Search

Introduction: Multiple pharmacologic therapies have been studied to prevent recurrence in patients with vasovagal syncope. Multiple head to head comparisons have been done with varying results. We aimed to perform a network meta-analysis to assess the efficacy of pharmacologic therapies in preventing recurrent syncope in patients with vasovagal syncope. Methods: A systematic review of the literature was performed to identify randomized controlled trials describing recurrence of vasovagal syncope after initiation of pharmacologic treatment in patients with syncope who had a baseline positive tilt table test. A Bayesian network meta-analysis was conducted utilizing the geMTC package available for R: A Language and Environment for Statistical Computing. Results: None of the included pharmacological therapies were found to significantly reduce the recurrence of vasovagal syncope when compared to placebo. When compared to one another atenolol did offer significant reduction in syncopal episodes when compared to cafedrine. Dihydroergotamine ranked the highest while cafedrine ranked the lowest. Conclusions: Pharmacologic therapies do not offer significant reduction in recurrence of vasovagal syncope. First line therapy for these patients should include lifestyle changes such as increased fluid intake, and when appropriate, increased salt intake.

The cholesteryl ester transfer protein (CETP) is a plasma protein that plays an important role in the transfer of lipids between plasma lipoproteins. The CETP inhibitors have been widely studied as a pharmacologic therapy to target plasma cholesterol in order to reduce the risk of atherosclerotic cardiovascular disease . Using CETP inhibitors as cholesterol modifiers was based on the genetic research that found correlations between CETP activity and cholesterol levels. Although CETP inhibitors are successful at altering targeted cholesterol markers, recent phase 3 outcome trials have shown limited benefit on cardiovascular outcomes when combined with the current standard of care. We discuss the science of CETP inhibition, compare the CETP inhibitors developed (torcetrapib, evacetrapib, dalcetrapib, and anacetrapib), the findings from the CETP inhibitor trials, and the future outlook for CETP inhibitors in cholesterol modification.

Conventional coronary angiography (CA) with static imaging is limited by the ability to properly select the optimal acquisition angle, vessel foreshortening, and significant radiation exposure. Rotational coronary angiography (RA) acquires coronary images in a multitude of viewing angles during a single injection by means of a moving gantry that rapidly completes a predefined arc. This study compares procedural characteristics of CA and RA. Electronic search of databases such as OVID, Medline, and PubMed was conducted to identify studies comparing procedural characteristics of CA and RA. End points for analysis included contrast volume, radiation dose by dose area product, radiation dose by air kerma, fluoroscopy time, and procedure time. Studies were assessed for quality and bias and were included if they compared coronary imaging of both the right and left coronary systems with CA and RA, included one of the end points of interest, and were in English. A total of 11 studies consisting of 940 patients who underwent RA and 976 who underwent CA were included in the final analysis. Contrast volume, radiation dose by dose area product, and radiation dose by air kerma were all found to be significantly lower with RA compared with CA. There was a statistically significant increase in fluoroscopy time, although this was not clinically significant, and there was no difference in procedure time. RA angiography is a feasible alternative to CA and offers reductions in contrast used and radiation exposure.

An increasing number of patients with congenital heart disease are now surviving into adulthood. This has also led to the emergence of complications from the underlying congenital heart disease, related surgical interventions, and associated combordities. While the prevalence of particular arrhythmias with specific congenital heart disease has been previously described, a detailed analysis of all lesions and a large number of comorbidities has not been previously published.Admissions with congenital heart disease were identified in the National Inpatient Sample. Associated comorbidities were also identified for these patients. Univariate analysis was done to compare those risk factors associated with specific arrhythmias in the setting of congenital heart disease. Next, regression analysis was done to identify what patient characteristics and comorbidities were associated with increased risk of specific arrhythmias.A total of 52,725,227 admissions were included in the analysis. Of these, 109,168 (0.21%) had congenital heart disease. Of those with congenital heart disease, 27,088 (25%) had an arrhythmia at some point. The most common arrhythmia in those with congenital heart disease was atrial fibrillation, which was noted in 86% of those with arrhythmia followed by atrial flutter which was noted in 20% of those with congenital heart disease. The largest burden of arrhythmia was found to be in those with tricuspid atresia with a 51% prevalence of arrhythmia in this group followed by Ebstein anomaly which had an arrhythmia prevalence of 39%. Increasing age, male gender, double outlet right ventricle, atrioventricular septal defect, heart failure, obstructive sleep apnea, transposition of the great arteries, congenitally corrected transposition, and tetralogy of Fallot were frequently noted to be independent risk factors of specific arrhythmias.Approximately, 25% of adult admissions with congenital heart disease are associated with arrhythmia. The burden of arrhythmia varies by the specific lesion and other risk factors as well. Understanding of these can help in risk stratification and can help devise strategies to lower this risk.

Pawan D Patel, Rohit R AroraDepartment of Cardiology, Chicago Medical School, North Chicago, IL, USAAbstract: Chronic stable angina is a debilitating illness affecting at least 6.6 million US residents. Despite being optimally treated by pharmacotherapy and revascularization up to 26% of patients still experience angina. Diabetes mellitus is a common co-morbid condition in angina patients. Several new investigational medications are being tested for chronic angina. Advances in understanding of myocardial ischemia have prompted evaluation of a number of new antianginal strategies. In this review we discuss the utility of ranolazine, a recently approved novel antianginal agent and its efficacy in the diabetic patient population. In addition to its antianginal action in diabetic patients with chronic angina, ranolazine may have favorable effects on glycated hemoglobin levels.Keywords: chronic stable angina, antianginal, ranolazine, diabetes mellitus, glycated hemoglobin

Background: So-called heterotaxy, better called bodily isomerism, is associated with increased frequency of thrombocytosis and thromboembolic events in childhood. This is likely mediated by splenic dysfunction present with isomerism. Data for adults with isomerism is lacking with a paucity of data regarding thrombosis and isomerism. This study aimed to determine the risk of thrombocytosis and thromboembolic events in adults with isomerism. Methods: The 2012 iteration of the Nationwide Inpatient Sample was used. International classification of disease codes were used to identify admissions associated with isomerism, thrombocytosis, and thromboembolic events. Chi-square analysis was conducted to determine factors associated with thrombocytosis and various thromboembolic events. Logistic regression was used to estimate the adjusted odds ratio of isomerism. Results: A total of 6,907,109 admissions were included, 861 of which had isomerism. Thrombocytosis was equally prevalent in those with and without isomerism with a frequency of 0.1%. Acute thromboembolic events were equally prevalent in both groups as well, with lower extremity thromboembolic events being most prevalent in both. Older age and male gender were both independent risk factors for thromboembolic events but not isomerism. Conclusion: Thrombocytosis and acute thromboembolic events are not more common in those with isomerism. They do, however, occur at a younger in those with isomerism and are associated with increased length and cost of hospitalization.

Children born with congenital malformations of the heart are increasingly surviving into adulthood. This population of patients possesses lesion-specific complication risks while still being at risk for common illnesses. Bodily isomerism or heterotaxy, is a unique clinical entity associated with congenital malformations of the heart which further increases the risk for future cardiovascular complications. We aimed to investigate the frequency of myocardial infarction in adults with bodily isomerism.We utilized the 2012 iteration of the Nationwide Inpatient Sample to identify adult inpatient admissions associated with acute myocardial infarction in patients with isomerism. Data regarding demographics, comorbidities and various procedures were collected and compared between those with and without isomerism.A total of 6,907,109 admissions were analyzed with a total of 172,394 admissions being associated with an initial encounter for acute myocardial infarction. The frequency of myocardial infarction did not differ between those with and without isomerism and was roughly 2% in both groups. Similarly, the number of procedures and in-hospital mortality did not differ between the two groups.The frequency and short-term prognosis of acute myocardial infarction is similar in patients with and without isomerism.

Since their discovery in the 1980s, angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease angiotensin formation, prevent breakdown of bradykinin, and may also act on peptides of the renin-angiotensin system. They are effective in reducing the risk of heart failure, myocardial infarction, and death from cardiovascular causes in patients with left ventricular systolic dysfunction or heart failure, and have been shown to reduce atherosclerotic complications in patients who have vascular disease without heart failure. They may preserve endothelial function and counteract initiation and progression of atherosclerosis. Broadly, ACE inhibitors can be divided into tissue specific or serum ACE inhibitors. Tissue-specific ACE inhibitors as a group are not superior to serum ACE inhibitors in the treatment of coronary artery disease. Pending direct comparator clinical trials between a tissue ACE inhibitor and a plasma ACE inhibitor, both ramipril and perindopril can be recommended for secondary risk prevention, based on the evidence.

Objectives: To test the hypothesis that patients with well-documented diastolic dysfunction (DD) in the setting of normal systolic function will have inspiratory muscle weakness when compared to normal control subjects, and will experience dyspnea and tachypnea during exercise. Background: Respiratory muscle weakness has been described in patients with (systolic) congestive heart failure; however, whether or not patients with DD may present with the findings of congestive heart failure is not known. Methods: We selected for study 14 patients with DD previously referred for cardiopulmonary evaluation whose diagnosis had been confirmed by data obtained at cardiac catheterization. Seven control subjects matched for age, sex, and weight were recruited from the hospital community. Subjects performed both basic pulmonary function tests and tests of muscle strength: handgrip strength (Hgr), and maximal subatmospheric static inspiratory muscle pressure (P i max). Subjects then performed a graded exercise test on a bicycle ergometer. Minute ventilation, oxygen consumption, carbon dioxide production, and heart rate were monitored continuously. Echocardiography was performed three times: before exercise, at a selected submaximal exercise level (20% of a predicted maximal workload), and at maximal exercise. Subjects rated their degree of dyspnea using the Borg scale at the same three time intervals. Results: P i max was − 102 ± 17 cm H 2 O in control subjects, and − 77 ± 19 cm H 2 O in patients with DD (p = 0.013) [mean ± SD]. Hgr was similar between the groups. At the selected submaximal exercise level, patients with DD rated dyspnea to be 2.6 ± 2.2 Borg scale units (control subjects, 0.5 ± 0.8 Borg scale units). Hey plots described a rapid, shallow breathing pattern in patients with DD during exercise. Patients with DD and control subjects achieved similar maximal work loads. Conclusion: Patients with DD have diminished P i max, adopt a rapid, shallow breathing pattern during exercise, and experience dyspnea at low work loads when compared to matched control subjects.

Background: Recent reports from quality improvement registries revealed high antiplatelet and anticoagulant use within 24 h of hospitalization for acute myocardial infarction (AMI). Objective: To produce an unbiased national estimate of the use of antiplatelets and anticoagulants during visits to the emergency department (ED) for AMI. Methods: Data from the National Hospital Ambulatory Medical Care Survey for AMI visits from 2002 to 2010 were analyzed. The complex survey design was taken into consideration to ensure that reliable national estimates were produced. Results: During the study period, there were 3,825,905±308,534 estimated eligible ED visits for AMI. Acetylsalicylic acid was not used in 55.5±2.9%, 55.7±4.0% and 55.2±4.8% of visits in 2002 to 2004, 2005 to 2007 and 2008 to 2010, respectively (Ptrend=0.96). The nonuse of thienopyridine or glycoprotein IIb/IIIa inhibitors (GPI) decreased during this period (92.9±1.4%, 88.1±2.6% and 83.4±3.4%, respectively; Ptrend=0.001). Anticoagulant nonuse did not change (72.1±2.6%, 68.0±3.7% and 65.5±4.4%, respectively; Ptrend=0.14). Even in definitive AMI visits, nonuse was high (acetylsalicylic acid, 48.7±4.5%, 44.7±6.2% and 55.6±5.6%, respectively, Ptrend=0.31; thienopyridine/GPI, 81.9%±3.4%, 77.0±5.0% and 71.1±5.5%, respectively, Ptrend=0.001; and anticoagulants, 49.3±9.6%, 47.1±7.1% and 45.3±6.20%, respectively, Ptrend=0.24). ED visits in a metropolitan statistical area were more likely to receive acetylsalicylic acid (OR 2.27 [95% CI 1.02 to 5.09]) and anticoagulants (OR 3.34 [95% CI 1.54 to 7.24]). Similarly, visits evaluated by a consulting physician were more likely to receive thienopyridine/GPI (OR 2.24 [95% CI 1.22 to 4.13]) and anticoagulants (OR 1.73 [95% CI 1.14 to 2.63]). Conclusion: In a significant proportion of AMI visits, including definitive AMI, antiplatelet and anticoagulant therapies were not administered in the ED.

As the last chapter of the book, we summarize it by answering the question, “Why autonomic (P&S) assessment?” Included in the answer are discussions on proactive patient management, individualized therapy titration, documenting outcomes, evidence-based medicine, value-based medicine, comparative effectiveness benefit, PQRI documentation, and improved patient care, and we finish with a look at P&S monitoring in different specialties.

Mild to moderate periprocedural elevation in CK with concurrent CK MB elevation result in increased subsequent myocardial infarction and mortality. However the potential risks that percutaneous revascularization interventions pose must be evaluated in light the risks of alternative procedures and the risks of continued medical management. Prospective clinical trials examining the relationship of periprocedural enzyme elevations to long term prognosis will need to address this issue.

More than 5 million people carry the diagnosis of heart failure in USA and almost 300,000 people die of heart failure each year in USA1. Heart failure remains the most common discharge diagnosis for patients older than 65 years of age. In the Western world, most heart failure is related to coronary disease, and although the survival of patients post acute myocardial infarction has improved, this has resulted in an increase in the number of patients ultimately developing heart failure2. Advances in medical therapy have resulted in improved survival in patients with moderate and severe heart failure, but the prognosis for end-stage heart failure patients remains poor3-5. In patients with end-stage heart failure cardiac transplantation remains the gold standard of cardiac replacement therapy and it has shown the greatest survival benefit. However, the supply of donor hearts is limited. There is also an increase in the number of heart failure patients who are not candidates for cardiac transplantation, mainly due to older age and presence of co-morbidities. There has therefore been considerable interest in alternative forms of cardiac replacement therapy, either as a temporary bridge to transplantation or as a definitive destination strategy. Multiple different mechanical devices for long-term circulatory support have been developed, ranging from total artificial hearts to ventricular assist devices (VADs). The main purpose of a VAD is to unload the failing heart and help maintain forward cardiac output and vital organ perfusion. Originally introduced as a temporary bridge to recovery and then as a bridge to transplantation, VADs have evolved into permanent or “destination” therapy for a growing number of patients with refractory heart failure6.

Repeat coronary angioplasty has become the standard approach to a first restenosis. However, the long-term outcome of such a strategy is not well defined. In the present study, 465 patients (mean age 58 years [range 27 to 79], 53% with multivessel disease) underwent a second angioplasty procedure at the same site. The procedure was successful in 96.8% with a 1.5% rate of in-hospital bypass surgery, a 0.9% incidence rate of myocardial infarction and no procedural deaths. Four hundred sixty-three patients (99.6%) were followed up for a mean of 40.5 months. Forty-nine patients (10.6%) underwent a third angioplasty procedure at the same site, 55 (11.8%) had coronary bypass surgery and 33 (7.1%) underwent angioplasty at a different site. During follow-up, 12 patients (2.6%) sustained a myocardial infarction and 21 (4.5%) died including 13 (2.8%) with cardiac death. Of the 442 surviving patients, 88% experienced sustained functional improvement and 78% were free of angina. The actuarial 5-year cardiac survival rate was 96% and the rate of freedom from cardiac death and myocardial infarction was 92%.For the subgroup of 49 patients who had a third angioplasty procedure at the same site, the success rate was 93.9% with a 2% incidence rate of myocardial infarction. There were no in-hospital deaths or coronary artery bypass operations. The mean follow-up interval for this subgroup was 30.5 months with a 22.4% crossover rate to coronary bypass surgery, a 4.1% incidence rate of myocardial infarction and a 2% cardiac mortality rate. At last follow-up, 89% of patients had sustained functional improvement and 76% were free of angina. The combined angiographic and clinical restenosis rate was 48%.Repeat angioplasty as treatment for restenosis is an effective approach associated with a high success rate, low incidence of procedural complications, and sustained functional improvement in combination with an acceptable rate of bypass surgery. However, there is a trend toward diminished angioplasty efficacy after a second restenosis. Thus, decisions for further revascularization should be made after careful review of available options.

Atrial fibrillation is the most common of the serious cardiac rhythm disturbances and is responsible for substantial morbidity and mortality. Amiodarone is currently one of the most widely used and most effective antiarrhythmic agents for atrial fibrillation. But during chronic usage amiodarone can cause some serious extra cardiac adverse effects, including effects on the thyroid. Dronedarone is a newer therapeutic agent with a structural resemblance to amiodarone, with two molecular changes, and with a better side effect profile. Dronedarone is a multichannel blocker and, like amiodarone, possesses both a rhythm and a rate control property in atrial fibrillation. The US Food and Drug Administration approved dronedarone for atrial fibrillation on July 2, 2009. In this review, we discuss the role of dronedarone in atrial fibrillation.

The renin-angiotensin-aldosterone system (RAAS) has emerged as an important hormonal system in the initiation and pathogenesis of atrial fibrillation (AF). Therefore, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are emerging as novel drugs for the prevention of AF. A meta-analysis of 11 randomized, controlled, parallel-design clinical trials evaluating effect of ACEIs or ARBs on the development of AF was performed. Treatment with ACEIs or ARBs reduced the relative risk (RR) of AF in patients with hypertension by 23% [RR 0.769, P < 0.001, 95% confidence interval (CI) 0.686-0.862] and by 11% in patients after myocardial infarction (RR 0.898, P < 0.05, 95% CI 0.814-0.992). Reduction in AF was greatest in patients after electrical cardioversion (RR 0.491, P < 0.001, 95% CI 0.334-0.720) and in patients with heart failure (RR 0.684, P < 0.001, 95% CI 0.594-0.787). Overall, inhibition of the RAAS reduced the RR of AF by 19% (RR 0.810, P < 0.001, 95% CI 0.759-0.865).

Noninvasive imaging of coronary arteries with computed tomography (CT) has become increasingly accurate with the technological advances in multidetector CT (MDCT). The authors review the utility of MDCT in quantitative and qualitative evaluations of coronary stenosis, plaques, bypass grafts, and stents. Recent studies demonstrate a high accuracy of MDCT in locating significant coronary stenosis, which may allow CT angiography to become an important screening tool for coronary artery disease in selected patient populations. Although factors such as arrhythmias, heart rate, calcifications, and patients' ability to hold their breath may limit the patient population that will ultimately benefit from this technology, MDCT coronary angiography has significant clinical potential. Studies are still needed to clarify the clinical role for CT angiography, but advances in this noninvasive technology are impressive and hold promise for clinical utility.

Cumulative evidence supports the use of angiotensin-converting enzyme (ACE) inhibitors for stable coronary artery disease in patients with and without heart failure. The dose and unique properties of ACE inhibitors, trial data, differences in trial design and demographics, may all contribute to variable responses in clinical outcomes. Pending direct comparator clinical trials between a tissue ACE inhibitor vs a plasma ACE inhibitor, evidence indicates that both ramipril and perindopril can be recommended for secondary risk prevention.

Background Enhanced external counterpulsation (EECP), a noninvasive treatment for patients with angina pectoris, provides long-term benefits of decreased anginal frequency and improved exercise tolerance. Previous studies have suggested that shear stress may result in angiogenesis and alter endothelial hemostatic factor release. Whether EECP therapy effects an alteration in endothelial cell proliferation and function remains unclear. The level of vascular endothelial growth factor (VEGF) and four other endothelial hemostatic factors (tissue plasminogen activator, plasminogen activator inhibitor-1, von Willebrand factor, and D-dimers) were measured in patients before and after 35 hours of EECP treatment. Methods Plasma levels of endothelial growth and hemostatic factors were assessed using the standard enzyme-linked immunosorbent method. Results No significant difference in the hemostatic factors and VEGF after EECP treatment was revealed; there was a trend toward an increase in VEGF levels posttreatment. Conclusions Vascular endothelial cells play a critical role in the regulation of coagulation because they control the expression of tissue plasminogen activator, plasminogen activator inhibitor-1, von Willebrand factor, and D-dimers. Our results suggest EECP may not play a role in controlling coagulation in patients with coronary artery disease through release of endothelial hemostatic factors. Although there was a tendency for increased VEGF release, larger studies are necessary to confirm these observations.

Ximelagatran, an emerging new direct, oral, fixed-dose thrombin inhibitor may offer an attractive alternate to warfarin for patients with nonvalvular atrial fibrillation. The lack of drug-to-drug interactions and need for coagulation monitoring parameters such as international normalized ratio and a short half-life make therapeutic control and withdrawal in the event of bleeding easier. The side-effect profile, including elevation of liver enzymes, may temper the clinical utility of long-term use ximelagatran.

The development of advanced revascularization techniques has resulted in the growth of a subset of patients with coronary artery disease who are nonrevascularizable and are considered to have refractory angina. Enhanced external counterpulsation (EECP) has been developed for the management of these patients with chronic, refractory disease. Evidence has shown that through improvement of vascular endothelial function and recruitment of collateral vessels, EECP provides many clinical benefits. These patients experience sustained decreases in angina, improvement in exercise time, improved myocardial perfusion, and enhanced quality of life. Furthermore, EECP appears to be safe and effective in the treatment of angina in patients with impaired systolic function and has similar potential in patients with congestive heart failure.

A 66-year-old man without symptoms, referred for the treatment of moderate hypertension, was found to have a right atrial mass by two-dimensional echocardiography. On transesophageal echocardiography two masses were detected on the tricuspid valve, the first one on the posterior leaflet and the second smaller one on the anterior leaflet. These findings were confirmed at surgery. Histologic analysis revealed that the masses represented papillary fibroelastomas.

Background The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of enhanced external counterpulsation (EECP) in the treatment of chronic stable angina. We previously reported that EECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now describe the effects of EECP therapy versus a sham-treated control group in terms of patients’ functioning, their senses of well-being and other Health-Related Quality Of Life (HQOL) parameters from baseline to end of treatment and from baseline to 12 months after treatment. Objective To determine whether a 35-hour course of EECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment. Methods Seventy-one of the 139 patients enrolled in MUST-EECP provided evaluable patient-completed questionnaires at baseline, at the end of treatment, and 12 months post-treatment. The Medical Outcomes Study 36-Item Short-Form Health Survey and the Quality of Life Index-Cardiac Version III were used to assess effects on HQOL. Results Both groups had similar HQOL scores at baseline. At end of treatment and at 12-month follow up, patients who had active-CP reported greater improvement than those who had inactive-CP in all nine quality of life scales, including ability to perform activities of daily living, ability to work, bodily pain, confidence in health, energy, ability to engage in social activities with family and friends, anxiety and depression, and quality of life issues from the effects of angina on health and functioning. Despite small sample sizes, active-CP patients demonstrated significantly greater improvement at 12 months following treatment in bodily pain, social functioning, and quality of life specific to cardiac patients compared with inactive-CP patients. Conclusion Significant health-related quality of life improvements were measurable up to 12 months after the completion of treatment with EECP. Improvements in this controlled study are consistent with HQOL changes reported in case series and patient registries. Larger studies are warranted.

Fungal endocarditis is an exceedingly rare complication of indwelling central venous catheters in adults. Here we describe what appears to be the first case of a right atrial thrombus superinfected with the yeast Torulopsis (Candida) glabrata and attached to an indwelling superior vena cava catheter that was not used for parenteral nutrition. A large vegetation-like mass adherent to the catheter tip was visualized by transesophageal echocardiography in a patient who presented with signs of septic pulmonary embolism. Following open-heart surgery, the definitive diagnosis was established by histopathologic examination of the surgical specimen.

With the increasing use of the internal mammary artery as the conduit of choice in coronary bypass surgery, it is anticipated that an expanding patient population will have stenosis, usually at the site of internal mammary-to-coronary artery anastomosis. In our series 31 patients underwent dilatation at either the site of anastomosis (24), the native coronary artery beyond the anastomosis (4), or both (3) with no mortality, myocardial infarction, or need for emergency coronary artery bypass surgery. Angiographic and clinical success was achieved in 28 patients (90%). There were two internal mammary artery dissections with both patients requiring elective coronary bypass surgery. Of the patients in whom dilatation was successful, 22 (79%) have been followed for longer than 6 months and 19 (86%) have had sustained functional improvement at a mean of 35 months after angioplasty. One patient is to undergo repeat coronary bypass surgery. No patient has had a myocardial infarction or died during follow-up. Although percutaneous transluminal coronary angioplasty of the internal mammary artery has inherent difficulties because of the anatomic characteristics of the vessel, it can be performed with a high degree of primary success and a low incidence of complications and can provide long-term clinical improvement.

In order to determine the relationship of restenosis following percutaneous transluminal coronary angioplasty (PTCA) to risk factors such as hypercholesterolemia, hyperglycemia, smoking, and weight, we performed a univariate analysis to test the association of these variables with restenosis in 723 patients who had percutaneous transluminal coronary angioplasty and follow-up catheterization. Cholesterol levels were higher in younger and female subjects (less than 0.0001). Initial cholesterol did not predict restenosis, and follow-up cholesterol levels showed an inverse relationship with restenosis (P less than .02). There was a trend (P less than .09) toward decreased restenosis in those who were active smokers at the time of follow-up catheterization. No differences were seen in diabetics with hyperglycemia, in both treated and untreated groups (P = NS). A stepwise multiple logistic regression was used to simultaneously test the association of the above risk factor variables to restenosis. None of the interactions were found to be significant, except cholesterol at follow-up (P = .001). Therefore, the status of serum cholesterol, blood sugar, smoking, and weight during the time of PTCA and at follow-up catheterization may be unimportant in predicting restenosis. Thus, we conclude 1) that to better determine the effect of these variables on restenosis, they should be estimated at times other than follow-up and 2) that the pathophysiological mechanism of restenosis may have different risk factors than progression of atherosclerotic coronary artery disease.

To the Editor: A 70-year-old man came to his physician with acute myocardial infarction after self-administration of sildenafil (Viagra) and nitrates, a case highlighting a new trigger for acute my...

Impaired diastolic function has been described in healthy elderly subjects. Pulmonary blood volume (PBV) changes with exercise have been associated with left ventricular dysfunction, but not directly related to diastolic abnormalities. Exercise-induced relative changes in PBV were measured using gated blood pool imaging with count density comparisons over the lung in 20 healthy volunteers: 13 elderly, age 76 +/- 5 years and seven young, age 27 +/- 4 years. Serial (first exercise stage, peak exercise, and post exercise) PBV ratios were measured and correlated to peak early filling rate, peak late filling rate, and percent atrial filling obtained from the resting left ventricular time-activity curve analysis. PBV ratios tended to be higher in elderly subjects, but reached significance only at the first stage of exercise (1.04 +/- 0.07 vs. 0.93 +/- 0.10, p less than 0.01). Significant correlations were found between PBV ratios at first exercise stage and peak early filling rate (r = -0.64), peak late filling rate (r = 0.47), and percent atrial filling (r = 0.48). A significant correlation was found between PBV changes at peak exercise and resting diastolic parameters. Exercise-induced PBV changes are associated with left ventricular diastolic dysfunction at rest. Diastolic abnormalities of the aged heart may explain the differential PBV response early into exercise between young and elderly healthy subjects.

As previously reported in acute presentations of unstable angina, an identifiable characteristic coronary artery lesion has been found in about 70% of cases at coronary arteriography. This takes the form of an eccentrically placed convex stenosis with a narrow neck due to one or more overhanging edges or irregular, scalloped borders, or both. To study the evolution of lesions responsible for unstable angina, coronary artery anatomy and morphology on angiography were evaluated in patients with stable angina progressing to unstable angina, Group I comprised 25 patients with a history of stable angina who were restudied after an acute episode of unstable angina and Group II comprised 21 patients with little or no change in symptoms between catheterizations. Progression of coronary disease occurred in 19 (76%) of 25 patients in Group I compared with 7 (33%) of 21 in Group II (p < 0.001). Of the 25 lesions with progression in Group I, 17 progressed to less than 100% and 8 to 100% occlusion. Eighteen of these 25 lesions in Group I were previously insignificant (< 50% occlusion on the first catheterization). In contrast, of the eight lesions with disease progression in Group II, only two were previously insignificant while six showed at least 50% occlusion on the initial study.The eccentric lesion was seen in 71% of all lesions with progression to'less than 100% occlusion in Group 1, but it was not seen in any Group II vessel with progression. Therefore, progression of disease is very common in acute presentations of unstable angina and most lesions progress from previously insignificant stenoses. An eccentric lesion with a narrow neck due to one or more overhanging edges or irregular, scalloped borders, or both, is the most common configuration of coronary lesions in this type of progression and it appears to be a major cause of unstable angina.

Mitral valve prolapse has been associated with septal to aortic root angle abnormalities determined by echocardiography. Thallium 201 imaging in the anterior view permits visualization of the left ventricular long axis. In the present study, the vertical angle was defined as the angle formed by the long axis of the left ventricle and a horizontal line. The vertical angle was determined in 25 patients who had 201 TL stress testing and M-mode echocardiography. Group I (11 patients) had mitral valve prolapse and group II (14 patients) did not have mitral valve prolapse. The vertical angle and ultrasound were read blinded to each other. Height, weight, and body surface area were compared for the two groups, and receiver operator curve analysis performed. Vertical angle measured by TL 201 was significantly more vertical in patients with mitral valve prolapse. Receiver operator curve analysis showed that an angle of greater than 30 degrees successfully identified 9/11 patients with mitral valve prolapse, with a sensitivity of 82% and a specificity of 79%. There were no significant differences in height, weight, or body surface area between the two groups. Thus, patients with mitral valve prolapse have more vertically positioned hearts than patients without mitral valvemore » prolapse, independent of body habitus. The different appearance of a vertically oriented heart may contribute to false-positive readings of TL 201 images.« less

The elderly population is projected to increase from the present 11 per cent of the overall population to 20 per cent by the year 2020. The efforts of the medical community are directed toward extending the quantity of life. However, economic necessity and technologic advance in medicine will dictate the health care delivery to the elderly, as quality of life becomes a major factor in therapeutic decision.

It has previously been shown that analysis of coronary morphology can separate unstable from stable angina. An eccentric stenosis with a narrow neck or irregular borders, or both, is very common in patients who present with acute unstable angina, whereas it is rare in patients with stable angina. To extend these observations to myocardial infarction, the coronary morphology of 41 patients with acute or recent infarction and nontotally occluded infarct vessels was studied. For all patients, 27 (66%) of 41 infarct vessels contained this eccentric narrowing, whereas only 2 (11%) of 18 noninfarct vessels with narrowing of 50 to less than 100% had this lesion (p less than 0.001). In addition, a separate group of patients with acute myocardial infarction who underwent intracoronary streptokinase infusion were also analyzed in similar fashion. Fourteen (61%) of 23 infarct vessels contained this lesion after streptokinase infusion compared with 1 (9%) of 11 noninfarct vessels with narrowing of 50 to less than 100% (p less than 0.01). Therefore, an eccentric coronary stenosis with a narrow neck or irregular borders, or both, is the most common morphologic feature on angiography in both acute and recent infarction as well as unstable angina. This lesion probably represents either a disrupted atherosclerotic plaque or a partially occlusive or lysed thrombus, or both. The predominance of this morphology in both unstable angina and acute infarction suggests a possible link between these two conditions. Unstable angina and myocardial infarction may form a continuous spectrum with the clinical outcome dependent on the subsequent change in coronary supply relative to myocardial demand.

OBJECTIVESThe purpose of this study was to assess safety and efficacy of enhanced external counterpulsation (EECP).BACKGROUNDCase series have shown that EECP can improve exercise tolerance, symptoms and myocardial perfusion in stable angina pectoris.METHODSA multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina, documented coronary artery disease (CAD) and positive exercise treadmill test. Patients were given 35 h of active counterpulsation (active CP) or inactive counterpulsation (inactive CP) over a four- to seven-week period. Outcome measures were exercise duration and time to ≥1-mm ST-segment depression, average daily anginal attack count and nitroglycerin usage.RESULTSExercise duration increased in both groups, but the between-group difference was not significant (p > 0.3). Time to ≥1-mm ST-segment depression increased significantly from baseline in active CP compared with inactive CP (p = 0.01). More active-CP patients saw a decrease and fewer experienced an increase in angina episodes as compared with inactive-CP patients (p < 0.05). Nitroglycerin usage decreased in active CP but did not change in the inactive-CP group. The between-group difference was not significant (p > 0.7).CONCLUSIONSEnhanced external counterpulsation reduces angina and extends time to exercise-induced ischemia in patients with symptomatic CAD. Treatment was relatively well tolerated and free of limiting side effects in most patients.

Deficiency of tryptophan with elevated serum serotonin and liver dysfunction are the prerequisites for the experimental production of cardiac lesions in the guinea pig model of carcinoid syndrome. To apply the above principles in human subjects with carcinoid disease, various indole markers were compared in patients with or without heart involvement, to a group of normal subjects. In the present study, plasma tryptophan (T), serotonin (5HT), and urinary 5 hydroxyindoleacetic acid (5HIAA) measurements were made in 18 (group 1) patients with carcinoid syndrome and 24 normal individuals (group 2). Of the 18 patients, seven (group 1A) had valvular involvement and 11 (group 1B) had none, as determined by clinical, roentgenographic, and echocardiographic (M-mode and 2-D) techniques. Analysis of the above data shows that unlike animal models, there is no difference in serum tryptophan, serum serotonin, and urinary 5 hydroxyindoleacetic acid levels, in patients with carcinoid syndrome with or without cardiac involvement (p greater than 0.05). Furthermore, the data confirm that serum tryptophan, a substrate in carcinoid syndrome, is decreased and in serum serotonin and urinary 5 hydroxyindoleacetic acid, the metabolites are elevated.

Coronary angiograms from 2,372 consecutive patients who underwent percutaneous transluminal coronary angioplasty (PTCA) were retrospectively reviewed for the presence of intracoronary thrombus (ICT) before dilatation. Patients with evolving acute myocardial infarction and those receiving thrombolytic therapy were excluded from analysis. Coronary artery thrombus was present in 126 patients (6%) (group 1). When compared to 2,246 patients (group 2) without ICT, group 1 had a higher incidence of unstable angina, 74% vs. 66% (less than 0.06), previous myocardial infarction, 59% vs. 37% (P less than .0001), and history of a recent myocardial infarction, 28% vs. 9% (P less than .0001). Patients with predilatation intracoronary thrombus had a higher risk for acute occlusion, 6% vs. 2% (P less than .002); however, the incidence of emergency coronary bypass surgery and myocardial infarction was similar in both groups. Therefore, the presence of predilatation intracoronary thrombus heralds an increased risk of acute occlusion, but not myocardial infarction or emergency coronary artery bypass surgery.

TRUE left ventricular aneurysm, congenital or acquired, may be defined as an abnormal bulge or outpouching of a portion of the left ventricular wall with or without paradoxical (dyskinetic) systolic expansion. The wall of the aneurysm is composed of either myocardium or fibrous tissue and may be calcified. 1-3 In contrast, a false aneurysm or pseudoaneurysm of the left ventricle (LV) represents a localized myocardial rupture, with the hemorrhage limited by adherent pericardium and fibrous tissue. 4,5 Congenital and false aneurysms of the LV must be differentiated from left ventricular aneurysms resulting from myocardial infarction because the former tend to rupture. Left ventricular aneurysms associated with postmyocardial infarction do not rupture and are repaired only if a complication such as intractable congestive heart failure, arrhythmia, or refractory angina is present. 6,7 Two cases of catastrophic congenital left ventricular aneurysms and a description of the various imaging modalities used to arrive