of 35 (80 per cent) with three vessel disease. In patients with two vessel disease, the frequency (p less than 0.05) of positive MEXT was greater in those with (15 of 21;71 per cent) than in those without (five of nine; 55 per cent) stenosis of the left anterior descending artery. Concerning the site of intravessel stenosis, the frequency of positive MEXT was greater (p less than 0.05) with stenosis proximal to the left anterior descending artery in patients with one vessel disease. Quantification of total numbers of intra- and intervessel stenoses revealed 2.7 stenoses in the 59 patients with positive MEXT in contrast (p less than 0.01) to 1.9 in 32 patients with negative MEXT. Similarly, graded luminal narrowing index of severity of total stenoses per patient was 9.9 in those with positive MEXT compared (p less than 0.01) to 6.1 in those with negative MEXT. The poststenotic myocardial perfusion index, estimated by graded distal vessel opacification per major vessel disease, was only 1.5 in those with positive MEXT contrasted (p less than 0.01) to 2.4 in those with negative MEXT. These data indicate that sensitivity of positive MEXT in patients with coronary disease is most closely determined by the number of major coronary vessels involved, the total number of major vessels stenosed, the severity of total stenoses and poststenotic distal vessel perfusion. Less important factors are the precise site of intravessesl stenosis and the specific major coronary artery involved, although stenosis proximal to the left anterior descending artery favored positive MEXT. Unimportant variables were the quality of collateral vessels, ventricular function and prior inferior infarction. Angina occurred more frequently in those with positive MEXT, and marked degree of positive MEXT indicated stenosis proximal to the left anterior descending artery.

Adult↗