[Program for the prevention of coronary disease].
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Coronary Disease↗
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[Regional myocardial blood supply in coronary disease].
1. Value and limitations of the precordial Xenon-clearance technique are analyzed. The results of this technique are compared to the scintigraphic display of the initial Xenon distribution and to microsphere scintigraphy (Engel et al. 1976a). 2. The effects of coronary obstructions and of segmental LV dysfunction on regional myocardial blood flow are analyzed (Engel et al. 1977). Independent of coronary obstructions, a clear reduction of regional myocardial blood flow in areas of hypokinesis and akinesis was observed. Thus in coronary disease a decrease of regional myocardial blood flow may represent either a cause or a result of abnormal segmental wall motion. 3. The effects of nitroglycerin, beta-blockade (Atenolol), calcium-antagonists (Nifedipine) and coronary dilatation (Dipyridamole) on regional myocardial blood flow were investigated (Engel et al. 1976b). Regional flow at rest decreased after nitroglycerin and beta-blockade, increased mildly after Nifedipine and markedly after Dipyridamole.
Adrenergic beta-Antagonists↗
[Coronary artery anomalies and coronary disease: is there a relationship?].
BACKGROUND: It has been suggested that in coronary anomalies the turbulence of the flow might develop atherosclerosis, but this theory remains controversial. The relationship between coronary anomalies and coronary artery disease have been studied. METHODS: Twenty-five patients [15 males, 10 females (mean age 75+/-1.4 years)] with coronary anomalies at coronary angiography were enrolled in a prospective study. Thirteen patients out of 25 (group 1) had critical coronary artery disease (>50% of reduction in luminal diameter). The anomalous vessels passing intramyocardial or between aorta and pulmonary veins were excluded. Twelve patients out of 25 had no sign of atherosclerosis (group 2). At clinical and instrumental follow-up (54+/-8.4 months) the number of cardiovascular events (acute myocardial infarct, unstable angina, silent ischemia, bypass or PTCA interventions, cardiovascular death) was evaluated in the two groups. RESULTS: Age and ejection fraction value were no statistically different in the two groups. Risk factors were significantly (p<0.04) higher in group 1 (smoke, hypertension, hypercholesterolemia, diabetes). The patients number with cardiovascular events was significantly higher in group 1(11 patients vs 2) confirming the independence of the two phenomena. No correlation was found between presence of risk factors and presence of events. A correlation (r=0.70) was found only between previous coronary artery disease and number of events. CONCLUSIONS: No relationship between coronary anomalies and coronary artery disease seems to be confirmed. The real relevance of flow turbulence in the development of atherosclerosis in coronary anomalies needs to be still confirmed.
Aged↗
Digital subtraction fluoroscopy: a new method of detecting coronary calcifications with improved sensitivity for the prediction of coronary disease.
The association between calcification of the coronary arteries and coronary artery narrowing is well established. However, fluoroscopic visualization of coronary calcifications has been insufficiently sensitive to be useful as a screening test. Since digitization of radiographic images permits the subtraction of noncardiac structures from moving cardiac structures, such subtraction might increase the sensitivity of coronary fluoroscopy. To determine whether coronary calcifications were better visualized with digital subtraction fluoroscopy than with conventional fluoroscopy, we taped diseased human coronary arteries to a pulsating water balloon inside the thorax of a dog cadaver and studied this model with both fluoroscopic techniques. Calcific atherosclerotic plaques were more easily identified with digital subtraction fluoroscopy than with conventional fluoroscopy. We tested the method clinically by submitting 191 subjects without history or electrocardiographic evidence of previous myocardial infarction who were referred for coronary arteriography to both fluoroscopic studies. For at least one, at least two, and three calcified coronary arteries, digital fluoroscopy was more sensitive (92%, 66%, and 40%) than conventional fluoroscopy (63%, 21%, and 2%) (all p less than .001) for the prediction of significant coronary obstructions (greater than 50%). Although digital fluoroscopy was less specific than conventional fluoroscopy (digital: 65%, 89%, and 97%; conventional: 81%, 98%, and 100%) (all but last, p less than .01), receiver operating curve analysis revealed a significantly larger area under the curve, indicating higher accuracy for the digital technique (p = .03). Digital subtraction fluoroscopy was more accurate in younger than in older patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Angiography↗
Pharmacologic stress testing for coronary disease diagnosis: A meta-analysis.
BACKGROUND: Although noninvasive pharmacologic stress tests are widely used, their relative performance is not clear. We compared the performance of pharmacologic stress tests combined with echocardiography or nuclear imaging for the diagnosis of coronary disease. METHODS: We performed a regression meta-analysis of published data. We included studies published between January 1975 and June 1999 in which subjects underwent echocardiographic or single-photon emission computed tomography (SPECT) stress testing with adenosine, dipyridamole, or dobutamine for diagnosis of coronary artery disease. All subjects also underwent coronary angiography. Two independent reviewers abstracted population characteristics, technical factors, methodologic factors, and results and calculated test sensitivity and specificity. RESULTS: Eighty-two studies met the inclusion criteria. The sensitivity of dipyridamole SPECT imaging, 89% (95% CI, 84%-93%), was higher than that of dipyridamole echocardiography, but the specificity of dipyridamole SPECT imaging, 65% (95% CI, 54%-74%), was lower than that of dipyridamole echocardiography. Dipyridamole and adenosine tests had similar sensitivities and specificities. The sensitivity of dobutamine echocardiography, 80% (95% CI, 77%-83%) was similar to that of dobutamine SPECT imaging, but dobutamine echocardiography had a higher specificity, 84% (95% CI, 80%-86%) than dobutamine SPECT imaging did. CONCLUSIONS: The findings of our study can be used to guide the selection of the optimal pharmacologic stress test for each patient. Maximum sensitivity can be attained by use of a vasodilator combined with SPECT imaging. Maximum specificity can be attained by use of a vasodilator with echocardiography. The highest combination of sensitivity and specificity can be attained with dobutamine echocardiography.
Adenosine↗
The impact of hyperhomocysteinemia as a cardiovascular risk factor in the prediction of coronary heart disease.
Coronary heart disease often occurs in the absence of traditional risk factors. Consequently, epidemiological studies exploring novel risk factors are necessary to improve the prediction of coronary heart disease. This study evaluated five promising markers of cardiovascular risk: homocysteine, C-reactive protein, fibrinogen, lipoprotein(a) (Lp(a)), free apolipoprotein(a) (apo(a)) and Lp(a) phenotypes. The study included 135 patients with angiographically confirmed atherosclerosis. The control group consisted of 93 sex- and age-matched individuals. The Mann-Whitney U-test was used for group comparison. New risk factors were evaluated by binary logistic regression. The odds ratios were calculated continuously for homocysteine in dependence on C-reactive protein. Low density lipoprotein (LDL)-cholesterol was nearly identical in controls and patients. Homocysteine, C-reactive protein, fibrinogen, high density lipoprotein (HDL)-cholesterol and Lp(a) discriminated highly significantly between both groups. The continuously calculated odds ratio for homocysteine demonstrated a distinct influence of C-reactive protein. In the group with high C-reactive protein levels, homocysteine levels above 9.6 micromol/l resulted in a markedly elevated risk (odds ratio 12), in the group with C-reactive protein levels below 5 mg/dl, a comparable risk increase was observed at a homocysteine level of 16.6 micromol/l. This data strongly suggests that plasma homocysteine helps identify individuals at risk, especially among those with elevated C-reactive protein levels.
Aged↗
Genetic research in coronary heart disease.
Coronary heart disease research along genetic lines is difficult. Studies in molecular genetics of apolipoprotein and receptor variability appear most promising in the near future. However, unexpected discoveries and methodology may turn up that may completely change the field. Exclusive concentration on lipid research therefore should be avoided. It is likely that most advances will come from carefully designed studies that ask specific questions. Such research design is appropriate not only for laboratory studies but also for clinical and epidemiological investigations. The collaboration of clinicians, biochemists, geneticists, epidemiologists, and statisticians is likely to lead to better understanding of coronary heart disease.
Alleles↗
[NUTRITIONAL PROBLEMS IN PATIENTS WITH CORONARY DISEASE].
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Cholesterol↗
Bayesian analysis of stress thallium scintigraphy for the detection of multivessel coronary disease.
This study was performed in 224 men to determine the respective contribution of history and thallium-201 stress myocardial scintigraphic imaging in the non-invasive prediction of the severity of coronary disease. Myocardial scintigraphic imaging had the better diagnostic accuracy (80%) for the detection of multivessel disease but the results emphasize the importance of the history in predicting the extent of coronary artery disease. In patients with myocardial infarction, the diagnostic accuracy of the history (80%) was similar to the diagnostic accuracy of myocardial scintigraphic imaging (79%); in the subgroup of patients with residual angina pectoris after infarction, the accuracy of the history was even greater (87%) than that of myocardial scintigraphic imaging (78%). Thus, after myocardial infarction, scintigraphy was useful only in the small subgroup of patients without residual angina pectoris when it had a diagnostic accuracy of 79%, slightly but insignificantly superior to that of the history (62%). In patients without previous myocardial infarction, but with typical angina, myocardial scintigraphy was clearly superior to the simple history (diagnostic accuracy of 78% versus 53%; P less than 0.001). In patients without myocardial infarction and with atypical angina the prevalence of multivessel disease was low (17%) and the diagnostic accuracy of history (83%) was barely different from the diagnostic accuracy of myocardial scintigraphic imaging (90%). Thus, when the likelihood of multivessel disease is very high (angina pectoris post myocardial infarction), or very low (atypical angina), the contribution of exercise testing is very limited. Important additional information is provided by maximal exercise testing and myocardial scintigraphic imaging only in the groups with an intermediate prevalence of multivessel disease, namely in the asymptomatic patients after myocardial infarction and in the patients with typical angina but no previous myocardial infarction.
Angiography↗
Diagnostic accuracy of single photon emission computed tomography with thallium-201 for the identification of diseased coronary arteries. Comparison between dipyridamole infusion and exercise stress test.
Myocardial perfusion imaging with 201Tl and single-photon emission computed tomography (SPECT) was carried out in two groups of patients, subsequently submitted to diagnostic coronary angiography. SPECT was performed in group 1 (41 patients) after slow i.v. infusion of dipyridamole and in group 2 (162 patients) after tracer injection at maximal ergometric exercise. To evaluate the diagnostic capability of SPECT in the detection of diseased coronary vessels, the left ventricular myocardium was subdivided into 6 segments related to the three major coronary arteries. Sensitivity for the left anterior descending artery was 77% in group 1 and 79% in group 2; specificity was 80% and 96%, respectively. Sensitivity for the right coronary artery was 91% in group 1 and 85% in group 2; specificity was 81% and 73%. For the left circumflex artery sensitivity was 65% for group 1 and 67% for group 2, while specificity was 89% and 88%, respectively. Myocardial SPECT results after ergometric exercise and dipyridamole infusion turned out to be almost superimposable. Dipyridamole stress might be considered appropriate as a provocative test when physical exercise cannot be carried out.
Adult↗
Seasonal variations in coronary heart disease.
Coronary heart disease exhibits a winter peak and summer trough in incidence and mortality, in countries both north and south of the equator. In England and Wales, the winter peak accounts for an additional 20,000 deaths per annum. It is likely that this reflects seasonal variations in risk factors. Seasonal variations have been demonstrated in a number of lifestyle risk factors such a physical activity and diet. However, a number of studies have also suggested a direct effect of environmental temperature on physiological and rheological factors. We review the available evidence on seasonal variations in coronary heart disease and possible explanations for them.
Cold Climate↗
[Diagnosis of coronary disease using echocardiography with inotropic dobutamine stimulation].
PURPOSE: To evaluate dobutamine echocardiography capacity to diagnose coronary artery disease. STUDY DESIGN: Prospective clinical study. SETTING: Cardiology Department of Hospital Santa Marta. PATIENTS: 32 patients with suspected coronary artery disease, without myocardial infarction, have been studied. METHODS: An intravenous perfusion of dobutamine with gradual doses, from 5 to 40 micrograms/kg/min, and increments of 5 to 10 micrograms/kg/min, in 3 minute stages, except the last stage which lasted only 1 minute with 40 micrograms/kg, was performed. Twelve-lead ECG were registered to detect ST changes and symptoms, namely chest pain. Basal and dobutamine bidimensional echocardiograms, in the end of each stage and during recovery, were registered in video. The segmental analysis was performed considering the left ventricle divided in 16 segments. It was considered positive the occurrence or aggravation of the contractility asynergy of the left ventricle with inotropic stress. All the patients were submitted to coronary arteriography. RESULTS: Due to the bad quality of the echocardiographic images 2 patients were excluded. The stress dobutamine echocardiograms were positive in 14 P and negative in 16 P. The coronary arteriography showed coronary disease in 18 cases and absence of significant lesions in 12 cases. The values for sensitivity, specificity positive predictive value and negative predictive value obtained with dobutamine echocardiography were, 78% and 100% and 75% respectively. In Dobutamine-ECG, 7P had ST segment changes, 2 of them with chest pain values for sensitivity, specificity, positive and negative predictive value with dobutamine-ECG were, 39%, 100% and 52%, respectively. The occurrence of side-effects was observed in 8 P (27%): ventricular tachycardia (2 P-7%), complex ventricular ectopy (4 P-13%), chest pain (2 P-7%), headache (1 P-3%), nausea (1 P-3%) and palpitations (2 P-7%). There was no significant difference in the occurrence of side-effects in the two groups of patients, with and without coronary artery disease (33% vs 17%, respectively; p = ns). The reasons for early discontinuation of dobutamine infusion were: ventricular tachycardia (2 P), complex ventricular ectopy (2 P) and chest pain (1 P). Heart rate, systolic blood pressure and double-product did not differ significantly in patients with and without coronary artery disease. In dobutamine electrocardiography 7 P had ST segment changes, 2 of them with chest pain. CONCLUSION: Dobutamine echocardiography showed in this study elevated values for sensitivity and specificity, however sensitivity can be increased with better technical conditions.
Aged↗
[Does diabetes affect the choice of pharmaceutical treatment in coronary artery disease?].
Coronary artery disease is the principal cause of death in diabetic patients. The choice of pharmaceutical treatment used in diabetic patients with coronary artery disease should be based on that of non-diabetic coronary patients (BASIC). However, diabetes has its own specificities. First of all, dietetic measures and physical exercise should be continually encouraged. The questions about the basic treatment concern mainly the choice of oral platelet antiaggregants and the need to associate these drugs systematically and definitively. With regards to the management of acute coronary syndromes, the important point is the improved short and long-term benefits of GP IIb/IIIa on the survival of diabetic coronary patients, especially when angioplasty is performed. Finally, intravenous insulin therapy is promising in the initial phase of treatment of acute coronary syndromes with better defined blood glucose objectives.
Coronary Artery Disease↗
Hematological risk factors for coronary heart disease.
Coronary heart disease (CHD) is a leading cause of morbidity and mortality in the developed and developing countries. Several underlying genetic and environmental factors have been implicated in its etiology. Some of the hematological risk factors implicated in the development of coronary heart disease include antithrombin III deficiency, protein C and protein S deficiency, factor V Leiden mutation, prothrombin gene (20210A) mutation hyperhomocystinaemia, elevated factor VIII levels, plasminogen activator inhibitor type 1 and dysfibrinogenaemia. In general, these factors result in thrombosis, thus having a negative effect on the heart and blood vessels. This paper presents an overview of some of the hematological risk factors involved in the development of CHD.
Antithrombins↗
Development of a program for identification of patients with familial hypercholesterolemia in British Columbia: a model for prevention of coronary disease.
We have developed a targeted approach to identification of high-risk patients in British Columbia, Canada, as an initial strategy for the prevention of coronary disease. Patients with the diagnosis of familial hypercholesterolemia have been identified through the Lipid Clinic. First degree relatives of these persons and subsequently identified individuals will be screened for the presence of hypercholesterolemia. Using this approach, the likelihood of identifying persons at high risk is high, close to 50%. The program will also allow collection of data on factors affecting the expression of hyperlipidemia and atherosclerosis and their response to therapy. In an effort to establish the infrastructure that would be necessary for identification and management of such patients throughout the province, a Lipid Clinic Outreach Program has been developed. The objective is to provide each community in the province with expertise to manage hyperlipidemia without traveling to a major urban area. With this infrastructure in place, this will serve patients who have premature atherosclerosis due to other causes and will also form the framework for dissemination of heart health policies and programs by different levels of government, voluntary and professional organizations, as well as the private sector. From a targeted family centered pilot program, a broad approach to the prevention of coronary artery disease in this community will be possible.
Ambulatory Care↗
Myocardial blood flow and flow reserve in response to hormone therapy in postmenopausal women with risk factors for coronary disease.
Estrogen has beneficial effects on markers of coronary heart disease (CHD) risk, but may increase overall CHD events. The effects of hormone therapy on vascular endothelial function have been mixed, and require further assessment. We studied the myocardial blood flow (MBF) response to postmenopausal combination hormone therapy (CHT) in postmenopausal women with risk factors for CHD. We performed dynamic [13N]ammonia positron emission tomography in 15 postmenopausal women in a 7-month placebo-controlled crossover trial of continuous conjugated equine estrogen/cyclical micronized progesterone. MBF was measured at rest, after sympathetic stimulation with the cold pressor test (CPT), and after i.v. adenosine infusion, to determine baseline, endothelium-dependent, and maximal flows, respectively. Response to CPT was neutral in all women at baseline (-0.51 +/- 27%). Adenosine induced a marked increase in MBF (161 +/- 111%). Treatment with 3 months of combined estrogen/progestin CHT did not change CPT or adenosine MBF responses. Myocardial flow reserve was unchanged as well. In this group of postmenopausal women at higher cardiovascular risk, no association was found between CHT assignment and change in MBF. Further study is needed to clarify the effects of CHT on the endothelium of women with presumably diseased vasculature.
Aged↗
Coronary disease and tracheal stenosis with tracheo-oesophageal fistula: a combined surgical procedure.
A patient with coronary disease class III of the New York Heart Association and tracheal stenosis with a tracheo-oesophageal fistula, which developed after long-term intubation, is described. As both conditions were symptomatic, an aortocoronary double bypass was combined with resection of the trachea and closure of the fistula. Postoperative recovery was uneventful and the patient is symptom-free after 3 years.
Adult↗
[Surgical therapy of coronary disease: aortocoronary bypass. Risks and complications].
The aorto-coronary bypass surgery is a well established method for treating patients with coronary artery disease. In the last five years at the University Clinic in Innsbruck 417 operations have been performed. The operation letality decreased down to 0.66%, whereby the mean revascularisation rate increased to 2.8. The specific aim of this paper is to show the benefits and the risks of this operation to validate and to verify the benefits in regard to the risks, which could be kept very low.
Adult↗