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PubMed2000

Cardiogenic shock complicating acute coronary syndromes.

Cardiogenic shock remains the major cause of death among patients with all types of acute coronary syndromes. Thus, there is a growing interest in the identification of patients who are at risk for developing cardiogenic shock, in the exploration of different therapeutic approaches to preventing its development, and in the improvement of outcome when it occurs. This article reviews the aetiology and pathophysiology of cardiogenic shock, its epidemiology, its treatment (including pharmaceutical agents, counterpulsation, and revascularisation), and its outcome. Algorithms are presented that predict its occurrence in both ST-segment-elevation myocardial infarction and unstable angina or non-ST-elevation myocardial infarction, and that predict its mortality in patients with ST-segment-elevation acute myocardial infarction. Such new areas as metabolic therapy and glycoprotein IIb/IIIa inhibitors are discussed, as are the economic implications of shock.

Acute Disease↗
PubMed1988

Profound reversible myocardial depression after anaphylaxis.

Profound myocardial depression developed in 2 patients after severe anaphylactic reactions following the induction of anaesthesia in 1 case and a bee-sting in the other. Neither patient had pre-existent cardiac disease. In both patients haemodynamic assessment, radionuclide ventriculography, and two-dimensional echocardiography confirmed the clinical impression of profound systolic myocardial dysfunction. Haemodynamic stability was attained by intra-aortic balloon counterpulsation, which was probably life-saving in both cases. Cardiac function improved rapidly although some contractile depression persisted for several days. At follow-up both patients had normal cardiac function with no evidence of underlying heart disease.

Adult↗
PubMed1997

Difference in countries' use of resources and clinical outcome for patients with cardiogenic shock after myocardial infarction: results from the GUSTO trial.

BACKGROUND: Use of aggressive and invasive interventions is more common in the USA than in other countries. We have compared use of resources for patients with cardiogenic shock after myocardial infarction in the USA and in other countries, and assessed the association between use of resources and clinical outcomes. METHODS: We analysed data for patients with cardiogenic shock after myocardial infarction who were enrolled in the GUSTO-I trial (1891 treated in the USA, 1081 treated in other countries). Patients were randomly assigned combinations of streptokinase, heparin, and accelerated tissue-plasminogen activator (t-PA), then decisions about further interventions were left to the discretion of the attending physician. The interventions included in our analysis were: pulmonary-artery catheterisation, cardiac catheterisation, intravenous inotropic agents, ventilatory support, intra-aortic balloon counterpulsation (IABP), percutaneous transluminal coronary angioplasty (PTCA), and coronary bypass graft surgery (CABG). The primary outcome measure was death from any cause at 30 days of follow-up. FINDINGS: Patients who were treated in the USA were significantly younger than those treated elsewhere (median 68 [IQR 59-75] vs 70 [62-76], p < 0.001), a smaller proportion had anterior infarction (49 vs 53%, p < 0.001), and they had a shorter time to treatment (mean 3.1 vs 3.3 h, p < 0.001). Aggressive diagnostic and therapeutic procedures were used more commonly in the USA than in the other countries: cardiac catheterisation (58 vs 23%); IABP (35 vs 7%); right-heart catheterisation (57 vs 22%); and ventilatory support (54 vs 38%). 483 (26%) of the patients treated in the USA underwent PTCA, compared with 82 (8%) patients in other countries. Patients who underwent revascularisation had better survival in all countries. Adjusted 30-day mortality was significantly lower among patients treated in the USA than among those treated elsewhere (50 vs 66%, p < 0.001). The difference in mortality remained at 1 year-56% of patients treated in the USA died versus 70% of patients treated elsewhere (hazard ratio 0.69 [95% CI 0.63-0.75], p < 0.001). INTERPRETATION: 30-day and 1-year mortality was significantly lower among patients treated in the USA than among those treated in other countries. This difference in mortality may be due to the greater use of invasive diagnostic and therapeutic interventions in the USA.

Aged↗
PubMed1998

Postpartum myocardial infarction rescued with an intraaortic balloon pump and extracorporeal membrane oxygenator.

A 37-year-old woman had postpartum myocardial infarction complicated with cardiogenic shock. The infarction was attributed to diffuse coronary artery spasm caused by methylergonovine, which had been used to treat the postpartum haemorrhage due to placenta increta. The haemodynamics could not be maintained with catecholamine infusion and intraaortic balloon counterpulsation. At last, an extracorporeal membrane oxygenator was used to save her life, and the patient was successfully weaned from the machine 100 h later; she made an uneventful recovery thereafter.

Adult↗
PubMed1998

The use of an implantable left ventricular assist device in a patient with cardiogenic shock following acute myocardial infarction.

We report the successful long-term use of an implantable left ventricular assist device in a 42-year old patient who suffered cardiogenic shock after an acute anterior myocardial infarction unresponsive to recanalisation of the infarct-related artery and intra-aortic balloon counterpulsation. Attempts to wean our patient from the assist device were not successful and the patient underwent cardiac transplantation after 35 weeks on device assistance. The intermediate and long-term use of an implantable left ventricular assist device may be lifesaving in post-myocardial infarction cardiogenic shock and may allow sufficient time for any stunned myocardium to recover. Should there be no recovery, the device acts as a bridge to cardiac transplantation.

Adult↗
PubMed1999

Total occlusion of the left main coronary artery in a young cocaine user.

A young woman, currently user of cocaine, was admitted because of acute myocardial infarction with cardiogenic shock. The coronary arteriography revealed total occlusion of the left main coronary artery. Despite the use of an intraaortic counterpulsation balloon and successful percutaneous transluminal coronary angioplasty, she developed electromechanical dissociation, unresponsive to resuscitation manoeuvres.

Adult↗
PubMed2000

[Coronary angioplasty in the acute myocardial infarction: in which patients is it less likely to obtain an adequate coronary reperfusion?].

INTRODUCTION: In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty. PATIENTS AND METHODS: The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure. RESULTS: A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0. 02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90). CONCLUSIONS: Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.

Acute Disease↗
PubMed2001

[Management of myocardial infarction in Spain (1995-99). Data from the registry of the Ischaemic Heart Disease Working Group (RISCI) of the Spanish Society of Cardiology].

INTRODUCTION AND OBJECTIVES: Limited information is available on how patients with myocardial infarction are treated in Spain. In order to make up for this deficiency, in October 1994, the Ischaemic Heart Disease Working Group of the Spanish Society of Cardiology initiated a myocardial infarction registry, which is currently active. METHODS: Patients are recruited from hospitals with intensive coronary care facilities. Demographic characteristics coronary risk factors and previous conditions are collected, as well as clinical events, and diagnostic and therapeutic procedures performed during the stay in the coronary care unit. RESULTS: From 1995 to 1999, 28,357 patients were registered. During this period the mean age increased slightly (from 64.4 +/- 12.2 to 65.2 +/- 12.7; p < 0.001), although the male proportion remained stable (from 76.7% to 77.1%). The median "onset of symptoms-hospital arrival for 1st emergency" time fell from 135 min to 120 min, and the median "onset of symptoms-needle" time from 180 to 175 (NS). The use of thrombolytic therapy did not change (from 42.4 to 43.9%), but the use of aspirin (from 87.4 to 91.7%), beta-blockers (from 32.7 to 39.6%) and angiotensin-converting inhibitors (from 27.9 to 34.8%) increased significantly (p < 0.001). The Swan-Ganz catheter and the intra-aortic balloon counterpulsation were rarely placed during the five years (4.2% and 1.2% respectively in 1999). Both early mortality (11.4 to 9.3%) and the median duration of intensive coronary care stay declined, in these 5 years. CONCLUSIONS: In Spain, during the 1995-1999 period, the use of aspirin, beta-blockers, and angiotensin-converting inhibitors increased significantly during the acute phase of infarction in the coronary care unit. However, both the usage of thrombolytic therapy and the delay between the onset of symptoms and therapy initiation remained unchanged. At the same time, the length of stay in the coronary care unit and early mortality declined, although the clinical profile of the patients did not improve.

Aged↗
PubMed2001

[Elective primary angioplasty in cardiogenic shock: results from a single center].

INTRODUCTION: Cardiogenic shock is the leading cause of death among patients hospitalized for acute myocardial infarction. Conventional treatment for acute myocardial infarction does not achieve a better outcome in these patients, but prior studies with emergency revascularization by coronary angioplasty seem to provide encouraging results. PATIENTS AND METHOD: A retrospective study of the clinical and angiographic results of elective primary angioplasty in 48 patients with cardiogenic shock complicating acute myocardial infarction of less than 12 hours is described. Intraaortic balloon counterpulsation was used in 79% of the patients. Patients with cardiogenic shock secondary to mechanical complications were excluded. RESULTS: Angiographic success, defined as a residual stenosis < 50% and final TIMI flow >/= 2, was achieved in 85% of the culprit lesions, and stents were implanted in 76%. Multivessel angioplasty was performed in 25% of the patients, and abciximab was used in 35% of the cases. Mean time from the onset of symptoms to angioplasty was 7.4 +/- 3.1 hours. In-hospital survival was 58%, and was 54% at six months follow-up. CONCLUSIONS: Emergency coronary revascularization with primary angioplasty and intracoronary stenting is effective in patients with acute myocardial infarction and cardiogenic shock. TIMI flow >/= 2 is achieved in most patients, and mortality is reduced when compared with conservative treatment in historical series.

Analysis of Variance↗
PubMed1980

Twenty-five years of treatment of circulatory failure.

Over the last twenty-five years, the treatment of circulatory failure has been profoundly modified not only by the introduction of new therapeutic agents but also by considerable advances in the understanding of the circulation in the severely ill patient. The considerable hazards of increasing blood pressure by the administration of vasoconstrictive agents have been recognized and it has become obvious that the first step in the treatment of circulatory failure is to ensure adequate filling of the vascular compartment. If correction of the pre-load does not improve the circulation, positive inotropic agents may find their indication and may improve cardiac output. The increased myocardial oxygen demand, the development of tachycardia and dysrhythmias may limit their usefulness. In the presence of high filling pressures, inotropic agents may improve the circulation but often better results are obtained from the administration of vasodilators. Artificial circulatory support by aortic balloon counterpulsation may have to be used as a last resource. The difficulties encountered in the treatment of acute circulatory failure relate to the delicate balance between myocardial oxygen demand and supply. Inotropic agents enhance performance, increase heart rate, systolic pressure and oxygen demand. Conversely, vasodilators by decreasing diastolic pressure may also decrease oxygen supply. Thus, it is not surprising that the treatment of circulatory failure remains difficult.

Adrenergic beta-Agonists↗
PubMed2001

Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV.

OBJECTIVES: The goal of this study was to evaluate the safety and efficacy of surgical anterior ventricular endocardial restoration (SAVER). The procedure excludes noncontracting segments in the dilated remodeled ventricle after anterior myocardial infarction. BACKGROUND: Anterior infarction leads to change in ventricular shape and volume. In the absence of reperfusion, dyskinesia develops. Reperfusion by thrombolysis or angioplasty leads to akinesia. Both lead to congestive heart failure by dysfunction of the remote muscle. The akinetic heart rarely undergoes surgical repair. METHODS: A new international group of cardiologists and surgeons from 11 centers (RESTORE group) investigated the role of SAVER in patients after anterior myocardial infarction. From January 1998 to July 1999, 439 patients underwent operation and were followed for 18 months. Early outcomes of the procedure and risk factors were investigated. RESULTS: Concomitant procedure included coronary artery bypass grafting in 89%, mitral valve (MV) repair in 22% and MV replacement in 4%. Hospital mortality was 6.6%, and few patients required mechanical support devices such as intraaortic balloon counterpulsation (7.7%), left ventricular assist device (0.5%) or extracorporeal membrane oxygenation (1.3%). Postoperatively, ejection fraction increased from 29 +/- 10.4 to 39 +/- 12.4%, and left ventricular end systolic volume index decreased from 109 +/- 71 to 69 +/- 42 ml/m2 (p < 0.005). At 18 months, survival was 89.2%. Time related survival at 18 months was 84% in the overall group and 88% among the 421 patients who had coronary artery bypass grafting or MV repair. Freedom from readmission to hospital for congestive heart failure at 18 months was 85%. Risk factors for death at any time after the operation included older age, MV replacement and lower postoperative ejection fraction. CONCLUSIONS: Surgical anterior ventricular endocardial restoration is a safe and effective operation in the treatment of the remodeled dilated anterior ventricle after anterior myocardial infarction.

Adult↗
PubMed2001

The evolving management of acute right-sided heart failure in cardiac transplant recipients.

Avoidance of the clinical syndrome of acute right-sided heart failure after heart transplantation is, unfortunately, not possible. Clinical experience and the literature certainly suggest that a significant factor in the successful management of right ventricular (RV) failure is recipient selection. Moreover, threshold hemodynamic values beyond which RV failure is certain to occur and heart transplantation is contraindicated do not exist. Nor are there values below which RV failure is always avoidable. Acute RV failure will remain a difficult and ever-present clinical syndrome in the transplant recipient. Goals in the treatment of this clinical problem include: 1. Preserving coronary perfusion through maintenance of systemic blood pressure. 2. Optimizing RV preload. 3. Reducing RV afterload by decreasing pulmonary vascular resistance (PVR). 4. Limiting pulmonary vasoconstriction through ventilation with high inspired oxygen concentrations (100% FiO(2)), increased tidal volume and optimal positive end expiratory pressure ventilation. Inhaled nitric oxide is recommended before leaving the operating room in cases where the initial therapies have had little impact. Intra-aortic balloon counterpulsation is employed in patients with impaired left ventricular (LV) function and may be of benefit in patients with RV dysfunction resulting from ischemia, preservation injury or reperfusion injury. Optimal LV function reduces RV afterload and PVR. A proactive decision regarding RV assist device implantation is made before leaving the operating room and is highly dependent upon overall hemodynamics, size and function of the ventricles as seen on transesophageal echocardiography, renal function and surgical bleeding. Only through careful preoperative planning can this life-threatening condition be managed in the postoperative period.

Alprostadil↗
PubMed2002

Refractory angina pectoris: mechanism and therapeutic options.

As the survival of patients with primary coronary events continues to increase, the number of patients presenting with coronary artery disease unsuitable to further revascularization techniques and symptoms refractory to medical therapy also continues to rise. The aims of this review were to define the population of patients with refractory angina pectoris and to present the therapeutic options currently available for this condition. Refractory angina pectoris is defined, and traditional medical therapies are discussed. Then, current therapeutic options for patients with refractory angina are extensively reviewed. A multitude of therapeutic options exist for patients with refractory angina pectoris. Small, uncontrolled studies have shown a potential benefit for additional antiplatelet and antithrombotic therapy. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Enhanced external counterpulsation is a viable treatment option for select patients with refractory angina. In many randomized trials, laser revascularization has been shown to diminish angina symptoms, although no placebo-controlled studies exist to date. Gene therapy is a promising area of research in this field. Percutaneous in situ coronary venous arterialization is in its infancy, but may be able to treat many patients if proved successful. No data support the role of chelation therapy in this population. Heart transplantation remains a final option for these patients. Further research of the techniques mentioned in this review is warranted. The importance of randomized, double-blinded, placebo-controlled trials cannot be overemphasized, as the placebo effect of these therapies is probably marked.

Angina Pectoris↗
PubMed2003

Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial.

OBJECTIVES: The goal of this study was to describe the core laboratory angiographic findings of "SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK" (SHOCK) trial participants and to determine the relationship of angiographic parameters to one-year survival. BACKGROUND: In the SHOCK trial, emergency revascularization improved one-year survival of patients with cardiogenic shock compared with initial medical stabilization including thrombolysis and intraaortic balloon counterpulsation. METHODS: Coronary angiography was performed by protocol in 147 of 152 (97%) patients in the emergency revascularization (ERV) group and by clinical selection in 100 of 150 (67%) patients in the initial medical stabilization (IMS) group. Of the other 50 IMS patients, 45 of 50 (90%) died rapidly and did not undergo angiography. RESULTS: Left ventricular ejection fraction was correlated with one-year survival in both treatment groups (p < 0.001). In the IMS group, the hazard ratio for death was 2.59 (95% confidence interval 1.47 to 4.58, p = 0.001) per diseased vessel (0/1 vs. 2 vs. 3). In the ERV group, the hazard ratio for death per diseased vessel was 1.11 (95% confidence interval 0.79 to 1.56, p = 0.559). Multivariate analysis of the angiography cohort (without regard for left ventriculogram measurements) identified initial Thrombolysis in Myocardial Infarction flow grade (p = 0.032), number of diseased vessels (for IMS patients only, p = 0.024), and culprit vessel (p = 0.004) as independent correlates of one-year survival, even after adjustment for key clinical factors. In the smaller cohort with left ventricular ejection fraction measured (n = 97), ejection fraction and culprit vessel remained independently correlated with survival. CONCLUSIONS: For patients in cardiogenic shock, left ventricular function and culprit vessel were independent correlates of one-year survival.

Aged↗
PubMed1991

Percutaneous support devices for high risk or complicated coronary angioplasty.

Indications for coronary angioplasty have expanded to include patients with unstable acute ischemic syndromes, severe multivessel coronary artery disease and impaired left ventricular function. Several mechanical approaches have been developed as adjuncts to high risk coronary angioplasty to improve patient tolerance of coronary balloon occlusion and maintain hemodynamic stability in the event of complications. These percutaneous techniques include intraaortic balloon counterpulsation, anterograde transcatheter coronary perfusion, coronary sinus retroperfusion, cardiopulmonary bypass, Hemopump left ventricular assistance and partial left heart bypass. The intraaortic balloon pump provides hemodynamic support and ameliorates ischemia by decreasing myocardial work; it may be inserted for periprocedural complications or before angioplasty in patients with ischemia or hypotension. Anterograde distal coronary artery perfusion may be accomplished passively through an autoperfusion catheter or by active pumping of oxygenated blood or fluorocarbons through the central lumen of an angioplasty catheter. Synchronized coronary sinus retroperfusion produces pulsatile blood flow via the cardiac veins to the coronary bed distal to a stenosis. Both perfusion techniques limit development of ischemic chest pain and myocardial dysfunction in patients undergoing prolonged balloon inflations. Percutaneous cardiopulmonary bypass provides complete systemic hemodynamic support which is independent of intrinsic cardiac function or rhythm and has been employed prophylactically in very high risk patients before coronary angioplasty or emergently for abrupt closure. These and newer support devices, while associated with significant complications, may ultimately improve the safety of coronary angioplasty and allow its application to those who would otherwise not be candidates for revascularization.

Angioplasty, Balloon, Coronary↗
PubMed1992

Cardiogenic shock complicating acute myocardial infarction: the use of coronary angioplasty and the integration of the new support devices into patient management.

Conventional therapy for cardiogenic shock complicating acute myocardial infarction continues to be associated with a high in-hospital mortality rate. Hemodynamic support with new mechanical devices and emergency coronary revascularization may alter the long-term prognosis for patients with this complication. Between July 1985 and March 1990, 68 patients presented to the University of Michigan with acute myocardial infarction and cardiogenic shock. Interventions performed included thrombolytic therapy (46%), intraaortic balloon pump counterpulsation (70%), cardiac catheterization (86%), coronary angioplasty (73%), emergency coronary artery bypass grafting/ventricular septal defect repair (15%), Hemopump insertion (11%), percutaneous cardiopulmonary support (4%) and ventricular assist device (3%). The 30-day survival rate was significantly better in patients who had successful angioplasty of the infarct-related artery than in patients with failed angioplasty (61% vs. 7%, p = 0.002) or no attempt at angioplasty (61% vs. 14%, p = 0.003). This difference was maintained over the 1-year follow-up period. The only clinical variable that predicted survival was age less than 65 years. The early use of the new support devices in 10 patients was associated with death in 8 (80%), but this poor outcome may reflect a selection bias for an especially high risk population. Collectively, these recent data continue to suggest that emergency revascularization with angioplasty may reduce the mortality rate, but further study is required to define optimal utilization and integration of new support devices.

Aged↗
PubMed1983

Unstable angina with episodic ST segment elevation and minimal creatine kinase release culminating in extensive, recurrent infarction.

The syndrome of episodic angina at rest, recurrent ST segment elevation (mean = 9 mV) and nontransmural infarction characterized by minimal serum creatine kinase (CK) (mean 243 IU; upper normal limit 132 IU) was studied in 15 patients who presented with these findings. All were initially managed with intensive nitrate and beta-receptor blocker therapy. Eleven patients underwent intraaortic balloon counterpulsation for refractory angina and 13 underwent cardiac catheterization. High grade (greater than or equal to 90%) stenosis of the proximal left anterior descending coronary artery was demonstrated in 11 patients, and coronary spasm without significant, fixed occlusive disease was noted in 2 patients. Urgent aortocoronary bypass surgery was performed in seven patients with recurrent pain or electrocardiographic injury, or both, unresponsive to maximal medical therapy. The initial mean ST segment elevation and CK elevation for this group was 10 mV and 232 IU, respectively. No surgical patient developed recurrent infarction; there was one late death after reoperation. Eight patients whose condition stabilized initially on medical therapy did not undergo urgent surgery. However, five subsequently developed large transmural anterior reinfarction despite intensive medical therapy, and three died from pump failure. These patients on medical therapy did not differ from the surgical group in magnitude of ST segment elevation or increase in serum CK. Their initial mean ST segment elevation and CK elevation were 8 mV and 254 IU, respectively (difference not significant). Thus, repetitive episodes of rest angina with marked anterior wall ST segment elevation and mild CK elevations may define a subset of patients who appear to progress rapidly from minimal nontransmural necrosis to massive transmural infarction. Prompt recognition of this syndrome, followed by cardiac catheterization and urgent aortocoronary bypass surgery, may prevent extensive cardiac muscle loss.

Adult↗
PubMed1984

Acute nifedipine withdrawal: consequences of preoperative and late cessation of therapy in patients with prior unstable angina.

Reports of acute ischemic events after withdrawal of calcium antagonist therapy in outpatients and during bypass surgery in patients with prior angina at rest prompted the examination of the effect of nifedipine withdrawal in 81 patients who had completed a prospective, double-blind randomized trial of nifedipine versus placebo for rest angina. Thirty-nine patients underwent bypass surgery for uncontrolled angina or left main coronary artery disease. No significant difference between patients withdrawn from nifedipine or placebo was seen in the incidence of perioperative myocardial infarction, hypotension requiring intraaortic balloon counterpulsation, vasopressor or vasodilator requirements or incidence of significant arrhythmias. An additional 42 patients had completed 2 years on a protocol consisting of nitrates and propranolol in addition to nifedipine or placebo. During a mean of 66 hours of continuous monitoring after withdrawal of nifedipine or placebo, heart rate and blood pressure were unchanged. A worsening of previously present angina at rest occurred in five patients who had continued to experience rest angina before drug withdrawal, four of whom were withdrawn from nifedipine. No patient with class I to III angina experienced new onset of rest angina during drug withdrawal. No patient experienced myocardial infarction. There was no significant difference between patients withdrawn from nifedipine or placebo in the duration or frequency of ischemic ST changes on continuous electrocardiographic monitoring, or in duration or positive results of serial exercise treadmill testing. Thus, no early adverse effects of acute nifedipine withdrawal were found in patients with prior rest angina at the time of bypass surgery or in stable patients receiving long-term medical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Angina Pectoris↗