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PubMed1996

The surgical management of allograft coronary disease: a paradigm shift.

The surgical options for heart transplant recipients who develop obstructive coronary artery disease in their allograft have historically been limited to retransplantation. Given the worse outcome in recipients of second grafts, often caused by recurrence of coronary disease, coupled with the significant increase in the number of patients on the transplantation waiting lists, has made retransplantation a limited option. However, as heart transplant recipients continue to live longer, there are an increasing number of patients who develop allograft coronary disease. Coronary bypass surgery has not been offered to these patients because of numerous pathology reports describing uniform involvement of the coronary vessel from its origin to the distal intramural branches, thereby eliminating any reasonable runoff vascular bed to handle increased flow that might be delivered with bypass conduits. However, new diagnostic techniques such as measurement of coronary flow reserve by Doppler flow wire can define the physiological vasodilating capacity or reserve which, if normal, should allow conventional bypass surgery if adequate target epicardial vessels are present. This approach would allow a more reasonable alternative to many patients who otherwise would die of this disease without any intervention. Other alternatives such as transmyocardial laser revascularization are discussed.

Coronary Disease↗
PubMed1994

A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. German Angioplasty Bypass Surgery Investigation (GABI)

BACKGROUND: The standard treatment for patients with symptomatic multivessel coronary artery disease is coronary-artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) is widely used as an alternative approach to revascularization, but a systematic comparison of the two procedures is needed. We compared the outcomes in patients one year after complete revascularization with CABG or PTCA. METHODS: A total of 8981 patients with multivessel coronary disease were screened at eight clinical sites, and 359 patients were randomly assigned to undergo CABG (177 patients) or PTCA (182 patients). Enrollment required that complete revascularization of at least two major vessels supplying different myocardial regions be deemed clinically necessary and technically feasible. RESULTS: Among the patients in the CABG group, an average of 2.2 +/- 0.6 vessels were grafted, and among those in the PTCA group, 1.9 +/- 0.5 vessels were dilated. After CABG, hospitalization was longer (median, 19, as compared with 5 days for PTCA), and Q-wave myocardial infarction in relation to the procedure was more frequent (8.1 percent, as compared with 2.3 percent after PTCA; P = 0.022), whereas in-hospital mortality did not differ significantly between the two groups (2.5 percent in the CABG group and 1.1 percent in the PTCA group). At discharge 93 percent of the patients in the CABG group were free of angina, as compared with 82 percent of those in the PTCA group (P = 0.005). During the first year of follow-up, further interventions were necessary in 44 percent of the patients in the PTCA group (repeated PTCA in 23 percent, CABG in 18 percent, and both in 3 percent) but in only 6 percent of the patients in the CABG group (repeated CABG in 1 percent and PTCA in 5 percent; P < 0.001). Seventy-four percent of the patients in the CABG group and 71 percent of those in the PTCA group were free of angina one year after treatment. Exercise capacity improved similarly in both groups. However, 22 percent of the CABG group, as compared with only 12 percent of the PTCA group, did not require antianginal medication (P = 0.041). CONCLUSIONS: In selected patients with multivessel coronary disease, PTCA and CABG as initial treatments resulted in equivalent improvement in angina after one year. However, in order to achieve similar clinical outcomes, the patients treated with PTCA were more likely to require further interventions and antianginal drugs, whereas the patients treated with CABG were more likely to sustain an acute myocardial infarction at the time of the procedure.

Aged↗
PubMedDate not supplied

Hypercholesterolemia in long-term survivors of heart transplantation: an early marker of accelerated coronary artery disease.

Coronary artery disease remains a significant long-term problem for survival after heart transplantation. Hyperlipidemia is a known risk factor for coronary artery disease in the general population, but the role of hyperlipidemia in cardiac allograft recipients has not been elucidated. To study this problem, we retrospectively reviewed 38 heart transplant recipients who survived more than 3 years after surgery and looked at age, development of diabetes, drug protocol, and development of hypercholesterolemia for a possible correlative or predictive value to the development of early coronary artery disease after heart transplantation. Eleven patients were identified as having coronary disease by the third year after transplantation. High-risk cholesterol values (in milligrams per deciliter) at 6 months after heart transplantation were defined as follows: for ages 10 to 20, 190; 20 to 30, 220; 30 to 40, 240; 40+, 260. We found a strong predictive value with high-risk lipid profiles (p less than 0.01) for the development of coronary artery disease by the third year. No significance was found for a low-risk value, the development of diabetes, or hypertension. All patients below the age of 20 years had coronary artery disease by the third year after transplantation. We conclude that a high-risk cholesterol value at 6 months after transplantation is a strong predictor for development of accelerated coronary artery disease and early graft failure. This has major implications for management of hyperlipidemia in the cardiac allograft recipient.

Adult↗
PubMed1985

Complete surgical revascularization: the treatment of choice in young patients with multivessel coronary disease.

Since the advent of coronary angioplasty, nonoperative techniques to manage coronary artery disease have become attractive alternatives to coronary artery bypass grafting (CABG). To provide a standard against which new procedures could be judged, 123 consecutive patients less than 45 years of age who have had CABG since 1978 were systematically followed. The indications for operation were unstable angina or postinfarction angina (60%), life-threatening coronary anatomy with stable angine (36%), and sudden death or uncontrolled ventricular tachycardia (4%). Seventy-five patients had documented preoperative myocardial infarction, 55% within 30 days of CABG. An average of 3.2 vessels were grafted per patient; only 10 had single CABG. Complete revascularization was accomplished in 91% of patients. Five patients (4%) had myocardial infarction within 30 days of operation. No operative deaths or strokes occurred. The 6-year follow-up was 94.4% (the 5-year actuarial survival rate, 87.4%). There were four late deaths; two were due to myocardial infarction, one to prosthetic valve failure, and one to sudden death. At 2.7 years, 88.1% of the patients were NYHA Functional Class I; 85.4% continued full-time employment, and 98% considered their quality of life the same or better than before CABG. Five patients suffered myocardial infarctions during the follow-up period. Nine patients required reoperation: eight for graft occlusion (three less than 1 year, five greater than 3 years), and one for disease progression. These data confirm that complete operative revascularization remains the standard of therapy for young patients with multivessel coronary artery disease as evidenced by the absence of early mortality, the low incidence of morbidity, the excellent functional recovery, and the high return to gainful employment.

Journal Article↗
PubMedDate not supplied

Assessment of behavioral risk for coronary disease by voice characteristics.

Behavior characterization is increasingly used and studied in the pathogenesis and management of coronary disease. A specific behavior pattern called Type A has been found to be independently associated with fatal and nonfatal coronary disease. The assessment of Type A is made without quantitative guidelines based on verbal and nonverbal behaviors in a standardized interview. This study has attempted to make this classification solely on the basis of quantifiable verbal behaviors. Two naive persons were trained to code speech behaviors from tape recorded behavior pattern interviews on which Type A had previously been assessed. Intercoder and intracoder reliability was acceptable. Using regression analysis 87% of the interviews were classified in agreement with the previous, standard assessment. Volume of voice and speed of speech were found to make the greatest predictive contribution. Other verbal characteristics including plosiveness were also important. It is concluded that Type A can be validly and repeatably measured by verbal behaviors in the standardized interview.

Aggression↗
PubMed2004

Is B-type natriuretic peptide a useful screening test for systolic or diastolic dysfunction in patients with coronary disease? Data from the Heart and Soul Study.

BACKGROUND: Whether B-type natriuretic peptide (BNP) levels can be used to screen for ventricular dysfunction in patients at risk of heart failure but without overt symptoms is not known. We examined the characteristics of a BNP test for identifying systolic and diastolic dysfunction in outpatients with stable coronary disease. METHODS: In a cross-sectional study of 293 outpatients who had stable coronary disease and no history of heart failure, we compared elevations in plasma BNP levels with echocardiography for the diagnosis of systolic dysfunction (ejection fraction <55%) and diastolic dysfunction (diastolic dominant pulmonary vein flow with ejection fraction > or =55%). RESULTS: A total of 48 patients (16%) had systolic dysfunction, and among the remaining 245 with preserved systolic function, 31 (13%) had diastolic dysfunction. At the standard cutpoint of >100 pg/mL, an elevated BNP level was 38% sensitive (80% specific) for systolic dysfunction and 55% sensitive (85% specific) for diastolic dysfunction. Negative likelihood ratios were 0.8 (95% confidence interval [CI]: 0.6 to 1.0) for systolic dysfunction and 0.5 (95% CI: 0.4 to 0.8) for diastolic dysfunction. Positive likelihood ratios were 1.9 (95% CI: 1.2 to 2.9) for systolic dysfunction and 3.8 (95% CI: 2.4 to 5.9) for diastolic dysfunction. Areas under the receiver operating characteristic curves were 0.59 (95% CI: 0.49 to 0.69) for systolic dysfunction and 0.79 (95% CI: 0.71 to 0.87) for diastolic dysfunction. CONCLUSION: These data suggest that BNP is not a useful screening test for asymptomatic ventricular dysfunction in patients with stable coronary disease.

Aged↗
PubMed1993

[Prognostic value of thallium-201 myocardial scintigraphy in patients with hypertension, suspected of coronary disease].

This study was undertaken to determine the prognostic value of exercise myocardial scintigraphy in hypertension patients suspected of coronary disease. One hundred and thirty six hypertension patients (mean age: 59) suspected of coronary disease were monitored for 46 months after thallium 201 exercise myocardial scintigraphy (tomographic mode). Prognostic factors analysed were clinical (typical nature of pain, exercise blood pressure), electrocardiographic (presence of repolarisation abnormalities in resting ECG), ergometric (electrically positive test) and scintigraphic (existence or not of transitory hypofixation). Events sought were: death of coronary origin, non-fatal myocardial infarction, aorto-coronary bypass and coronary angioplasty. One-way analysis showed that the existence of transitory hypofixation by scintigraphy, positive exercise electrocardiogram and typical angina pain enabled the prediction of coronary events. Thus 14 of 36 patients (39%) with transitory or combined hypofixation had a coronary event as against 7 of the 100 patients without transitory hypofixation. Only the existence of transitory hypofixation retained a prognostic value for coronary events by multivariate analysis (relative risk = 5.4, p = 0.001). It was also found that the prognosis was good when scintigraphy did not reveal transitory hypofixation while exercise testing was positive (2 coronary events/27 patients). It is concluded that, despite the possibility of "false positives", linked in particular to myocardial hypertrophy, myocardial scintigraphy offers better prediction of coronary events in hypertension patients that other clinical or electrocardiographic parameters.

Adult↗
PubMed1997

Prevalence of coronary artery disease and coronary risk factors in rural and urban populations of north India.

OBJECTIVE: This study was conducted to determine and compare the prevalence of coronary artery disease and coronary risk factors in both a rural and an urban population of Moradabad in north India. DESIGN AND SETTING: A cross-sectional survey of two randomly selected villages from the Moradabad district and 20 randomly selected streets in the city of Moradabad. SUBJECTS AND METHODS: The 3575 subjects were between 25 and 64 years old; 1769 (894 men and 875 women) lived in the countryside and 1806 (904 men and 902 women) lived in the city. The survey methods were questionnaires, physical examination and electrocardiography. RESULTS: The overall prevalence of coronary artery disease, based on a clinical diagnosis and an electrocardiogram, was 9.0% in the urban and 3.3% in the rural population. The prevalences were significantly (P < 0.001) higher in the men compared with the women in both urban (11.0 vs 6.9%) and rural (3.9 vs 2.6%) populations, respectively. The prevalence of symptomatic coronary artery disease (known coronary disease and Rose questionnaire-positive angina) was 2.3% in the men (n = 19) and 1.5% in the women (n = 13) in the rural subjects, and 8.5% in the men (n = 77) and 3.4% in the women (n = 31) in the urban population. When diagnosed on the basis of electrocardiographic changes alone, the prevalences were 1.5% (n = 26) in the rural population and 3.0% (n = 55) in the urban. Coronary risk factors were two- or three-fold more common among urban subjects compared to the rural population in both sexes. Central obesity was four times more common in the urban population compared to the rural in both sexes. Sedentary lifestyle and alcohol intake were significantly (P < 0.01) higher in the urban population compared to the rural subjects. There was a significant association between coronary disease and age, hypercholesterolaemia, hypertension and central obesity in both sexes. Smoking was a significant risk factor of coronary disease in men. CONCLUSIONS: Coronary artery disease and coronary risk factors were two or three times higher among the urban compared with the rural subjects, which may be due to greater sedentary behaviour and alcohol intake among urbans. It is possible that some Indian populations can benefit by reducing serum cholesterol, blood pressure and central obesity and increasing physical activity.

Adult↗
PubMed1981

Vasectomy and coronary disease in men less than 50 years old: absence of association.

Because recent experiments in primates suggest a relationship between vasectomy, and the development and promotion of atherosclerosis a case control study was performed to explore this possibility in humans. The prevalence of prior vasectomy was determined in 55 men less than 50 years old with onset of documented coronary disease and in a matched control group of close relatives (45 brothers and 10 first cousins) free of coronary disease. The prevalence was the same in each group, 25.5 per cent (14 of 55), and there was no significant difference between study groups in the mean interval since vasectomy. Thus, within the limitations of this study no association of coronary disease with prior vasectomy was found. Further work is needed to evaluate whether the animal findings pertain to humans.

Coronary Disease↗
PubMed1980

Economics of surgery and medical treatment in coronary artery disease.

Coronary disease is a major cause of increase in health-care costs. The disease is widespread, crippling, affects the money-making age groups and is expensive to treat whether medically or surgically. As benefits of surgery become more clearly realized, and receive a stronger statistical backing, it may be found that an expensive operation is more cost-beneficial than a series of less expensive hospital admissions. Whatever the cost-benefit or cost-effective ratios prove to be, it is likely that most patients faced with a choice between painful or pain-free life will choose the pain-free option, especially if 'the insurance will pay for it'.

Cardiac Care Facilities↗
PubMed2001

Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting.

OBJECTIVE: Percutaneous transluminal coronary angioplasty (PTCA) or surgery can be chosen as first-line therapies in multiple-vessel coronary disease. A mammary-to-left anterior descending (LAD) graft is the most important statistical determinant of a favorable outcome after coronary artery bypass grafting (CABG) and can be performed with lower morbidity off pump through a minithoracotomy. PTCA and stenting of the "non-LAD" vessels compete with CABG in terms of patency rates. Our purpose was to compare a combination of minimally invasive direct coronary artery bypass (MIDCAB) and PTCA with double CABG as a treatment for double-vessel coronary artery disease involving the proximal LAD. METHODS: Two matched groups of 20 patients with double-vessel coronary disease undergoing either sequential MIDCAB and PTCA (group 1) or double CABG on cardiopulmonary bypass (group 2) were compared. Angiographic control, complications, hospital costs, quality of life, and 2-year follow-up of ischemia are reported. RESULTS: All bypasses were patent at early control. Three adverse events were noted in group 1 and 17 in group 2. The hybrid-procedure group exhibited a shorter intensive care unit stay, fewer blood products transfused, less pain, better early quality of life, faster return to work, and similar cost. Three patients required a second PTCA in group 1, one of which for restenosis. At 2 years all the patients are asymptomatic with no residual ischemia. CONCLUSIONS: We conclude from this pilot study that the hybrid procedure is feasible and appears to be a safe therapy for double-vessel coronary artery disease and that it appears to generate less perioperative morbidity than classic double CABG does. Therefore we believe that there is room to undertake prospective randomized studies on a larger-scale basis.

Aged↗
PubMed1997

Social class and coronary disease in rural population of north India. The Indian Social Class and Heart Survey.

OBJECTIVE: To demonstrate the association of socio-economic status with prevalence of coronary artery disease and coronary risk factors. DESIGN AND SETTING: Cross-sectional survey in two randomly selected villages in the Moradabad district in North India. SUBJECTS AND METHODS: One thousand seven hundred and sixty-seven subjects (894 males and 875 females; 25-64 years of age) were randomly selected from two villages. They were divided into social classes 1 to 4, according to education, occupation, housing conditions, ownership of land, ownership of consumer durables and per capita income. The survey was based on questionnaires administered by dietitians and physicians, physical examination and electrocardiography. RESULTS: Social classes 1 and 2 were mainly high and middle socio-economic groups and 3 and 4 low income groups. The prevalence of coronary artery disease was significantly higher among classes 1 and 2 in both sexes, and there was a higher prevalence of hypercholesterolaemia, hypertension, and sedentary lifestyle. This population also showed a significant association with higher serum cholesterol, body mass index, triglycerides and blood pressures. Logistic regression analysis with adjustment for age showed that social class positively related to coronary disease (odds ratio: men 0.83, women 0.61), hypercholesterolaemia (men 0.85, women 0.87), hypertension (men 0.89, women 0.87), body mass index (men 0.91, women 0.93) and smoking in men (0.68). Smoking and sedentary lifestyle were not associated with social class in women. The association between coronary artery disease and social class abated after adjustment for smoking, sedentary lifestyle, body mass index and blood pressure (odds ratio: men 0.96, women 0.81). CONCLUSION: Subjects in social classes 1 and 2 in rural North India have a higher prevalence of coronary artery disease and of the coronary risk factors hypercholesterolaemia, hypertension, higher body mass index and sedentary lifestyle. The overall prevalence of coronary artery disease was 3.3%.

Adult↗
PubMedDate not supplied

A reduction in accelerated graft coronary disease and an improvement in cardiac allograft survival using low molecular weight heparin in combination with cyclosporine.

Heparin compounds are a complex mixture of mucopolysaccharides that, in addition to their anticoagulant properties, have immunosuppressive activities and affect the reparative aspects of the response to arterial injury. Heparin inhibits smooth muscle cell migration and proliferation and can alter the accumulation of the components of the extracellular matrix after arterial injury. Heparin also interacts specifically with the endothelium. Our hypothesis was that if heparin compounds do affect the immune system, coagulation, smooth muscle cell proliferation, and the endothelium, then heparin combined with cyclosporine should improve allograft survival, reduce rejection, and prevent accelerated graft coronary disease. Low molecular-weight heparins are derived from the larger molecular-weight unfractionated heparin. We chose to use low molecular-weight heparins because of their longer half-life, better bioavailability, and decreased incidence of induced thrombocytopenia and bleeding. With a rat intraabdominal heterotopic model of heart transplantation (Lewis-Brown Norway to Lewis), low molecular-weight heparin in combination with a low dose of cyclosporine (0.5 mg/kg/day) significantly improved allograft survival compared to controls and either low molecular-weight heparin or cyclosporine alone. Histologically, smooth muscle cells are an important cellular component of the lesions of accelerated graft coronary disease. In comparison to animals treated with cyclosporine alone (2 mg/kg/day), the addition of low molecular-weight heparin to cyclosporine (2 mg/kg/day) reduced the frequency and the severity of accelerated graft coronary disease and the extent of parenchymal rejection.

Abdomen↗
PubMed1983

Balloon angioplasty in multivessel coronary artery disease.

Coronary angioplasty with use of the balloon catheter was initially performed only in patients with single-vessel coronary artery disease. Most symptomatic patients with coronary artery disease who require revascularization for control of their symptoms, however, have stenoses in more than one major coronary artery. Therefore, we have evaluated the results of balloon angioplasty in patients with multivessel disease. Of 261 patients who underwent percutaneous transluminal coronary angioplasty at our institution up to February 1983, 100 had multivessel disease. Of these 100 patients, 72 had an initially successful procedure, defined as successful dilation of one or more major coronary arteries without significant complication. Of the remaining 28 patients, 25 underwent coronary artery bypass grafting (6 on an urgent basis for coronary occlusion). No deaths occurred. In selected patients with multivessel disease, coronary angioplasty is associated with low morbidity and mortality and might be an excellent alternative to coronary artery bypass grafting when medical treatment fails. Percutaneous transluminal coronary angioplasty merits the critical comparison with standard therapy that can be achieved only in a properly designed clinical trial.

Angiography↗
PubMed1981

Coronary artery spasm and myocardial infarction in the absence of angiographically demonstrable obstructive coronary disease.

Myocardial infarction due to spasm of an "angiographically normal coronary artery" is rare, and its significance as a cause of myocardial infarction in patients without obstructive coronary disease has not been determined. Two patients are described with transmural myocardial infarction, nonobstructive coronary arteries, and suggestive evidence of coronary vasospasm as the cause of infarction. In one patient, angiography was carried out within 7 days of infarction and the documentation of normal coronary arteries argued strongly against a thromboembolic cause for infarction. This patient also had the combination of asthma, hypereosinophilia, and a systemic disease suggesting an immunologic disturbance with increased autoantibody production. A temporal association was noted between the episodes of asthma and those of coronary spasm during exacerbation of the eosinophilia, which raised the speculative issue of "allergic" coronary vasospasm. It is concluded that spasm of a nonobstructed coronary artery may cause transmural myocardial infarction. Further documentation is required in order to place this association in perspective among the other potential cause of infarction in patients with normal coronary artery anatomy.

Adult↗
PubMed1994

Changes in drinking water selenium and mortality for coronary disease in a residential cohort.

In a part of the municipal territory of Reggio Emilia, northern Italy, selenium in drinking water decreased from 7 micrograms/L to less than 1 micrograms/L. In a cohort of 4419 individuals, previously exposed for at least 5 yr to the drinking water with higher selenium content, the 7-yr temporal distribution of deaths for coronary disease and for stroke was analyzed to examine a possible relationship with changes in drinking water selenium. From January 1986 until August 1988, when tap water selenium was 7 micrograms/L, deaths for coronary disease were one in males and two in females. After the decrease in drinking water selenium, 21 and 10 coronary deaths were observed, respectively, in males and in females from September 1988 to December 1992. No significant difference in the temporal distribution of stroke deaths was observed both in males and in females. Even if an effect of chance and aging in the temporal distribution of coronary deaths may not be excluded, findings of the study seem to be consistent with the hypothesis of a beneficial effect of selenium on coronary disease mortality.

Adolescent↗
PubMed1996

A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events).

OBJECTIVE: To measure the potential for secondary prevention of coronary disease in the United Kingdom. DESIGN: Cross sectional survey of a representative sample of coronary patients from a retrospective review of hospital medical records and patient interview and examination. SETTING: Stratified random sample of 12 specialist cardiac centres and 12 district general hospitals drawn from 34 specialist cardiac centres and 261 district general hospitals in 12 geographic areas in the United Kingdom. SUBJECTS: 2583 patients < or = 70 yr; 25 consecutive males and 25 consecutive females identified retrospectively in each of four diagnostic categories: coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute myocardial infarction, and acute myocardial ischaemia without evidence of infarction. MAIN OUTCOME MEASURES: Risk factor recording and management in medical records; the prevalence and control of risk factors at interview six months after the procedure or event. RESULTS: Recording of coronary risk factors in patient's records was incomplete and this varied by risk factor. Smoking habit and blood pressure were most completely recorded, whereas a history of hyperlipidaemia and blood cholesterol concentrations were least complete. Risk factor records were more likely to be complete in cardiac centres than in district hospitals. At interview 10% to 27% of patients were still smoking cigarettes and 75% remained overweight, females more severely so. Up to a quarter of patients remained hypertensive, males more severely so than females. Over three quarters had a total cholesterol > 5.2 mmol/l. In patients on medication for blood pressure, cholesterol or glucose, risk factor profiles were little better than in those who were not. Only about one patient in three was taking a beta blocker after infarction. Up to a fifth of patients who had had acute myocardial ischaemia were not taking aspirin at follow up. CONCLUSIONS: There is considerable potential to reduce the risk of a further major ischaemic event in patients with established coronary disease. This can be achieved by effective lifestyle intervention, the rigorous management of blood pressure and cholesterol, and the appropriate use of prophylactic drugs.

Adrenergic beta-Antagonists↗