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AIM: To explore the safety and feasibility of coronary angioplasty and stenting via the radial artery in a heterogenous group of patients and to report the immediate and 3-month clinical follow-up. BACKGROUND: The use of the transradial approach for coronary angiography was first described by Lucien Campeau in 1989. Based on the favourable initial results, this technique has gained widespread acceptance worldwide. Ferdinand Kiemeneij's work in transradial angioplasty and stenting has taken invasive cardiology into the exciting new era of "minimally invasive coronary intervention". METHODS AND RESULTS: Fifty consecutive patients underwent Transradial Percutaneous Transluminal Coronary Angioplasty (PTCA) with or without stenting from mid March 98-December 98. The right radial approach was utilised in 41 patients (80%) while the left in 9 patients. Ninety percent of the procedures was done on an adhoc basis. Diabetes mellitus was present in 38% of patients. Eighty percent of patients had unstable angina pectoris and 60% had a prior history of acute myocardial infarction. The commonest vessel involved was the LAD (51%) and type B lesions predominated (54%). PTCA was successful in 96%. One patient had a total LAD occlusion, which could not be wired, and another developed severe spasm during catheter manipulation. The latter had successful PTCA via the right femoral route Stents were utilised in 57% of patients. The commonest indication for stenting was suboptimal PTCA results (89%) and dissection (14%). There was no stent embolisation and all stents were successfully deployed (100%). One patient developed acute stent thrombosis necessitating repeat PTCA and another patient sustained an acute anteroseptal myocardial infarction 5 days post procedure as a result of subacute stent thrombosis and died. Two patients had successful primary PTCA. There was no bleeding or vascular complications. 60% of patients were treated on an outpatient basis. At 3-months follow up, 1 patient required CABG's for disease progression. Three patients had absent radial pulses without adverse consequence. No patient required repeat PTCA at follow up. CONCLUSION: In summary, adhoc PTCA and stenting is safe and feasible in our patient population. A study on the cost effectiveness of the procedure compared to conventional femoral PTCA is warranted.
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This retrospective study illustrates our approach to this problem over the years, from performing subclavian flap aortoplasty initially to the more accepted procedure now, which is resection and end-to-end anastomosis. Coarctation of aorta in our population is seen in a varying age groups and are also associated with other cardiac anomalies including both acyanotic and cyanotic congenital cardiac defects. Therefore a wide variety of surgical procedures were performed including resection of the coarcted segment and end-to-end anastomosis, subclavian flap aortoplasty, patch aortoplasty and synthetic tube graft interposition. Subclavian flap aortoplasty is not widely practised anymore in favour of resection with end-to-end anastomosis. Fifty four point four percent of patients had isolated coarctation, 10.5% had associated valvular defects, 28.1% had other simple congenital defects and 7.0% had associated complex cyanotic congenital defects. Perioperative mortality was 5.26% and is correlated with the younger age of patients at time of surgery and severity of cardiac failure at time of presentation. We did not see any difference in mortality for patients with complex congenital disease or between the different surgical procedures. However, we did find that in the early period when resection with end-to-end anastomosis was performed, there was a significantly higher incidence of morbidities.
BACKGROUND: Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, < 50% stenosis) coronary artery disease (CAD) is frequently reported. Few data exist regarding the type and intensity of resource consumption in women with chest pain after coronary angiography. METHODS AND RESULTS: A total of 883 women referred for coronary angiography were prospectively enrolled in the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation (WISE). Cardiovascular prognosis and cost data were collected. Direct (hospitalizations, office visits, procedures, and drug utilization) and indirect (out-of-pocket, lost productivity, and travel) costs were estimated through 5 years of follow-up. Among 883 women, 62%, 17%, 11%, and 10% had nonobstructive and 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Five-year cardiovascular death or myocardial infarction rates ranged from 4% to 38% for women with nonobstructive to 3-vessel CAD (P < 0.0001). Five-year rates of hospitalization for chest pain occurred in 20% of women with nonobstructive CAD, increasing to 38% to 55% for women with 1-vessel to 3-vessel CAD (P < 0.0001). The volume of repeat catheterizations or angina hospitalizations was 1.8-fold higher in women with nonobstructive versus 1-vessel CAD after 1 year of follow-up (P < 0.0001). Drug treatment was highest for those with nonobstructive or 1-vessel CAD (P < 0.0001). The proportion of costs for anti-ischemic therapy was higher for women with nonobstructive CAD (15% versus 12% for 1-vessel to 3-vessel CAD; P = 0.001). For women with nonobstructive CAD, average lifetime cost estimates were $767,288 (95% CI, $708,480 to $826,097) and ranged from $1,001,493 to $1,051,302 for women with 1-vessel to 3-vessel CAD (P = 0.0003). CONCLUSIONS: Symptom-driven care is costly even for women with nonobstructive CAD. Our lifetime estimates for costs of cardiovascular care identify a significant subset of women who are unaccounted for within current estimates of the economic burden of coronary heart disease.
The National Heart Institute, now known as the National Heart, Lung and Blood Institute (NHLBI), initiated its first multicentre randomized clinical trials of rheumatic fever and rheumatic heart disease in 1951. The modern era of multicentre trials began, however, when the Coronary Drug Project was initiated in the 1960s. This trial and subsequent NHLBI trials stimulated a wide variety of research on clinical trial methodology. This paper reviews early methodologic developments in four areas. First, an organizational structure for multicentre clinical trials was developed and codified in the 'Greenberg Report' in 1967. Second, design considerations related to patient risk, non-compliance, a lag in treatment effect, and changing risk were explored. The 'intention-to-treat' principle was implicit in these investigations. Thirdly, the concept of periodic review of accumulating data, recommended in the Greenberg report, stimulated research on methods for sequential analysis. Three statistical approaches were developed and investigation of their statistical properties continues today. These approaches are usually described as group sequential, stochastic curtailment, and Bayesian methods. Finally, comparison of treatments in longitudinal studies has been an increasing part of NHLBI research and methods have been developed for design and analysis of longitudinal studies.
Gaston, Lamont W. (National Heart Institute, National Institutes of Health, Bethesda, Md.) and E. R. Stadtman. Fermentation of ethylene glycol by Clostridium glycolicum, sp. n. J. Bacteriol. 85:356-362. 1963.-An anaerobic organism which utilizes ethylene glycol as a source of energy and carbon has been isolated from mud. It is a long (5 mu), slender, motile, gram-positive, spore-forming rod, with peritrichous flagellae. It grows well from 22 to 37 C at pH 7.4 to 7.6, and ferments glucose, fructose, sorbitol, dulcitol, and cellulose. It does not reduce nitrates, form indole, or cause hemolysis or proteolysis except for a slight attack on coagulated egg albumin. Fifteen amino acids and the vitamins biotin and pantothenate are required for optimal growth on ethylene glycol. Analogues other than propylene glycol do not support growth. Ethylene glycol and propylene glycol are stoichiometrically converted to equal amounts of the respective acid and alcohol.
Hardman, John K. (National Heart Institute, National Institutes of Health, Bethesda, Md.) and Thressa C. Stadtman. Metabolism of omega-amino acids. V. Energetics of the gamma-aminobutyrate fermentation by Clostridium aminobutyricum. J. Bacteriol. 85:1326-1333. 1963.-Clostridium aminobutyricum utilizes gamma-aminobutyrate as its sole carbon, nitrogen, and energy source, producing ammonia, acetate, and butyrate as a result of this fermentation. Coenzyme A (CoA)-transferase, phosphotransacetylase, and acetokinase activities have been demonstrated in crude extracts of the organism; the coupling of the reactions catalyzed by these enzymes to the fermentation reactions provides a mechanism whereby C. aminobutyricum can obtain energy, in the form of adenosine triphosphate, from the decomposition of gamma-aminobutyrate. Indirect evidence of additional phosphorylation, at the electron-transport level, has been obtained from molar growth yield studies and from the inhibition by 2,4-dinitrophenol of butyrate synthesis from gamma-aminobutyrate and from crotonyl-CoA.
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This meeting was organized by Professors Peter Barnes (National Heart & Lung Institute, London, UK) and Neil Pride (National Heart and Lung Institute, London, UK) to highlight the major health problems caused by chronic obstructive pulmonary disease (COPD). It also addressed the efficacy of existing therapeutic approaches as well as examining progress in developing novel classes of therapeutic agents and in improving our understanding of the disease. This well organized meeting was attended by approximately 100 delegates, the majority of whom were chest physicians, with a significant number of delegates from the pharmaceutical industry. In turn, the sessions addressed the definition and pathophysiology of the disease, the development of methodology suitable for performing clinical studies and then various therapeutic approaches culminating with lectures describing the potential of phosphodiesterase (PDE) 4 inhibitors.
The National Heart, Lung, and Blood Institute is currently sponsoring a multicenter clinical trial to evaluate the long-term efficacy of partial ileal bypass in the prevention of recurrent myocardial infarction in hypercholesterolemia patients. Thus we felt that a report of our clinical results with this intervention at the Montreal Heart Institute during the last 11 years would be of interest. Twenty patients with type II hyperlipoproteinemia and a mean age of 38 (range 25-54) years underwent partial ileal bypass between March 1971 and April 1978. This intervention was associated with aortocoronary bypass surgery in 11 patients. All patients were followed at regular intervals. The mean survival time was 70.7 (range 1-123) months. Two deaths were observed during follow-up, one from an acute myocardial infarction and the other from ventricular fibrillation, respectively, 1 month and 1 and one-half years after partial ileal bypass. The ileal bypass was undone twice because of gastrointestinal problems including a malabsorption syndrome and repeated episodes of subocclusion. A progressive decrease of the effects of the operation on serum cholesterol was noted, from a 33 per cent reduction at 3 months to 43 per cent at 2 years and 16 per cent at 6 years. Two patients presented an acute myocardial infarction respectively 3 and 4 years after the operation, respectively, and one patient suffered a right-sided hemiplegia at age 30, 12 months after the operation. Of 14 patients with angina pectoris preoperatively (class III in 10), eight remained symptomatic postoperatively (class I and II angina in five).(ABSTRACT TRUNCATED AT 250 WORDS)
Since its creation as the National Heart Institute in 1948, the National Heart, Lung, and Blood Institute (NHLBI) has led a national biomedical research program in heart, lung, blood, and blood vessel diseases, and has become increasingly involved in complex clinical trials to validate its research findings. In addition, NHLBI sponsors demonstrations and educational activities to apply proved research findings in the health care community. NHLBI's approach to these responsibilities involves acquiring new and basic information, testing and evaluating the information, and applying it to improve prevention, detection, and treatment of disease. New equipment such as the heart-lung machine and the pacemaker, better diagnostic procedures, new operative and treatment devices, new drugs, and increased use of preventive medicine have dramatically reduced mortality from heart attack, hypertension and stroke.
This manuscript is a summary of a comprehensive report dealing with asthma and pregnancy issued by the working group on Asthma and Pregnancy, National Institutes of Health (NIH), National Heart, Lung, and Blood Institute. The report was developed by a panel of obstetricians, pharmacologists, internists, allergists, and pulmonologists, who met over an 18-month period under the auspices of the NIH. Undertreatment of pregnant asthmatics, partially because of unfounded fears of adverse pharmacologic effects on the developing fetus, remains the major problem in the management of asthma during pregnancy in the United States. The four key components of asthma management during pregnancy are: 1) objective assessment of maternal lung function and fetal well-being, 2) avoidance or control of environmental precipitating factors, 3) pharmacologic therapy, and 4) patient education.
Martin Rodbell, recipient of the Nobel Prize in Physiology or Medicine in 1994, passed away 7 December 1998 after a long illness. Rodbell had a long and distinguished career in research and senior leadership positions at the National Institutes of Health. At different times in his career, he conducted research at the National Heart Institute, the National Institute of Arthritis and Metabolic Diseases (NIAMD), and the National Institute of Environmental Health Sciences (NIEHS). He served as Scientific Director of the NIEHS from 1985 to 1989. In 1994 he shared the Nobel Prize in Physiology or Medicine with Alfred Gilman, Professor and Chairman in the Department of Pharmacology at University of Texas Southwestern Medical Center in Dallas, for their work on G-proteins, a key component of the communication system that regulates cellular activity. Rodbell was the fifth NIH intramural scientist to be awarded a Nobel Prize.