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PubMed1996

Diabetics with coronary disease have a prevalence of asymptomatic ischemia during exercise treadmill testing and ambulatory ischemia monitoring similar to that of nondiabetic patients. An ACIP database study. ACIP Investigators. Asymptomatic Cardiac Ischemia Pilot Investigators.

BACKGROUND: There are conflicting data as to whether diabetics have a higher prevalence of asymptomatic ST-segment depression during exercise treadmill testing (ETT) and ambulatory ECG (AECG) monitoring. This study was conducted to determine whether diabetic patients with coronary disease enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) have more episodes of asymptomatic ischemia during ETT and 48-hour AECG monitoring than nondiabetic patients and to compare differences in angiographic variables and the magnitude of ischemia as measured by standard ETT and AECG criteria. METHODS AND RESULTS: Angiographic variables and the prevalence and magnitude of ischemia during the qualifying ETT and 48-hour AECG were compared by the presence and absence of diabetes mellitus in 558 randomized ACIP patients. Seventy-seven patients had a history of diabetes and were taking oral hypoglycemics or insulin (diabetic group); 481 patients did not meet these criteria (nondiabetic group). Multivessel disease (87% versus 74%, P = .01) was more frequent in the diabetic group. The percentages of patients without angina during the ETT were similar in the diabetic and nondiabetic groups (36% and 39%, respectively). Time to onset of > or = 1-mm ST-segment depression and time to onset of angina were similar in both groups. The percentages of patients with only asymptomatic ST-segment depression during the 48-hour AECG were similar in the diabetic and nondiabetic groups (94% versus 88%, respectively). However, total ischemic time per 24 hours (15.0 +/- 21.4 versus 23.6 +/- 31.1 minutes, P = .02), ischemic time per episode (6.3 +/- 4.6 versus 9.0 +/- 8.7 minutes, P < .01), and the maximum depth of ST-segment depression tended to be less in the diabetic group. CONCLUSIONS: Patients enrolled in ACIP were selected on the basis of an abnormal ETT and 48-hour AECG and ability to undergo coronary revascularization. When patients with diabetes mellitus were compared with those without diabetes, there was a similar prevalence of asymptomatic ischemia during ETT and 48-hour AECG monitoring. Despite more extensive and diffuse coronary disease, diabetic ACIP patients tended to have less measurable ischemia during the 48-hour AECG.

Aged↗
PubMed1977

Use of the exercise test in the diagnosis of coronary disease.

The two-step test remains a useful office procedure for the diagnosis of serious coronary disease. The graded exercise test has improved sensitivity. Requiring a good performance and a normal electrocardiographic response as well can exclude prognostically important disease.

Arrhythmias, Cardiac↗
PubMed1988

Does hypertension predispose to coronary disease? Conflicting epidemiological and experimental evidence.

Hypertension is associated with an increased risk of coronary events. Treatment of hypertension in controlled trials has not reduced the incidence of coronary events, although the risk of stroke is reduced. In untreated hypertension, about one-half the deaths were due to hypertensive heart failure, whereas myocardial infarction caused 10%-12% of deaths. In treated hypertension, coronary events cause about 40% of deaths. Although in autopsy serious coronary atherosclerosis is commonly found in hypertension, in severe hypertension, dilated coronary vessels free of atheroma were a common finding. No correlation was noted between the height of blood pressure and degree of coronary atherosclerosis. The relationship between coronary disease and hypertension is consistent with an association between them rather than hypertension being a causal factor. The factors that cause acute myocardial infarction may differ from those which predispose to coronary atherosclerosis.

Coronary Disease↗
PubMedDate not supplied

Use of exercise electrocardiography, technetium-99m-MIBI perfusion tomography, and two-dimensional echocardiography for coronary disease surveillance in a low-prevalence population of heart transplant recipients.

BACKGROUND: Coronary artery disease has been reported to be a significant cause of long-term morbidity and mortality after heart transplantation. However, the diagnosis of coronary disease by means of noninvasive procedures has shown disappointing accuracy, and many centers currently recommend an annual surveillance coronary angiogram. METHODS: We prospectively studied the accuracy and feasibility of a symptom-limited upright bicycle exercise, combined with computerized electrocardiogram analysis, echocardiography, and perfusion scintigraphy in 37 consecutive heart transplant recipients at 2.8 +/- 1.4 years after transplantation for routine follow-up coronary angiography. RESULTS: No patient had any hemodynamically significant (> 50% diameter) coronary stenosis, but luminal irregularities were detectable in four patients. The exercise electrocardiogram was interpretable in only 22 patients (59%), and two of the remaining patients (9%) had false-positive results. The feasibility of perfusion tomography (100%) and two-dimensional echocardiography (97%) were greater than for stress electrocardiogram (p < 0.001 and p < 0.01 respectively). False-positive results were obtained at stress echocardiography in one patient (3%), and at scintigraphy in six patients (16%, p = not significant). None of these methods detected coronary artery stenoses of less than 50% diameter. CONCLUSIONS: Both exercise perfusion tomography and two-dimensional echocardiography are feasible and can be used with adequate specificity for the noninvasive diagnosis of coronary artery disease in heart transplant recipients. However further studies are needed to determine their respective sensitivity.

Coronary Angiography↗
PubMed2005

Iron status and clinical outcome in patients with coronary artery disease after coronary stenting.

BACKGROUND AND AIM: So far, no studies have assessed whether there is an association between iron status and the incidence of major adverse cardiac events or restenosis after coronary stenting. We conducted this study to investigate whether there is an association between body iron status and clinical outcome in patients with coronary artery disease after coronary stenting. METHODS AND RESULTS: The study included 664 patients with coronary artery disease who underwent coronary stent implantation. The soluble transferring receptor/ferritin ratio (sTfR/ferritin ratio) was used as an index of iron status. Patients were divided into three groups according to the tertiles of sTfR/ferritin ratio: lower tertile (<11.9; n = 221), middle tertile (11.9-27.8; n = 221) and upper tertile (>27.8; n = 222). The combined incidence of major adverse cardiac events (death, myocardial infarction and target vessel revascularization) was the primary end point of the study. Patients in the lower tertile of the sTfR/ferritin ratio presented more often with unstable angina or acute myocardial infarction and had longer lesions and higher grade of stenosis than the patients in the middle or upper tertile of the sTfR/ferritin ratio. Angiographic restenosis at 6-month angiography was also evaluated. The cumulative event rate of composite end point of death, myocardial infarction or target vessel revascularization was 27.6% in patients in the lower tertile, 24.4% in patients in the middle tertile and 28.4% in patients in the upper tertile of the sTfR/ferritin ratio (p = 0.68). Restenosis was found in 27.8% (n = 45) in the lower tertile, 25.8% (n = 42) in the middle tertile and 27.5% (n = 38) in the upper tertile of the sTfR/ferritin ratio (p = 0.90). CONCLUSIONS: Our study showed no association between iron status and the incidence of major adverse cardiac events or angiographic coronary restenosis in patients with coronary artery disease after coronary stenting.

Aged↗
PubMed1995

[The recanalization of the chronically occluded infarct vessel in single-vessel coronary disease. The reduction of cardiac events in long-term clinical follow-up].

OBJECTIVE: The prognostic significance of recanalisation of a chronically occluded infarct vessel in single-vessel coronary disease remains controversial, in contrast to early re-opening of the infarct vessel in the acute state of infarction. It was the purpose of this prospective study to discover whether successful recanalisation in the former influences the incidence of cardiac events (death, infarction, by-pass operation) and clinical symptoms in the long term. PATIENTS AND METHOD: Recanalisation procedures were successful in 58, unsuccessful in 41 of 99 patients (81 men, 18 women; mean age 55 [28-79] years) with anterior wall (n = 53) or posterior wall (n = 46) myocardial infarction (AMI and PMI, respectively). The two groups were similar with respect to age, sex, left-ventricular function, indication, exercise capacity and premedication. But the interval between infarction and recanalisation was shorter in the patients who had successful recanalisation (5.1 +/- 5.3 vs 7.8 +/- 7.6 months; P < 0.05). Mean follow-up period for all patients was 55.8 +/- 8.9 months after the recanalisation procedure. RESULTS: There were significantly fewer cardiac events after successful than failed recanalisation, both for the total group of patients (5% vs 23%; P < 0.01) and those with AMI (9 vs 36%; P = 0.012). In the patients with PMI there was only a trend in favour of those with successful recanalisation (0% vs 14%; P = 0.058). Symptomatic improvement was reported by 73% of patients after successful but only 40% after failed recanalisation (P < 0.01). CONCLUSION: The results provide pointers towards prognostic indications of recanalisation even after chronic occlusion of the infarct vessel. The procedure should therefore be attempted if the occlusion is morphologically suitable.

Angioplasty, Balloon, Coronary↗
PubMed2000

[Percutaneous angioplasty of unprotected left main coronary disease with implantation of systematic stenting. Immediate and mid-term results].

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.

Aged↗
PubMed1985

Coronary disease in women.

Myocardial infarction is uncommon in younger women in the absence of coronary risk factors; cigarette smoking and diabetes mellitus are major contributors to coronary risk. The presentation of coronary disease in women is more likely to be angina pectoris than myocardial infarction or sudden death. Myocardial infarction in women is characterized by increased morbidity and mortality, an excess of congestive heart failure, and a less favorable response to coronary bypass surgery. Psychosocial complications are greater and return to work is less likely.

Angina Pectoris↗
PubMed2003

Comparison of methods to identify individuals at increased risk of coronary disease from the general population.

OBJECTIVES: To evaluate the guidelines on measurement of cholesterol in the national service framework for coronary heart disease and to compare alternative strategies for identifying people at high risk of coronary disease in the general population. DESIGN: Comparison of methods (national service framework criteria, Sheffield tables, age threshold of 50 years, estimated risk assessment using fixed cholesterol values) for identifying people with a 10 year coronary event risk of 15% or greater. SETTING: Health survey for England 1998. SUBJECTS: 6307 people aged between 30 and 74 years with no history of myocardial infarction, stroke, or angina. MAIN OUTCOME MEASURES: Proportion of the total population selected for measurement of cholesterol and proportion of people at 15% or greater risk identified. RESULTS: The national service framework guidelines selected 43.4% (95% confidence interval 42.2% to 44.6%) of the study population for cholesterol measurement and identified 81.2% (80.2% to 82.2%) of those at 15% or greater risk. The Sheffield tables selected 73.1% (72.0% to 74.2%) for cholesterol measurement and identified 99.91% (99.83% to 99.99%) of those at 15% or greater risk. An age threshold of 50 years selected 46.3% (45.1% to 47.5%) for cholesterol measurement and identified 92.8% (92.1% to 93.4%) of those at 15% or greater risk. Estimated risk assessments using fixed cholesterol values selected 17.8% (16.8% to 18.7%) for cholesterol measurement and identified 75.9% (74.8% to 76.9%) of those at 15% or greater risk. CONCLUSION: Measuring the cholesterol concentration of everyone aged 50 years and over is a simple and efficient method of identifying people at high risk of coronary disease in the general population.

Adolescent↗
PubMedDate not supplied

[Reversible dysfunction of the left ventricle in coronary disease (part two): hibernation and methods for detection of viability].

HIBERNATION: Hibernating myocardium is defined as a state of persistently impaired myocardial function, as a consequence of reduced coronary flow, which can be partially or completely reversed if the myocardial oxygen consumption/demand ratio is favorably altered. Since it indicates concordance between flow and function (flow-function relation), it can be concluded that hibernating myocardium, caused by reduced myocardial perfusion, improves its function after surgical revascularization, giving its detection a great clinical importance. Hibernating myocardium can be found in majority of patients with coronary artery disease and chronic left ventricular dysfunction. These patients, even without typical symptoms of angina, will benefit from myocardial revascularization. This beneficial effect is expressed by ejection fraction enhancement, which is directly proportional to the number of dysfunctional, but viable segments. Also, symptom improvement depends on the mass of revascularized myocardium, which is previously shown to be viable. Having that in mind, the mass of viable myocardium must be large enough, so that the degree of expected improvement of myocardial function after revascularization justifies the operation itself. Opposing this classical concept of hibernating myocardium, recent studies have shown that in patients with coronary artery disease, coronary flow at rest is normal or just slightly reduced, which cannot explain the degree of myocardial dysfunction. According to that, it is proposed that myocardial dysfunction is, like in myocardial stunning, the result of flow-function mismatch, meaning that pathophysiology of hibernating myocardium includes a component of stunning as well. Therefore, hibernating myocardium can be defined as a form of reversible left ventricular dysfunction, caused by chronic coronary artery disease, which is partially due to episodes of repetitive stunning and shows improvement after inotropic stimulation. From practical point of view, it is important to detect hibernating myocardium in all patients with coronary artery disease and left ventricular dysfunction, since their treatment and prognosis directly depend on whether the dysfunction is reversible or not. METHODS FOR IDENTIFICATION OF MYOCARDIAL VIABILITY: Detection of myocardial viability has great clinical importance, since both regional and global left ventricular function can significantly improve, either spontaneously or by myocardial revascularization. Noninvasive imaging procedures used for that purpose include positron emission tomography, thallium-201 imaging, technetium-99 imaging, dobutamine echocardiography and tissue characterization. Using these methods, it is possible to assess the presence of viable tissue through evaluation of metabolic activity, integrity of myocyte membrane and the inotropic reserve of myocardium.

Coronary Disease↗
PubMed1997

Minimally invasive treatment for coronary artery disease.

Coronary artery disease is the leading cause of morbidity and mortality in the United States. One advancement in the treatment of this disease is the minimally invasive direct coronary artery bypass (MIDCAB) procedure, which is an alternative to the traditional open heart bypass procedure. The MIDCAB procedure is becoming a viable alternative to the traditional coronary artery bypass grafting procedure for a select group of patients. With further experience and follow-up, this procedure will offer lower hospital costs by decreasing lengths of stay and offering patients the optimal conduit for coronary artery bypass grafting without the complications of cardiopulmonary bypass.

Aged↗
PubMed2001

[The classification of coronary lesion from Society for Cardiac Angiography and Intervention predicts better results of coronary angioplasty than the one from American College of Cardiology/American Heart Association Coronary Disease].

BACKGROUND: The classification of coronary lesion complexity, using the American College of Cardiology/American Heart Association (ACC/AHA) is a predictor of balloon angioplasty success. Stents have improved results even in complex lesions. AIM: To compare the ACC/AHA and the new Society for Cardiac Angiography (SCA&I) coronary lesion scores as predictors of angioplasty success. PATIENTS AND METHODS: Ali consecutive angioplasty procedures (n = 346, 456 lesions, 47% stents) were prospectively analyzed from August 1996 to March 1999. Coronary lesions were classified using the ACC/AHA and SCA&I scores. Angiographic success was assessed and its multivariate predictors determined with logistic regression analysis. RESULTS: According to the ACC/AHA score, angiographic success was 97, 92.7, 93.3, and 82.3% in A, Bl, B2 and C lesions respectively (p = 0.013). There only were significant differences in success between C and A, Bl or B2 lesions. According to the SCA&I score success was achieved in 97.3, 97.9, 75.8 and 33.3% in nonCP, CP, nonCO and CO lesions respectively (P < 0.001). With the SCA&I score statistically significant differences in angiographic success were found for all lesion score comparisons, except between nonCP and CP lesions. No other variables had predictive value for angiographic success. CONCLUSIONS: Coronary angioplasty angiographic success is better predicted by the new SCA&l lesion score than with the ACC/AHA lesion classification in a group of patients with frequent use of stents.

Adult↗
PubMed2005

Successful withdrawal of oral long-acting nitrates to facilitate phosphodiesterase type 5 inhibitor use in stable coronary disease patients with erectile dysfunction.

INTRODUCTION: Vascular disease is the most common cause of male erectile dysfunction (ED). Phosphodiesterase type 5 (PDE5) inhibitors are effective in up to 80% of men but are contraindicated in the presence of oral nitrates, because of a potentially severe hypotensive interaction. AIMS: To see if stable coronary disease patients with ED could have their oral nitrates discontinued to allow safe use of a PDE5 inhibitor. METHODS: Prospective study of 425 men with ED and cardiac disease conducted in an outpatient cardiac sexual advice clinic. MAIN OUTCOME MEASURES: Discontinuation of oral nitrates to facilitate subsequent use of PDE5 therapy. RESULTS: Oral nitrates were being used by 88 (21%) coronary artery disease patients all of whom were clinically stable. Fifty-five (63%) of these men with a good exercise ability had their nitrates discontinued in the presence of continuing beta-blockade or calcium antagonist therapy. They were reviewed 1 week later. Only three restarted their nitrate therapy because of an increase in symptoms. Forty-nine of the 52 men no longer taking nitrates were treated with a PDE5 inhibitor which was effective in 22 out of 26 (85%) patients who have completed follow-up. Fifteen patients are currently undergoing clinic follow-up in order to optimize treatment, and nine patients have continued therapy with their family doctors. Importantly, there have been no adverse cardiac events. CONCLUSION: Oral nitrates can be discontinued in the presence of continuing beta-blockade and/or calcium antagonist therapy in stable coronary disease patients with ED to allow for the safe use of PDE5 inhibitors.

Administration, Oral↗
PubMed1990

Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain.

In a prospective study of 278 consecutive patients admitted to an emergency ward for chest pain, the 115 clinical and paraclinical parameters available at the time of admission were evaluated by computer comparison with the final diagnoses. The most valuable items for making the diagnosis were classified according to their sensitivity, specificity and predictive value. Among the 278 patients, 100 individuals had myocardial infarctions (MI), 47 had unstable angina, 25 had stable angina and 106 patients had a non-coronary disease. The twelve most sensitive items for distinguishing MI from other conditions were the following: sudden onset of pain (70%); duration of more than 60 min (88%); constriction and squeezing (79%); oppression (75%); prior anginal attacks (61%); sex male (72%); age over 60 years (74%); abnormal heart auscultation (62%); abnormal electrocardiogram (ECG) (98%); segment (ST) disturbances (86%); increased glucose level (77%); CKMB fraction greater than 6% of total creatine kinase (CK) level (63%). Among the twelve most specific items, also with the best positive predictive value, irradiation in the right arm is of most importance; among the 51 patients with right arm involvement, 48 suffered from a coronary disease and 41 from a myocardial infarction. The largest extension of pain was reported in the latter group. It is concluded that chest pain with a wide irradiation involving the right arm strongly suggests that a myocardial infarction is ongoing.

Arm↗