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PubMedDate not supplied

[Progress in the treatment of coronary disease at the University Clinic for Cardiovascular Surgery in Novi Sad].

More than 12,000 open heart operations have been performed at the University Clinic of Cardiovascular Surgery in Novi Sad, with the total postoperative mortality rate of 2.6%. Myocardial revascularization has been done in case of 7,944 patients with the operative risk of 2.8%. The advancement in surgical treatment of coronary disease is especially prominent in case of the most severe coronary patients, such as those with left ventricle failure, diffuse and distal coronary disease and associated valvular lesion.

Coronary Disease↗
PubMed1984

Bayesian probability analysis: a prospective demonstration of its clinical utility in diagnosing coronary disease.

One hundred fifty-four patients referred for coronary arteriography were prospectively studied with stress electrocardiography, stress thallium scintigraphy, cine fluoroscopy (for coronary calcifications), and coronary angiography. Pretest probabilities of coronary disease were determined based on age, sex, and type of chest pain. These and pooled literature values for the conditional probabilities of test results based on disease state were used in Bayes' theorem to calculate posttest probabilities of disease. The results of the three noninvasive tests were compared for statistical independence, a necessary condition for their simultaneous use in Bayes' theorem. The test results were found to demonstrate pairwise independence in patients with and those without disease. Some dependencies that were observed between the test results and the clinical variables of age and sex were not sufficient to invalidate application of the theorem. Sixty-eight of the study patients had at least one major coronary artery obstruction of greater than 50%. When these patients were divided into low-, intermediate-, and high-probability subgroups according to their pretest probabilities, noninvasive test results analyzed by Bayesian probability analysis appropriately advanced 17 of them by at least one probability subgroup while only seven were moved backward. Of the 76 patients without disease, 34 were appropriately moved into a lower probability subgroup while 10 were incorrectly moved up. We conclude that posttest probabilities calculated from Bayes' theorem more accurately classified patients with and without disease than did pretest probabilities, thus demonstrating the utility of the theorem in this application.

Angiography↗
PubMed1986

Bayesian analysis versus discriminant function analysis: their relative utility in the diagnosis of coronary disease.

Both Bayesian analysis assuming independence and discriminant function analysis have been used to estimate probabilities of coronary disease. To compare their relative accuracy, we submitted 303 subjects referred for coronary angiography to stress electrocardiography, thallium scintigraphy, and cine fluoroscopy. Severe angiographic disease was defined as at least one greater than 50% occlusion of a major vessel. Four calculations were done: (1) Bayesian analysis using literature estimates of pretest probabilities, sensitivities, and specificities was applied to the clinical and test data of a randomly selected subgroup (group I, 151 patients) to calculate posttest probabilities. (2) Bayesian analysis using literature estimates of pretest probabilities (but with sensitivities and specificities derived from the remaining 152 subjects [group II]) was applied to group I data to estimate posttest probabilities. (3) A discriminant function with logistic regression coefficients derived from the clinical and test variables of group II was used to calculate posttest probabilities of group I. (4) A discriminant function derived with the use of test results from group II and pretest probabilities from the literature was used to calculate posttest probabilities of group I. Receiver operating characteristic curve analysis showed that all four calculations could equivalently rank the disease probabilities for our patients. A goodness-of-fit analysis suggested the following relationship between the accuracies of the four calculations: (1) less than (2) approximately equal to (4) less than (3). Our results suggest that data-based discriminant functions are more accurate than literature-based Bayesian analysis assuming independence in predicting severe coronary disease based on clinical and noninvasive test results.

Bayes Theorem↗
PubMed2002

First experience with direct factor Xa inhibition in patients with stable coronary disease: a pharmacokinetic and pharmacodynamic evaluation.

BACKGROUND: Thrombin generation is critical to the formation of an arterial thrombus after rupture of an atherosclerotic plaque. In patients with stable coronary disease receiving standard medical therapy, we evaluated the pharmacokinetics, pharmacodynamics, and safety profile of DX-9065a, a novel small-molecule anticoagulant that directly, selectively, and reversibly inhibits factor Xa. METHODS AND RESULTS: In a double-blind trial, 73 patients (median age, 63 years; 29% women) were randomly assigned to receive a fixed-dose intravenous bolus, followed by a 72-hour infusion of placebo or 1 of 4 weight-adjusted regimens of DX-9065a. Plasma samples were collected during infusion and a 24-hour elimination period. Only minor bleeding occurred, predominantly ecchymoses at infusion sites, and its incidence did not differ significantly among the groups, including placebo. Median hemoglobin, platelet count, serum creatinine level, and liver function tests did not change significantly from baseline during infusion or elimination. Significant predictors of pharmacokinetic response included infusion dose and weight. At 60 hours into the DX-9065a infusion, plasma drug levels correlated strongly with anti-factor Xa activity (r=0.97), prothrombin time (r=0.77), and international normalized ratio (r=0.72) but less so with activated partial thromboplastin time (r=0.56; all P<0.001). CONCLUSIONS: This is the first study of a selective, reversible, and direct small-molecule factor Xa inhibitor in patients with stable coronary disease. These data lay the foundation for further investigation of factor Xa inhibitors in the treatment of patients with coronary atherothrombosis.

Adrenergic beta-Antagonists↗
PubMed1995

The influence of patient positioning on the hemodynamic changes in TURP patients with severe coronary disease.

Hemodynamic changes were studied in 10 patients with severe coronary disease during routine transurethral prostatectomy (TURP) when performed in the lithotomy position with and without elevation of the legs. The patients undergoing the procedure in the lithotomy position with elevation of the legs exhibited significant hemodynamic changes as compared with those undergoing the procedure without elevation of the legs. This leads us to conclude that performing TURP in the lithotomy position without elevation of the legs benefited the patient by stabilizing hemodynamic factors.

Aged↗
PubMed1986

Body weight and coronary disease risk: patterns of risk factor change associated with long-term weight change. The Normative Aging Study.

Previous studies have suggested that excess body weight increases coronary disease risk by modification of the levels of other risk factors and in addition may contribute to overall risk independently. Few studies, however, have systematically characterized long-term change in risk factors with specific changes in overall weight while they have controlled for the effects of multiple potential confounders. Also, very little information is available on the differential impact of weight change on risk factor changes with advancing age. The present investigation used 15 years of longitudinal data collected on 1,396 men participating in the Veterans Administration Normative Aging Study in Boston, Massachusetts. Multiple regression analysis was used to predict change in each of eight putative coronary disease risk factors from change in weight and the interaction between weight change and age. These included blood pressure, serum cholesterol, triglycerides, fasting and two-hour postprandial blood glucose, uric acid, and forced vital capacity of the lungs. After controlling for initial levels of the risk factor, weight, age, and smoking status, change in weight remained a significant predictor of long-term change in each of the risk factors studied. In addition, the interaction between weight change and age was significant for fasting glucose, uric acid, and forced vital capacity, indicating that the effect of weight gain on uric acid and forced vital capacity was greater in younger men whereas the effect of weight gain on fasting glucose was greater in older men.

Adult↗
PubMedDate not supplied

Graft coronary disease in pediatric heart and combined heart-lung transplant recipients: a study of fifteen cases.

Graft coronary disease (GCD) has emerged as the most important deterrent to long-term survival in adult heart transplant recipients. The incidence, natural history, and pathobiology of GCD is less well understood in the pediatric transplant population. This study evaluated the histopathologic and immunohistochemical features of GCD in the Stanford pediatric heart and heart-lung group. Eighty-eight patients, ages 1 week to 18 years, received heart transplants between 1974 and 1992, and 15 patients, ages 1 month to 18 years received heart-lung transplants between 1981 and 1992 at Stanford University Hospital. There were 50 males and 38 females in the heart transplant group; 39 (11%) had idiopathic cardiomyopathy, 26 (30%) had congenital heart disease, 13 (15%) had viral cardiomyopathy, seven (8%) had familial cardiomyopathy, two (2%) had cardiomyopathy resulting from doxorubicin therapy, and one other case was not further delineated. In the heart-lung transplant group, there were eight males and seven females; pretransplantation diagnoses included nine (60%) with congenital heart disease and Eisenmenger's physiology, three (20%) with primary pulmonary hypertension, and one (7%) each with cystic fibrosis, bronchopulmonary dysplasia, and congenital lymphangiectasia. Fifteen (17%) of the heart transplant recipients and three (20%) of the heart-lung transplant recipients had GCD on angiographic or pathologic examination. Histopathologic samples were available on 14 cases (11 heart transplants and three heart-lung transplants).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2005

Cardiac CT angiography: comprehensive assessment of patient suspected coronary artery disease.

Coronary artery disease is the leading cause of mortality and morbidity worldwide. Although coronary angiography is currently a gold standard for diagnosis of coronary artery disease, some patients are of concern regarding small but not negligible risk of complications and discomfort of the procedure. In recent years, cardiac computerized tomographic angiography (CTA) is an attractive non-invasive modality for evaluation of chest pain in patients suspected to have coronary artery disease. The authors report a 61 year-old-man with a history of hypertension and hypercholesterolemia who presented with exertional angina pectoris for 3 weeks. Cardiac CTA was performed and revealed a severely stenotic lesion at the proximal left anterior descending coronary artery (LAD) with left ventricular ejection fraction of 53% and hypokinesia of anteroseptal and apical wall. The patient then was planned and underwent percutaneous coronary interventional procedure. This case highlights the utility of comprehensive information from cardiac CTA as a modality for coronary interventional procedure planning.

Chest Pain↗
PubMed2001

C-reactive protein--a screening test for coronary disease?

C-reactive protein (CRP) is one of a number of substances termed "acute phase reactants," biologic substances that appear in the circulation when an active inflammatory process occurs. Although traditionally used to monitor or detect major infectious or inflammatory conditions, elevations of CRP levels within the conventional range of "normals" has been intensively studied as a marker for coronary disease and risk of future coronary events. Sensitive assays that can be performed on a high-volume, commercial basis are now available. CRP appears to be a valuable marker for the prediction of future events in individuals who have known coronary artery disease. CRP has been proposed as a coronary disease-screening test for healthy individuals; however, available data suggest that use of CRP in this context may be premature. This paper reviews published research concerning CRP and the prediction of cardiovascular and total mortality risk, then outlines the current "state of the art" for the application of CRP to the risk assessment process.

Aged↗
PubMed1998

Are risk factors for stroke and coronary disease the same?

Many risk factors operate in both coronary heart disease and stroke, especially ischaemic stroke--age, sex, social class, blood pressure, pre-existing vascular disease (angina, myocardial infarction, cardiac failure, diabetes and peripheral vascular disease, transient ischaemic attack and stroke), atrial fibrillation and fibrinogen, smoking, alcohol and height. Total cholesterol has also recently been recruited to this list. The various mechanisms involved in stroke and its subtypes and the epidemiological problems in evaluating aetiological factors in stroke make the comparison with coronary heart disease more difficult. The recent discrepancy between much of the epidemiology and the clinical trials evaluating the role of lipids in stroke has spurred the systematic review (meta-analysis) of major prospective observational studies. These will provide a clearer assessment about the quantitative comparison of some of the more important risk factors for stroke and coronary heart disease in the near future.

Humans↗
PubMed2000

[Elevated cortisol level in blood of patients with unstable coronary disease and acute myocardial infarction--new approach].

The aim of this study was to assess changes in serum cortisol concentration, enzymatic markers of myocardial ischemia and necrosis, leucocytosis and glucose in patients with unstable coronary disease and acute myocardial infarction. The study was performed in 75 patients (20 females and 55 males aged 38-75 years; mean age 59.4 +/- 6.52), including 13 patients with unstable coronary disease (6 females and 7 males aged 40-66 years; mean age 59.4 +/- 6.52; group I), 40 patients with acute myocardial infarction (8 females and 32 males aged 38-72 years; mean age 57.3 +/- 9.57; group II) and 22 healthy volunteers (6 females and 16 males aged 39-75 years; mean age 53.1 +/- 9.62; control group). Acute ischemia as well as myocardial infarction are potent stress factors that destabilisate the functional equilibrium of the body. Considering the mechanism of action of cortisol and its physiological role, it seems that current views on elevated plasma cortisol levels as a response to stress and pain in infarction and acute ischemia should be supplemented. Anti-inflammatory properties of cortisol deserve more attention, while elevated levels might be of prognostic value in the above-mentioned diseases.

Adult↗
PubMed2001

Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial.

BACKGROUND: Our aims were to compare coronary artery bypass grafting (CABG) and stenting for the treatment of diabetic patients with multivessel coronary disease enrolled in the Arterial Revascularization Therapy Study (ARTS) trial and to determine the costs of these 2 treatment strategies. METHODS AND RESULTS: Patients (n=1205) were randomly assigned to stent implantation (n=600; diabetic, 112) or CABG (n=605; diabetic, 96). Costs per patient were calculated as the product of each patient's use of resources and the corresponding unit costs. Baseline characteristics were similar between the groups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63.4%) because of a higher incidence of repeat revascularization compared with both diabetic patients treated with CABG (84.4%, P<0.001) and nondiabetic patients treated with stents (76.2%, P=0.04). Conversely, diabetic and nondiabetic patients experienced similar 1-year event-free survival rates when treated with CABG (84.4% and 88.4%). The total 1-year costs for stenting and CABG in diabetic patients were $12 855 and $16 585 (P<0.001) and in the nondiabetic groups, $10 164 for stenting and $13 082 for surgery. CONCLUSIONS: Multivessel diabetic patients treated with stenting had a worse 1-year outcome than patients assigned to CABG or nondiabetics treated with stenting. The strategy of stenting was less costly than CABG, however, regardless of diabetic status.

Cerebrovascular Disorders↗
PubMed1999

Genetic risk factors in acute coronary disease.

OBJECTIVE: We investigate whether each of the following: HPA-1, Factor V Leiden, prothrombin gene variant and the methylene tetrahydrofolate reductase gene (MTHFR) mutation, are risk factors for acute coronary disease in Portuguese patients. MATERIAL AND METHODS: 100 blood donors and 52 patients with an established diagnosis of myocardial infarction or unstable angina were evaluated for genetic risk factors, by determining HPA-1 genotype, Factor V Leiden, Prothrombin 20210 variant and MTHFR mutation. RESULTS: We found a prevalence of 2.0% for Factor V Leiden, 5.0% for the Prothrombin 20210 variant and 66% for the MTHFR mutation in blood donors. These values are similar to those found in the patients (1.9, 3.8 and 58%, respectively). We found that 28/100 controls had the PI(A2) polymorphism, a frequency statistically different from that in the patients (23/52). This difference was even more pronounced in patients less than 60 years old (27/96 vs. 13/24). CONCLUSION: Factor V Leiden, Prothrombin 20210 variant and MTHFR mutation do not seem to represent risk factors for acute coronary disease. However, the PI(A2) polymorphism could have a role in the pathogenesis of this disease. The presence of multiple genetic factors, more than single ones, could influence the development and outcome of myocardial infarction and unstable angina. Larger studies are needed in order to have a better insight into the pathophysiological mechanisms of this disease, along with its prevention and the development of new treatments.

Activated Protein C Resistance↗
PubMedDate not supplied

[Nuclear cardiology in the preoperative evaluation of the patient at risk of coronary disease; meta-analysis of the contribution of thallium dipyridamole scintigraphy].

Coronary disease may be assessed by several techniques of nuclear cardiology: classical thallium myocardial scintigraphy, position scintigraphy, left ventricular angioscintigraphy. These techniques measure the response of coronary flow, myocardial metabolism, or left ventricular contractility during a physical or pharmacologic stress test. Many studies have reported the interest of dipyridamole thallium scintigraphy in the assessment of the surgical risk for a coronary event. Regarding the meta-analysis of up-to-day published studies, the surgical risk is 26% for an abnormal test against 3% for a normal study. Considering only the risk of infarction or cardiac death, corresponding probabilities are 18% and 2%, respectively. Dipyridamole stress test is a fairly safe and accurate method for discriminating between high and low risk patients in a population selected on clinical grounds.

Coronary Disease↗
PubMed2004

Unanswered ethical and scientific questions for trials of invasive interventions for coronary disease: The case of single vessel disease.

Trials in the 1990s demonstrated that medical therapy is as effective as invasive therapies for treating single-vessel coronary disease. Yet more recent studies enrolling patients with this condition have focused on evaluating only invasive approaches, namely, stenting versus coronary artery bypass surgery. Several ethical and scientific questions remain unanswered regarding the conduct of these later trials. Were they justified? Why wasn't a medical therapy arm included? Were subjects informed about the availability of medical therapy as an equivalent option? Was optimized medical therapy given prior to randomization? The absence of clear answers to these questions raises the possibility of serious bias in favor of invasive interventions. Considering that medical therapy is underutilized in patients with coronary disease, efforts should focus more on increasing utilization of medical therapy and proper selection of noninvasive interventions.

Journal Article↗
PubMed1990

Antiplatelet agents in coronary artery disease.

Coronary artery disease pathophysiology and platelet physiology are summarized, and the use of antiplatelet drugs in coronary artery disease is reviewed. Aspirin, sulfinpyrazone, and most other nonsteroidal anti-inflammatory agents alter platelet function by inhibiting the activity of cyclooxygenase, an enzyme necessary for the production of prostaglandins. Drugs that inhibit thromboxane synthetase or antagonize thromboxane A2 at the receptor level are under investigation. Prostacyclin and dipyridamole inhibit platelet function by elevating the concentration of cyclic AMP in platelets, but proof of their efficacy is limited. Most clinical trials of antiplatelet drugs in coronary artery disease have been small and of short duration; many have demonstrated short-term benefits, but long-term benefits are less obvious. Retrospective studies of patients before initial myocardial infarction suggest that regular aspirin ingestion may reduce the occurrence of cardiovascular complications. In prospective trials, the benefit of aspirin therapy for primary prevention of coronary artery disease was balanced by an increased likelihood of stroke. For secondary--after initial infarction--prevention of cardiovascular complications, the administration of aspirin and other antiplatelet agents has consistently decreased the rate of nonfatal myocardial infarction, overall mortality, or both. In the Second International Study of Infarct Survival, patients treated with streptokinase plus aspirin showed the greatest reduction in mortality, while each drug alone was associated with significantly lower mortality than placebo. Aspirin may improve clinical outcome in patients with or without previous myocardial infarction or with unstable angina pectoris. The daily dose should not exceed 325 mg. Antiplatelet therapy should not be used in patients at high risk for bleeding.

Coronary Disease↗