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PubMedDate not supplied

[Unstable coronary disease--clinical course and significance of exercise tests in patients with left coronary artery stenosis].

This study aimed at evaluating predictive value of exercise tests in case of left coronary artery stenosis. The study involved 57 patients with left coronary artery stenosis, including 10 patients with isolated left main stenosis (group X), and 47 patients with left coronary artery stenosis and multivessel involvement (group Y). Unstable angina was staged according to Booth et al. classification as type I or II. Exercise tests were performed according to Bruce's protocol. Unstable angina of type I was diagnosed in 51 (89%) patients, and type II in 6 (11%) patients. Electrocardiographic evidence of myocardial ischemia both et rest and anginal pain was seen in 46 (80%) patients. Electrocardiographic recording was within normal limits in 11 (20%) patients at rest. Clinical and ECG improvement was seen in 38 (66%) patients. Exercise tests in all of these patients were positive at low load work--mean 50 W. The obtained results suggest that patients with left coronary stenosis constitute heterogenous group. Therefore, prediction of the left main stenosis on the clinical ground alone is impossible. Exercise tests producing positive results at low load indicate with high probability critical multivessel lesions and/or left main stenosis in such patients.

Adult↗
PubMed1994

[The exercise-recovery loop and exercise slope of ST segment changes/heart rate in the diagnosis of coronary disease and restenosis after angioplasty].

This study addresses the diagnostic value of two new criteria of exercise stress testing for primary coronary artery disease and restenosis after angioplasty: the slope of the linear relation between ST segment changes and heart rate during exercise; the exercise-recovery loop (clockwise direction in normal subjects and anticlockwise direction in coronary patients). These two criteria were compared with the standard diagnostic criteria (horizontal or descending ST segment depression greater than 1 mm or ascending ST segment depression greater than 2 mm) in 125 patients with suspected coronary artery disease who underwent computerised exercise stress testing and coronary angiography (30 single, 31 double and 30 triple vessel disease; 34 without significant stenosis) and in 24 patients with single vessel disease who underwent successful angioplasty and who performed exercise stress testing before, immediately after and 6 months after angioplasty before routine control coronary angiography. The sensitivity (Se), specificity (Sp), positive predictive value (PPV) of the exercise-recovery loop for the diagnosis of coronary disease were 81 %, 82 %, 89 %, respectively, versus 69 %, 71 % and 88 % for the standard criteria. The detection of restenosis by these criteria also appeared to be better (71 %, 91% and 91 % versus 46 %, 63 % and 60 %, respectively). However, for the classical threshold value of 2.4 mv/beat/min, the ST/HR criteria seemed to be less useful (Se : 80 %, Sp : 26 %).

Adult↗
PubMed1992

[Ventricular extrasystole and coronary disease: to treat or not to treat?].

The prognostic significance of ventricular premature beats (VPB) and their proper management are still a subject of controversy, particularly since during the last few years a number of publications have raised doubts as to the effectiveness and safety of antiarrhythmic drugs. An appropriate assessment of the VPB must consider: 1) electrocardiographic characteristics. 2) Associated symptoms. 3) Presence or absence of underlying disease, and 4) Ventricular function (VF). On this basis VPB may be classified as "Benign" (isolated; asymptomatic; mild or absent cardiopathy, and preserved VF); "Hazardous" (presence of complex VPB; with or without symptoms, and recognized organic heart disease), and "Malignant" (complex VPB and ventricular tachyarrhythmias; symptomatic cardiac disease, and compromised VF). Antiarrhythmic drugs are indicated for "Hazardous" and "Malignant" VPB. However, selection and efficacy must be documented by objective testing (Holter, stress, plasma levels). When utilized in well defined groups of patients, with reduction in the hourly number of VPB (more than 50-70%) and mainly of complex forms, there is clear benefit in terms of long-term survival, including coronary disease and congestive heart failure.

Anti-Arrhythmia Agents↗
PubMed1990

[Natural and postoperative course of coronary disease in late observations: prognostic value of clinical indicators and invasive and non-invasive studies].

The results of a prospective study in 301 patients (pts) with angiographically documented coronary artery disease are presented. The mean follow-up period was 30 +/- 14 months, the mean age of pts was 48 +/- 9 years. A prognostic significance of 37 indicators obtained from clinical, hemodynamical, angiographical and noninvasive studies was investigated. In the group of pts treated medically (n = 202) the natural history of disease was defined by the following indicators: history of myocardial infarction, congestive heart failure, NYHA functional class III and IV, frequent ventricular premature depolarizations (VPD), abnormal ecg at rest, QT greater than QS2 index, left ventricular (LV) ejection fraction less than 50%, elevation of LV end-diastolic pressure and LV end-diastolic volume index LV wall motion abnormalities in particular dyskinesia, left main coronary artery disease and three vessel coronary artery disease. In a multivariate Cox model analysis, the independent correlates of long-term survival were frequency of VPD (p less than 0.001), NYHA functional class III-IV (p less than 0.003), QT greater than QS2 index (p less than 0.01), LV ejection fraction (LVEF) less than 50% (p less than 0.02). The combination of two indicators: LVEF less than 50% and QT greater than QS2 identify pts with high mortality rate (31%) during a two year follow-up period as compared with only 1% in the group with LVEF greater than or equal to 50% and QT less than or equal to QS2. The different clinical and hemodynamical characteristics of both the groups of pts treated medically or surgically made a reliable comparison of those two methods of treatment impossible.

Adult↗
PubMed2002

Clinical relevance of left ventricular volume assessment by gated myocardial SPET in patients with coronary artery disease.

Coronary artery disease (CAD) is the leading cause of mortality in the Western world. Multiple parameters have been investigated to predict prognosis in CAD patients. The prognostic value of the left ventricular ejection fraction (LVEF) in patients with CAD is well established. More recently, left ventricular (LV) volumes have also shown prognostic value. Due to the favourable imaging characteristics of technetium-99m (high count density), the development of (99m)Tc-labelled myocardial perfusion tracers has made it possible to perform an electrocardiogram-gated acquisition during routine myocardial perfusion imaging. This enables assessment of LVEF and LV volumes during myocardial perfusion scintigraphy. This review considers the possible prognostic abilities of LV volume assessment by gated cardiac SPET.

Cardiac Volume↗
PubMed2005

Relationship among epicardial coronary disease, tissue myocardial perfusion, and survival in heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy continues to represent the major limitation to long-term cardiac allograft survival. Routine angiography and intravascular ultrasound fall short in their ability to detect microcirculatory aberrations. Thrombolysis in myocardial infarction (TIMI) myocardial perfusion grades (TMPG) have been used as a measure of microvascular circulation in patients treated for acute myocardial infarction. We studied the correlation of epicardial coronary anatomy with microvascular flow as determined by TMPG and correlated it with patient outcome. METHODS: We enrolled 66 consecutive cardiac transplant recipients (49 men; mean age 52 +/- 13 years; range 15-70 years) undergoing surveillance coronary angiogram during a 9-month period. All angiograms were interpreted for epicardial coronary anatomy by an independent investigator. Another investigator, blinded for clinical data and angiogram interpretation, interpreted TMPGs. TMPG 0 was defined as no apparent tissue-level perfusion; TMPG 1 indicated presence of myocardial blush but no clearance from the microvasculature; TMPG 2 blush cleared slowly; and TMPG 3 indicated that blush began to clear during washout (blush is minimally persistent after 3 cardiac cycles of washout). Cardiac deaths served as the primary outcome variable. RESULTS: Fifty-eight of 66 patients had an abnormal TMPG. Mean TMPG in all these patients was 4.2 +/- 3 (normal is 9). Forty-four patients (Group A) with no angiographic coronary narrowing had TMPG 4.81 +/- 3.1, and 22 patients (Group B) with epicardial coronary narrowing 40% of lumen diameter had TMPG 3.0 +/- 2.5 (p = 0.007). There was no difference in TMPG related to the coronary territory involved. At a mean follow-up of 30 +/- 2.5 months, 6 (13.6%) of 44 patients in Group A had died, and 7 (31.8%) of 22 in Group B had died (p < 0.03). CONCLUSIONS: Microcirculatory aberrations as assessed by tissue TMPG is abnormal across all coronary territories in cardiac transplant recipients and associated with poor survival, suggesting a generalized microvascular involvement even in the presence of a normal angiogram. Patients with focal epicardial coronary narrowing have significantly greater decline in tissue perfusion, independent of the coronary territory involved, and exhibit poor survival compared with patients without epicardial coronary disease.

Adolescent↗
PubMed2005

Evaluation of the patient with diabetes mellitus and suspected coronary artery disease.

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. In fact, patients with diabetes have the same risk of myocardial infarction as do nondiabetic subjects with a history of infarction. For this reason, diabetes has been designated by the American College of Cardiology (ACC) and the American Heart Association (AHA) as a CAD equivalent. For women, data indicate a substantially elevated risk of cardiovascular disease (CVD) even before a clinical diagnosis of type 2 diabetes has been made. Identifying patients with diabetes who have CAD and who will benefit from medical and/or invasive intervention to prevent cardiovascular events is a challenge in both symptomatic and asymptomatic patients. The decision to evaluate patients with diabetes who are asymptomatic for CAD presents the greatest challenge; investigation will reveal 10% to 15% of these patients to have CAD. Current diagnostic tools include exercise tolerance testing, stress echocardiography, stress myocardial perfusion imaging (MPI), and cardiac catheterization. Few guidelines are available to aid in the choice of testing modalities for a given patient. Although cardiac catheterization is useful, it is generally reserved for patients in whom invasive intervention is suitable. The American Diabetes Association (ADA) recommends exercise tolerance testing alone in symptomatic patients with > or = 2 CAD risk factors or an abnormal resting electrocardiogram (ECG). However, that recommendation is not based on data; it is the consensus of an expert panel. Stress echocardiography is a useful, noninvasive procedure; however, there is limited experience with this technology in the diabetic population. Recently accumulated data support both diagnostic and prognostic roles for stress MPI, particularly with ECG-gated single-photon emission computed tomographic imaging. In symptomatic patients with diabetes, the presence and extent of abnormal stress MPI findings have been found to be highly accurate independent predictors of subsequent cardiac events: 18% to 26% of asymptomatic patients with diabetes have perfusion defects consistent with CAD. However, CVD risk factors are not predictive of abnormal MPI findings even though duration of diabetes and abnormal ECGs are. The results of future studies may be helpful in guiding the selection of asymptomatic patients to undergo myocardial perfusion and function studies. In conclusion, MPI provides clinicians with an important diagnostic tool, because it offers perfusion as well as functional information for diagnosis and risk stratification in patients with diabetes. These capabilities facilitate decision making regarding the appropriateness of medical therapy or surgical intervention in these individuals.

Cardiac Catheterization↗
PubMed2001

Off-pump bypass grafting is safe in patients with left main coronary disease.

BACKGROUND: Because of a concern about the ability to tolerate beating heart grafting, patients with left main coronary artery stenosis have been excluded from off-pump bypass. We reviewed our experience with off-pump coronary artery bypass grafting for patients with left main coronary artery disease. METHODS: Eight hundred twenty-three patients underwent bypass grafting for left main coronary artery disease from January 1998 to October 1999. One hundred patients were revascularized without the use of cardiopulmonary bypass and compared with a contemporaneous cohort of 723 patients who underwent grafting with the aid of cardiopulmonary bypass. All patients had multivessel grafting performed through a sternotomy. RESULTS: There was one death (1%) in the group undergoing off-pump grafting as compared with a 30-day mortality of 4.7% (p = 0.059) in the on-pump group. Univariate analysis established that patients revascularized without cardiopulmonary bypass were significantly less likely to require postoperative inotropic support (23% versus 62%, p < 0.001) and transfusion (35% versus 67%, p < 0.001). Logistic regression analysis revealed that cardiopulmonary bypass was an independent risk factor for mortality (odds ratio, 7.3; 95% confidence interval, 1.34 to 138.4). CONCLUSIONS: Coronary artery bypass grafting using off-pump techniques are safe and effective in left main coronary artery disease.

Adult↗
PubMed1996

Alcohol, coronary disease, and hypertension.

Disparities in the relationships between alcohol consumption and various cardiovascular conditions are now evident, with complex interrelationships between conditions. An inverse relationship of alcohol use to coronary heart disease is supported by many population studies. Interpretation of these data as a protective effect of alcohol against coronary disease is strengthened by plausible mechanisms. Although some experimental data suggest the hypothesis that wine, in particular, has additional protective benefit, prospective studies show no consensus on this point. Strong, consistent epidemiologic data support a relationship of heavier drinking to hypertension. Intervention studies show a pressor effect of alcohol, which appears and regresses within several days, but a mechanism has not yet been established. As with most aspects of alcohol and health effects, the data do not suggest monotonic relationships of alcohol with these conditions. Thus, amount of alcohol taken is a crucial consideration. Advice to concerned persons needs to take into account individual factors in drinkers or potential drinkers.

Alcohol Drinking↗