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Your Heart and Nutrition

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Natural Secrets For Healing Your Heart

This eBook is devoted to exposing the secrets that cardiologists and surgeons don't want you to know, and how to take control of your own heart and heal yourself. Eight out of every ten coronary bypasses will not actually help the patient. So why risk being in the 80% that will get no benefit from a bypass? Learn to heal your own heart and keep yourself healthy with this eBook guide. Bob Livingston has poured years of research into his findings, and is now sharing the methods that he has developed from careful, methodical research that the medical industry would never allow. It would make them go bankrupt! You will learn what supernutrient doctors don't want you to know about, and how to make an all-natural, chemical and drug-free blood thinner And even more information that doctors don't want revealed to the public. You don't have to be one of the 70% of Americans diagnosed with heart disease. You can heal your heart!

Natural Secrets For Healing Your Heart Overview

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Acute Coronary Syndromes in the Emergency Department Diagnostic Characteristics Tests and Challenges423

Failure to diagnose patients who have acute coronary syndromes (ACSs) either acute myocardial infarction (AMI) or unstable angina pectoris (UAP) who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.

Rehabilitation after Large Myocardial Infarction

After large myocardial infarction, even patients in NYHA functional class III or IV may achieve some relative benefit from an exercise program. Clinical studies have shown that, although patients with left ventricular dysfunction, especially those with ischemic heart disease, are at potentially high risk of exercise-related arrhythmias, the actual risk is relatively small when compared with the high incidence of non-exercise-related sudden death. Patients with large infarction should be considered with caution for long-term exercise therapy. Serial clinical evaluation of heart size and left ventricular function should be carried out in case of worsening, physical training should be reduced or stopped.35-38

Prevalence of Risk Factors for Heart Disease

Number of known risk factors associated with heart disease including smoking, sedentary lifestyle, and increased intake of dietary fat.3-5 Furthermore, South Africans have a high prevalence of overweight and obesity, with over 50 of women and more than 20 of men considered overweight by World Health Organization (WHO) standards (body mass index (kg m2) > 25). Indeed, the World Health Survey 2003, published by the WHO, suggests that the prevalence of physical inactivity in South African adults is greater than 60 for both males and females. In fact, nearly 60 of all South African adults have at least one major reversible factor. Thus, the need for both secondary and indeed primary intervention initiatives including cardiac rehabilitation is large.

Permanent Pacing After the Acute Phase of Acute Myocardial Infarction

Bradyarrhythmias and conduction defects are relatively common after acute myocardial infarction. In patients who have these problems, a decision about permanent pacing must be made prior to the patient's discharge from the hospital. It is important to realize that the indications for temporary pacing in the setting of acute myocardial infarction are different from those for permanent pacing following infarction. Unfortunately, there is some uncertainty regarding permanent pacing for these patients because large prospective controlled trials have not been performed. In addition, the criteria for permanent pacing in patients after a myocardial infarction do not necessarily require the presence of symptoms and the need for temporary pacing in the acute stages of infarction is not by itself an indication for permanent pacing. The prognosis for these patients is strongly influenced by the amount of underlying myocardial damage.37 In general, sinus node dysfunction tends to be benign and...

Insights Cardiovascular Disease

Chronic infections with C. pneumoniae and the sequelae with which it has been associated could arguably place this bacterium among the most important pathogens in the developed world. The most significant disease state connected to the organism is atherosclerosis and cardiovascular disease.(23) Ngeh and Gupta provide an overview of this association citing the large body of epidemiological studies. This field is highly controversial due in large part to the lack of standardized methods between laboratories for example, there is a variety of home brew methods currently used for DNA extraction and for serological testing. Also, antibiotic treatment studies that have shown inconclusive data may need further refinement to better identify those patients who would have the greatest benefit. Chlamydia pneumoniae as an agent of myocarditis is discussed by Gnarpe and Gnarpe. In spite of the association of this bacterium with atherosclerosis, there have been relatively few documented cases of...

Exercise Testing in Coronary Heart Disease

Exercise testing is probably the most often performed diagnostic test for persons with suspected coronary heart disease. It provides not only information about ST-segment depression, heart rate, and blood pressure during and after exercise but more importantly information also on the overall exercise performance in relation to the expected performance adjusted for age and gender, which is of greater prognostic importance than a limited look at the ST segments. Exercise testing provides additional prognostic information particularly in persons with an intermediate pretest probability of disease. This chapter provides a thorough overview of the different types of exercise testing from treadmill exercise to different imaging modalities, and is aimed at the interested new

Confirmation of diagnosis of acute myocardial infarction

According to the World Health Organization, a definite diagnosis of acute myocardial infarction (AMI) is made in the presence of unequivocal ECG changes (development of abnormal, persistent Q waves or QS waves and evolving injury current for > 24 h) and or unequivocal biomarker changes (serial changes related to the onset of symptoms and the respective marker) (3). More recently, an ESC AHA task force has recommended the use of troponins as the preferred cardiac marker and stated that any significant elevation of a cardiospecific troponin in the setting of myocardial ischemia establishes the diagnosis of AMI (4).

Exercise Testing in Valvular Heart Disease

Although more often performed in patients with suspected or proven coronary artery disease, exercise testing is also of great value in patients with valvular heart disease. It has an important role in eliciting symptoms in asymptomatic patients, in evaluating atypical symptoms, and in assessing true exercise capacity. Exercise testing is not only of prognostic importance but is also useful for advising patients about their physical activities and exercise limits. It also gives clues about where and how to start medical therapy (heart rate or blood pressure control). After valve interventions or valve surgery an exercise test is advised prior to starting an exercise training program, to assess its safety but also to evaluate the medical management. Exercise testing should be used more often to optimize clinical management in patients with valvular heart disease.

Exercise Testing in Patients with Acute Coronary Syndromes

Acute coronary syndromes (i.e. unstable angina and non-ST-elevation myocardial infarction) represent an acute phase in the natural history of chronic CAD, which may either progress to myocardial infarction and death or return to the chronic stable phase of CAD. Patients with unstable angina are separated into low-, intermediate-, or high-risk groups on the basis of history and physical examination, 12-lead ECG, and serum cardiac markers. Low-risk patients can be treated on an outpatient basis, intermediate-risk patients can be treated in a monitored hospital bed, and high-risk patients are typically admitted to an intensive care unit. Little evidence exists regarding the safety of early exercise testing in unstable angina. One review of this topic found three studies including 632 patients with stabilized unstable angina who had a 0.5 death or myocardial infarction rate within 24 hours of their exercise test.19 The Research on Instability in Coronary Artery Disease (RISC) study group...

Exercise Testing after Myocardial Infarction

Over the past decade treatment strategies for the patients with acute myocardial infarction have dramatically changed. Shorter duration of hospi-talization, widespread use of thrombolytic agents and coronary revascularization, and increased use of beta-adrenergic blockers and angiotensin-converting enzyme inhibitors have led to The exercise protocols after myocardial infarction can be either submaximal or symptom-limited. Submaximal protocols have a predetermined endpoint, defined as a peak heart rate of 120 beats min, or 70 of the predicted maximum heart rate, or a peak MET level of 5. Symptom-limited tests are designed to continue until the patient demonstrates signs or symptoms that necessitate termination of exercise. The most commonly used treadmill protocols are the modified Bruce,the modified Naughton, and the standard Bruce. Timing of predischarge exercise tests in the relevant literature ranges from 5 to 26 days after infarction. Some studies have evaluated symptom-limited...

Acute Coronary Syndromes Risk Stratification and Initial Management

In the United States, there are approximately 1.68 million patients admitted every year to hospitals with acute coronary syndromes (ACSs) 1 . Of these, one quarter present with acute myocardial infarction (MI) associated with ECG ST-segment elevation (STEMI), whereas three quarters, or approximately 1.3 million patients, have unstable angina non-ST elevation MI (UA NSTEMI) 1 . The former is most commonly caused by acute total occlusion of a coronary artery and therefore urgent reperfusion is the mainstay of therapy, whereas UA NSTEMI is usually associated with a nonocclusive thrombus

Assessment of likelihood of coronary artery disease

Approximately 6 to 7 million persons per year in the United States present to EDs or chest pain units with a complaint of chest pain or other symptoms suggestive of possible ACS. Of these, approximately 20 to 25 have a final diagnosis of unstable angina or MI 5,6 . Thus, the first step in evaluating patients who have possible UA NSTEMI is to determine the likelihood that coronary artery disease (CAD) is the cause of the presenting symptoms. The 2002 ACC AHA guidelines list factors associated with increased likelihood that the patient actually has unstable angina (Table 1). Estimating the likelihood that the suspected acute coronary syndrome event is secondary to coronary artery disease Estimating the likelihood that the suspected acute coronary syndrome event is secondary to coronary artery disease of coronary artery disease including myocardial infarction

Introduction Exercise Testing in Patients with Valvular Heart Disease

Exercise testing (ET) has been the cornerstone in the diagnosis and prognostic evaluation of coronary artery disease (see Chapter 14).12 Even in apparently healthy men exercise testing provides important prognostic informations.3 Although ET was recently recommended in the management of asymptomatic patients with valvular heart disease (VHD),4,5 this recommendation is based on a small database. In the Euro Heart Survey on Valvular Heart Disease of the European Society of Cardiology, exercise testing was used in less than 8 of 5001 patients, evaluated in hospital or as an outpatient in 27 European countries.6 The reasons for performing exercise testing in these patients are listed in Table 16-1. There are several explanations for the infrequent use of exercise testing in patients with VHD. Previously exercise testing was used to diagnose coronary artery disease also in adult patients with VHD, particularly in patients with aortic stenosis. But because of the occurrence of...

Annexins And Heart Disease

Annexin 2 is localised in intra-myocardial capillaries, extracellular matrix and in endothelial cells of the coronary arteries but is undetectable in ventricular and atrial myocytes. In hypertensive guinea pigs at the onset of heart failure and in failing human hearts it was found to be significantly up-regulated and was localized to the interstitium between the cardiomyocytes and the coronary arteries (Trouve et al., 1999). In this region it might be involved in regulation of fibrinolysis and the coagulability of the endothelial surface of the heart blood vessels as previously described. Heart tissue derived from patients with end-stage congestive heart failure due to coronary artery disease showed increased levels of annexins 2 and 5 but significantly reduced expression of annexin 6 (Song et al., 1998).

Regression of coronary artery disease as a result of intensive lipidlowering therapy in men with high levels of

BACKGROUND AND METHODS The effect of intensive lipid-lowering therapy on coronary atherosclerosis among men at high risk for cardiovascular events was assessed by quantitative arteriography. Of 146 men no more than 62 years of age who had apolipoprotein B levels greater than or equal to 125 mg per deciliter, documented coronary artery disease, and a family history of vascular disease, 120 completed the 2.5-year double-blind study, which included arteriography at base line and after treatment. Patients were given dietary counseling and were randomly assigned to one of three treatments lovastatin (20 mg twice a day) and colestipol (10 g three times a day) niacin (1 g four times a day) and colestipol (10 g three times a day) or conventional therapy with placebo (or colestipol if the low-density lipoprotein LDL cholesterol level was elevated). RESULTS The levels of LDL and high-density lipoprotein (HDL) cholesterol changed only slightly in the conventional-therapy group (mean changes, -7...

Box 1 Shortterm high risk for death myocardial infarction in unstable anginaNSTEMI

From Braunwald E, Antman EM, Beasley JW, et al. ACC AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction a report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000 36 970-1062 with permission.

Box 2 Shortterm intermediate risk for deathmyocardial infarction in unstable anginaNSTEMI

Prior myocardial infarction, peripheral vascular disease, or cerebrovascular disease Prolonged (> 20 min) rest angina, now resolved, with moderate or high likelihood of coronary artery disease From Braunwald E, Antman EM, Beasley JW, et al. ACC AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction a report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000 36 970-1062 with permission. developed using clinical variables and ECG and initial serum cardiac marker data 30,31 . The Thrombolysis in Myocardial Infarction (TIMI) risk score was developed using multivariate analysis to predict the occurrence of death, MI, or recurrent ischemia leading to urgent revascularization in the TIMI 11B trial. Seven independent risk factors emerged age over 65 years, more than three risk factors for CAD,...

Exercise Training in Valvular Heart Disease

Asymptomatic or mildly symptomatic patients with valvular heart disease are usually not included in medically supervised exercise training programs as part of the conservative management. However, physical conditioning and individually tailored exercise training are advisable for most patients after valve replacement, taking into account left ventricular function, previous level of training, the type of valve replaced, pulmonary hypertension, and heart rate. The general circulatory responses to exercise are of benefit to most of these patients, and could contribute to an overall improvement in the quality of life.

Habitual Exercise and Cardiovascular Disease

The majority of these studies refer to subjects without definite CAD. But because of the gradual development of cardiovascular disease it can be assumed that many of these individuals had asymptomatic atherosclerotic disease and the conclusions derived from these studies are also applicable to patients with stable coronary artery disease. In studies of male Harvard college alumni, the risk of death became progressively lower as physical activity levels increased from an expenditure of 500 to 3500kcal week (2.1 to 14.7 kJ week). There was a 24 reduction in cardiovascular mortality in subjects whose energy expenditure was 2000kcal week (8.4kJ week). Alumni who were initially inactive and later increased their activity levels demonstrated significantly reduced cardiovascular risk compared with those remaining inactive.3 The data regarding exercise intensity are less clear than those addressing total dose. Minimal adherence to current physical activity guidelines,...

Summaryacute therapy for nonST elevation acute coronary syndrome

The weight of the evidence'' showing benefit of an invasive versus conservative strategy in patients who have unstable angina non-ST elevation acute coronary syndrome. The size of the boxes for each of the nine randomized trials corresponds to the number of patients enrolled. (Modifiedfrom Cannon CP, Turpie AG. Unstable angina and non-ST-elevation myocardial infarction initial antithrombotic therapy and early invasive strategy. Circulation 2003 107 2640-5 with permission.) Fig. 2. The weight of the evidence'' showing benefit of an invasive versus conservative strategy in patients who have unstable angina non-ST elevation acute coronary syndrome. The size of the boxes for each of the nine randomized trials corresponds to the number of patients enrolled. (Modifiedfrom Cannon CP, Turpie AG. Unstable angina and non-ST-elevation myocardial infarction initial antithrombotic therapy and early invasive strategy. Circulation 2003 107 2640-5 with permission.) Box 4. ACC AHA guideline...

Exercise and Myocardial Infarction

Exercise can be a potent trigger of myocardial infarction (MI), which is seven times more likely to occur than sudden cardiac death. It can be assumed that this increased risk is confined to persons with pre-existing coronary artery disease. Approximately 4-20 of MIs occur during or soon after exertion.31-33 Physical exertion at a level > 6 METs has been reported within 1 hour of acute MI in 4-7 of patients. However, the adjusted relative risk has been found to be greater in persons who do not regularly participate in physical activ-ity.31,32 Among sedentary individuals, the relative risk of MI during exercise was 107 times that of baseline, whereas among individuals who regularly exercise 5 times per week, the relative risk of infarction during exercise is only 2.4 times greater than that of baseline.31 This inverse relationship between regular physical activity and MI is of clinical importance because a person's functional capacity must be considered when recommending the...

Recommendations for Physical Activity in Patients with Coronary Artery Disease

Risk classification for exercise training. Class B Presence of known,stable coronary heart disease with low risk for complications with vigorous exercise, but slightly greater than for apparently healthy individuals c. Previous episode of primary cardiac arrest (i.e. cardiac arrest that did not occur in the presence of an acute myocardial infarction or during a cardiac procedure) When advising the patient about physical activity early after myocardial infarction or after bypass surgery, risk classification is important to delineate the intensity of the recommended activity. Patients with established or suspected coronary artery disease will usually be in the risk category B (Table 17-2) or C (Table 17-3). It should be decided whether medical supervision is advisable during exercise training sessions before starting with a structured exercise program (Tables 17-2 and 17-3). The available evidence strongly suggests that for patients with coronary artery disease the benefits...

A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial

METHODS We randomly assigned 56 patients who presented within 12 hours of their first symptoms of acute myocardial infarction to treatment with either intracoronary streptokinase or coronary angioplasty. RESULTS The mean ( SD) duration of symptoms (3.0 1.2 hours in the group treated with angioplasty vs. 3.6 1.8 in the group treated with streptokinase p not significant) and time to recanalization (4.1 1.4 hours vs. 4.8 1.7 hours p not significant) were similar in both groups. Coronary recanalization was achieved in 83 percent of the patients treated with angioplasty and in 85 percent of those treated with streptokinase (p not significant). Residual luminal stenosis in the coronary artery was significantly decreased after angioplasty, as compared with streptokinase therapy (43 31 percent of patients vs. 83 17 p < 0.001). Residual stenosis of 70 percent or more was present in 4 percent of the angioplasty-treated patients and in 83 percent of the streptokinase-treated patients (p <...

Acute myocardial infarction intracoronary application of nitroglycerin and streptokinase

In five patients with acute myocardial infarction, the effects of both intracoronary nitroglycerin (NTG) and subsequent intracoronary streptokinase application were evaluated. In addition, transluminal recanalization was performed in one of these patients. Injection of NTG into the infarct-related coronary artery resulted in improved distal filling of the subtotally occluded left circumflex artery in one patient, and in transient patency of the completely occluded right coronary artery in a second patient. In a third patient patency of the totally occluded left anterior descending artery (LAD) was achieved by transluminal recanalization with a guide wire. In a fourth patient with occlusion of the LAD, there was no response to intracoronary NTG and mechanical recanalization was not attempted. Subsequent intracoronary infusion of streptokinase (1000-2000 U min for 15-60 min) resulted in a further and long-term reduction of narrowing at the site of acute occlusion in patients I-III and...

Inflammation in pathogenesis of acute coronary syndromes

The understanding ofthe pathogenesis ofthe acute thrombotic complications of atherosclerosis has burgeoned in recent years. It is now understood that many acute thrombotic coronary occlusions do not necessarily result from critically stenosed sites in the arteries (17). Rather, lesions that do not cause critical stenosis often underlie thrombi that cause acute coronary syndromes (ACSs). This distinction between lesion vs lumen has challenged the traditional reliance on coronary anatomy as revealed by angiogram as the sole arbiter ofthe risk ofACS (18). Much ofthe thinking about ACS has shifted from a hydraulic viewpoint to a more nuanced biological perspective (19). As in the initiation and progression of atherosclerosis, ample data support the participation of inflammation in these thrombotic complications of atherosclerosis.

The Impact of Fitness on Cardiovascular Diseases

Physical fitness can be measured easily and exactly, and has been shown to have a negative correlation to coronary heart disease. However, there is also a negative correlation between increasing fitness and risk factors like hypertension and hypercholesterolemia. Intervention by physical training has been shown to reduce these risk factors in studies at the Cooper Clinic in Dallas. If these confounders are corrected for, physical inactivity doubles the risk of coronary disease. In highly trained Norwegian skiers, a risk reduction of 4.8 was found compared to the least fit group in the study. In the same study, the quar-tile with the highest fitness had a relative risk of cardiovascular death of 0.4 compared to the quar-tile with poorest fitness.5 Large studies from the US also show a double risk in persons with low exercise capacity compared to those with a high exercise capacity.6 Still it may be questioned whether the training or the high fitness per se is protective. This is...

Role of Sports in Prevention of Cardiovascular Disease

There are many studies showing reduced mortality in training when following rehabilitation programs. However, there are no specific studies on sports participation in secondary prevention. Still, sport is a useful tool in the maintenance of physical activity. Play and sports in school children now outweigh walking to school as a source of physical activity. In fact one study10 showed no effect of walking to school on total physical activity in primary school children, demonstrating the dominant effect of play and sports in this regard. In Nordic athletes an active lifestyle is maintained after the active career both in an old11 and in our own study done recently. The effect of sports on the level of exercise in the community and thereby as a preventive tool on cardiovascular disease will be dealt with separately.

Novel risk factors and cardiovascular risk prediction

Identifying asymptomatic individuals at high risk of developing a first cardiovascular disease (CVD) event is a critical issue in primary prevention. Although the use of global Relative Risk of Future Cardiovascular Events Fig. 1. Head-to-head comparison ofvarious biomarkers in cardiovascular risk prediction. TC, total cholesterol sICAM-1, soluble intercellular adhesion molecule type 1 SAA, serum amyloid A Apo B, apolipoprotein B-100. (Adapted from ref. 10.) prediction algorithms such as those derived from the Framingham Heart Study (1) greatly improves the assessment of heart disease risk in primary prevention settings, as many as 20 of all coronary events occur in the absence of any of the major classic vascular risk factors. In a recent analysis of more than 120,000 patients with coronary heart disease (CHD), 15 of the men and 19 ofthe women had no evidence ofhyperlipidemia, hypertension, diabetes, or smoking, and more than half had only one of these traditional risk factors (2)....

Coronary angioplasty for acute coronary syndromes

Acute coronary syndrome (ACS) is a term of relatively recent origin, encompassing all clinical conditions that are manifestations of acute myocardial ischaemia. The label of unstable angina was first applied in 1971, when it was recognized that patients with new or worsening angina were at increased risk for cardiovascular morbidity and mortality compared to those with more chronic symptoms. Further, it was obvious that there was a need to define diagnostic criteria for this group of patients in order to develop risk stratification and treatment strategies, particularly to identify those who would benefit from urgent surgical revascularization. A variety of terms have been associated with this clinical presentation, including preinfarction angina, crescendo angina, acute coronary insufficiency, and intermediate coronary syndrome. Among the large number of patients who receive these labels is a subgroup of patients at increased risk for acute myocardial infarction and cardiovascular...

Acute coronary syndrome an inflammatory disease

Because acute coronary syndromes (ACSs) are heterogeneous with respect to their pathogenesis, it may be anticipated that they are also varied with respect to their risk and appropriate treatment (1,2). The growing evidence that atherosclerosis is an inflammatory disease and that inflammation plays a pivotal role in the complex processes that are responsible for destabilization of atherosclerosis have led to the use of inflammatory markers as risk predictors and potential guides for therapy in these syndromes (3-9). Traditional cardiovascular risk factors, such as diabetes, hypertension, smoking, family history, obesity, and sedentary lifestyle, explain only in part the occurrence of ACS. For example, more than 50 of patients with ACS have normal levels of cholesterol. The potential to identify patients at increased risk of future cardiovascular events by assessing their inflammatory status is appealing because this approach may also be useful for targeting more appropriate and...

The Burden of Smoking on Cardiovascular Disease

Among the risk factors for cardiovascular disease, smoking still ranks as main cause of premature coronary disease. In this chapter the present epidemiology of smoking is described. The relation between both active and passive smoking and coronary heart disease (CHD) and the causal mechanisms are discussed. Severe consequences for public health are demonstrated.

Smoking and Cardiovascular Diseases

Compared to non-smokers of developing lung cancer was 14. On the other hand, the relative risk for the relationship between smoking and coronary heart disease (CHD) mortality turned out to be only 1.6. Because of the greater number of deaths from CHD compared to those from lung cancer the attributable risk for smoking and CHD was nearly twice as big as the respective figure for smoking and lung cancer (Table 27-2). With these data, Doll and Peto could show that a reduction in smoking would save more people from heart disease than from lung cancer.7 Coronary heart disease Figure 27-4. Regression of 10-year CHD incidence rate on smoking class of 8717 men free of cardiovascular disease at entry in northern Europe, Italy and Greece, and Yugoslavia.15 Figure 27-4. Regression of 10-year CHD incidence rate on smoking class of 8717 men free of cardiovascular disease at entry in northern Europe, Italy and Greece, and Yugoslavia.15 Figure 27-5. Prediction of 10-year risk for fatal...

Acute Myocardial Infarction

The heart muscle, or myocardium, receives its blood flow from three coronary arteries rather than from the blood it constantly pumps through its chambers and out to the circulation for the rest of the body. If blood flow from the coronary arteries to the heart muscle is restricted, not enough oxygen reaches the heart. This is termed ischemia. It can cause chest pain or angina. If blood flow to a portion of the heart muscle is stopped entirely, it can cause cell death, necrosis, and heart attack, or acute myocardial infarction (AMI). The precipitating event that leads to blocking of blood flow is a clot or dislodged plaque particle that prevents blood flow to tissue. Table 8-1 lists risk factors for the development of cardiovascular disease. In the cellular damage process, troponin leaks from the heart tissue and is released into the bloodstream.1 Damage to heart muscle fibers releases CK-MB into the bloodstream as well. Other constituents released by damaged heart cells include...

Passive Smoking and Cardiovascular Diseases

The burden of cardiovascular disease from second hand smoke in the US is estimated to amount to about 35,000-62,000 deaths from CHD per year.19 Conservative estimates for Germany come up with 3700 cases of CHD (fatal and nonfatal) and 1800 cases of stroke (fatal and nonfatal) due to second hand smoke.20

Atherosclerotic Cardiovascular Disease

Cachexia, by virtue of MICS, may predispose CKD patients to atherosclerotic cardiovascular disease 24, 49, 51 . Dialysis patients with coronary heart disease often have hypoalbuminaemia and elevated levels of acute-phase reactants 24 . Moreover, progression of carotid atherosclerosis during dialysis may be related to IL-6 levels 137 . It should be noted that the cascade of inflammatory factors leading to an acute-phase reaction is counter-regulated by various anti-inflammatory cytokines, such as IL-10. Recently, Girndt et al., in a study of 300 haemodialysis patients 138 , showed that the -1082A allele, which is associated with low production of IL-10, is associated with an increased risk of cardiovascular events. Inflammatory processes may promote proliferation and infiltration of inflammatory cells into the tunica intima of small arteries, including the coronary arteries these processes lead to atherosclerosis and stenosis of blood vessels and consequent coronary and other vascular...

Depression Following Myocardial Infarction Prevalence Clinical Consequences and Patient Management

Depressive symptoms and major depression have been consistently reported as common psychological reactions to myocardial infarction (MI). It has also been argued, on the basis of prospective observational evidence, that depression following MI constitutes an independent, that is, causal, risk for subsequent mortality and morbidity. Two recent meta-analyses have examined this evidence. Unadjusted pooled analyses of both meta-analyses indicate that depression following MI is associated with a 2-fold increased risk of death and recurrent cardiac events. However, with adjustment for potential confounders the associations between depression and these outcomes were attenuated. In addition, two recent randomized trials addressing depression in MI patients (SADHART and ENRICHD) observed a relative reduction in depression with treatment, but found no effects of treatment on mortality, nonfatal rein-

Myocardial Infarction

Research in this area has been recently sum-marised.41 Some studies of HRQoL following a myocardial infarction (MI) have used generic or utility instruments.42-44 Others have opted for heart-disease-specific instruments.8'9'12'13 A widely used MI-specific HRQoL instrument is the Quality of Life after Myocardial Infarction (QLMI) questionnaire.8 Since development, it has been further modified to a version called the MacNew QLMI.9 This consists of 26 items in three dimensions -Limitations, Emotions, and Social - with an overall HRQoL score as the sum of the MacNew QLMI dimensions (see Hoefer et al.45 for a review). A number of studies with the MacNew QLMI have shown it predicts later adverse health events.46'47 Predictors of quality of life have also been examined for MI patients. In a large British study, 288 MI patients were followed over the subsequent year. Levels of depression and anxiety during hospitalization did not predict mortality but did predict HRQoL, measured with a...

Returning to Work after Myocardial Infarction

Assisting the patient to resume work after a myocardial infarction is one of the main aims of a comprehensive rehabilitation program after myocardial infarction. A majority of patients will be able to return to work but non-medical factors are more important predictors than medical factors of the likelihood of resuming work. Yet, through vocational counseling, adapted training models and adequate communication with work

Kallikreinkinin Attenuates Cardiac Remodeling After Myocardial Infarction

ACE inhibition has been shown to improve the survival of rats with coronary ligation-induced myocardial infarction and with congestive heart failure (9,10). ACE inhibitors have many beneficial effects in respect to the reduction of morbidity and mortality rates and improvement of the quality of life for patients with heart disease (48,49). Ang II formation in the heart increases after myocardial infarction (50), and elevation of Ang II levels causes cardiac hypertrophy, fibrosis, and apoptosis, leading to cardiac remodeling and heart failure (50-53). A continuous supply of kallikrein kinin may counteract the action of Ang II and thus protect against cardiac remodeling and heart failure. Our studies showed that kallikrein gene transfer improved cardiac and endothelial function and attenuated myocardial infarction in normotensive animals with acute ischemic and chronic heart disease (46,54). Kallikrein gene delivery reduced cardiac remodeling and apoptosis after myocardial infarction...

Myocardial infarction Ml

The acute coronary syndromes (ACS) are now classified on the basis of the ECG and plasma troponin measurements into (1) patients with ST elevation myocardial infarction (STEMI), (2) non-ST elevation myocardial infarction (non-STEMI, by ECG and a positive troponin test) and (3) unstable angina (by ECG and negative troponin test). The present account recognises that this is a rapidly evolving field, but therapeutic strategies are likely to evolve according to these forms of ACS. The immediate objectives are relief of pain and initiation of treatment demonstrated to reduce mortality. Subsequent management of proven myocardial infarction is concerned with treatment of complications, arrhythmias, heart failure and thromboemboli, and then secondary prevention of further myocardial infarctions. 27 Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet 1986 2 57-66...

Kallikrein Gene Delivery Protects Against Ischemic Stroke

Stroke is the third leading cause of death, and the most common cause of long-term disability, in the United States (82). Currently, therapeutic options for the treatment of ischemic stroke are limited primarily to agents that block platelet aggregation or the coagulation cascade (83). However, these antiplatelet agents are only effective in decreasing the incidence of ischemic stroke, and not in reducing cerebral infarct size (83). Stroke-induced neurological deficits and mortality are often associated with timing of treatment after the onset of stroke. The therapy approved for the treatment of acute ischemic stroke is intravenous recombinant tissue-type plasminogen activator initiated within 3 h of symptom onset (84). Focal brain ischemia is the most common event leading to stroke in humans. To prevent or reduce irreversible ischemic brain damage, it is necessary to develop new interventions for acute stroke therapies to meet the large need for this important and undertreated...

Antimicrobials On The Course Of Coronary Artery Disease

One method of evaluating the effect of antiinfective therapy on coronary artery disease has been to retrospectively analyze patient registries to determine an association between the incidence of myocardial infarction and prior use of antibiotic therapy. Results of this endeavor have been mixed. In one of the first published studies, Meir, et al.,(7) in order to determine whether previous use of antibiotics decreases the risk of developing a first-time acute myocardial infarction, evaluated a total of 3,315 case patients aged 75 years or younger with a diagnosis of first-time acute myocardial infarction between 1992 and 1997 and 13,139 controls without myocardial infarction matched to cases for age, sex, general practice attended, and calendar time. Cases were significantly less likely to have used tetracycline antibiotics (adjusted odds ratio OR , 0.70 95 confidence interval Cl , 0.55-0.90) or quinolones (adjusted OR, 0.45 95 CI, 0.21-0.95). No effect was found for previous use of...

For Clinical Coronary Artery Disease

Several small pilot randomized clinical trials of antibiotic therapy for the secondary prevention of coronary artery disease have been reported. Their results are summarized below. In a small study from London(15) 60 stable post-myocardial infarction male patients who were seropositive to Chlamydia pneumoniae were randomized to receive azithromycin (500 mg day for 3 days n 28 or 500 mg day for 6 days n 12 ) or placebo and followed for 18 months, looking for the endpoints

Why Women And Men Experience Different Risk For Heart Attacks

The Food and Drug Administration (FDA) and American Heart Association suggest that women are protected from heart attacks due to lipid plaque before they reach menopause. Estrogen levels in younger women are typically a factor causing them to maintain high levels of HDL in most situations. Once menopause occurs, women experience a reduction in HDL as their estrogen levels decline. Post- menopausal women are at the same risk for coronary artery disease and heart attack as men, particularly if they have risk factors of smoking, elevated cholesterol, elevated triglycerides, family history, and or elevated blood pressure.9'10'17,18 It has only been through recent research that the effect of lowered estrogen levels in postmenopausal women with coronary artery disease has become evident. Previously risk of heart attacks was not studied in women because it was not considered a common event. Also, there currently is evidence that women do not express the same physical symptoms of a heart...

Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction a randomised study

Bonnefoy E, Lapostolle F, Leizorovicz A, et a ., on behalf of the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) Study Group BACKGROUND Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis. METHODS We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n 419) with accelerated alteplase or primary angioplasty (n 421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by...

Primary angioplasty PPCI in STelevation myocardial infarction

Almost all acute ST-elevation myocardial infarction (STEMI) is due to thrombotic occlusion of the coronary artery. Non-STEMI (NSTEMI), diagnosed on the basis of subsequent cardiac troponin (c-Trop-T or c-Trop-I) or creatinine kinase (CPK) rise, but without initial ST elevation on the electrocardiography (ECG) is probably related to intermittent or incomplete coronary occlusion. This chapter deals specifically with the treatment of STEMI. The era of reperfusion as the mainstay of treatment was ushered in with the realization that the occlusive thrombus could be managed by use of a combination of a guidewire to mechanically initiate coronary blood flow and the intracoronary infusion of streptokinase. The recognition that the prompt restoration of flow salvages myocardium, reduces infarct size, and prolongs life has been the driving force behind a large number of clinical trials, assessing thrombolytic therapy for acute myocardial infarction (AMI). The results of these trials, done in...

Cardiovascular Disease Introduction Atherosclerosis

Cardiovascular disease is the major cause of death in the industrialized countries of the world. Most cardiovascular disease is caused by atherosclerosis. Atherosclerosis is a disorder in which fatty plaques deposit within arteries, thickening the walls and reducing blood flow. Often the final event that abruptly closes off a narrowed vessel is the formation of a thrombus. About half of all deaths in Europe and North America are due to the two main forms of cardiovascular disease - myo-cardial infarction (heart attack) and stroke. These disorders kill nearly three times as many people each year as all types of cancer combined.

Cardiac Rehabilitation in Congenital Heart Disease

With the progress in the treatment of congenital heart disease (CHD),more and more affected children reach adulthood. This causes morbidity within this population to be a growing problem which demands special expertise. We expect CHD to be accompanied by deficits in the fields of motor skills, cognition, and emotion (not only in the person affected but also in their social environment). Preventive diagnostics and treatment have to be initiated early, aiming to find deficits and alleviate them through the use of specific measures. This is the reason for rehabilitative intervention in CHD, targeting a long-tem reduction of morbidity and an enhancement of the patient's quality of life.

Exercise Training in Coronary Artery Disease

Training Coronary Artery Disease

In contrast to these encouraging results in pathologic situations, dietary L-arginine uptake was unrelated to the incidence of acute coronary events among 1981 men in the Kuopio Ischaemic Heart Disease Risk Factor Study.22 Among patients with overt atherosclerosis a number of gene polymorphisms of the eNOS gene have been described in recent years. Recent clinical trials suggest that the T768C and the Glu298Asp polymorphism may be associated with an increased risk for premature development of CAD.23,24 However, data are still controversial, with other studies failing to show an association between the Glu298Asp polymorphism and atherosclerotic heart disease.25 Data from training studies with invasive measurement of endothelial function suggest that the improvement of vasomo-tion after exercise is attenuated or even abolished in eNOS promoter (T768C) polymorphisms.26 These data may have important implications for exercise-based rehabilitation strategies. endothelial cells by cell...

Rehabilitation in Congenital Heart Disease

With the availability of long-term follow-up data for the entire spectrum of cardiac defects, it is becoming clear that life-long, qualified care -which may include rehabilitation measures - is required for affected children, adolescents, and adults. The decision on whether rehabilitation measures are required, and at which point and to what extent they are necessary, has to be made on an individual basis. Most frequently rehabilitation has to be initiated directly after surgery. However, rehabilitation measures may also be indicated several years after original intervention. While extensive rehabilitation is currently being offered for adult patients with coronary artery disease, such measures are not widely available to children with CHD.27 Outpatient rehabilitation measures are often not accepted because of the long distances between patients' homes and the rehabilitation institutions. Inpatient care is very rarely offered and can only be carried out if at least one parent is...

Silent myocardial infarction and ischaemia

In view of the increased prevalence of coronary artery disease (CAD) in diabetic patients, it is difficult to differentiate between the impact of coronary ischemia and CAN on cardiac autonomic function. In other words, silent ischemia in diabetic patients may either result from CAN or from autonomic dysfunction due to CAD itself, or both. In the Framingham study, the rates of unrecognised myocardial infarctions were 39 in diabetic subjects and 22 in non-diabetic subjects, but the difference was not significant (Margolis et al. 1973). In a survey from the National Registry of Myocardial Infarction 2 (NRMI-2), of 434,877 patients with myocardial infarction, 33 did not have chest pain on presentation. The rates of patients with diabetes were 32.6 among those presenting without chest pain vs 25.4 among those with (Canto et al. 2000). It has been suggested that features such as sympathovagal balance (see below), impaired fibrinolysis and altered hemostasis, which are commonly clustered...

Gender Differences in Coronary Heart Disease

Coronary heart disease is the leading cause of death and disability among men and women in Western countries. Of the 4 million people in Europe dying every year of cardiovascular disease, 53 are women. In recent decades CHD mortality rates have declined across all age groups among middle-aged and older persons, in a majority of Western countries however, the overall decline rate has been slower in women than in men. The gender difference in CHD mortality has consequently been reduced. Women have a longer life expectancy than men and suffer from clinical manifestations of CHD about 10 years later than men. Younger women have a lower incidence of CHD compared with men the same age, but by age 70 the incidence of CHD is comparable for men and women. This gender differential in CHD incidence is not fully understood. A cardioprotective effect of endogenous estrogens has been hypothesized as the main pathophysiological explanation. In addition, a gender bias among physicians in recognizing...

Complicating Factors in Elderly Patients with Heart Disease

Elderly patients constitute a high percentage of patients with myocardial infarction,heart surgery, and percutaneous transluminal coronary angio-plasty (PTCA). Elderly patients are also at high risk of disability following a cardiovascular event (Table 47-2). The prevalence of diabetes and arterial hypertension is relatively high. There is also an increased incidence of complicated forms of coronary disease such as multi-vessel disease and left main coronary artery disease, severe and unstable angina as well as sinus node dysfunction, conduction disturbances, and heart failure. The risk of complications is increased in elderly patients after myocardial infarction, coronary angiography, PTCA, and surgery of the heart or the thoracic aorta. The duration of hospitalization is usually prolonged. Severe deconditioning may be a consequence of prolonged immobility. The risk of neurological complications and also of cognitive defects after heart surgery is increased. There is also a high...

Cardiovascular Risk Factors

Complicating factors in elderly patients with cardiovascular disease - Increased complication rates after myocardial infarction, coronary arteriography, PTCA and heart surgery The cardiovascular risk profile in elderly patients differs considerably from that in younger patients (Table 47-3). There are fewer smokers but more patients with diabetes and arterial hypertension. The body mass generally decreases with age. The lipid profile shows generally lower triglycerides and a higher HDL cholesterol. Psychosocial risk factors such as hostility, anxiety, and stress are encountered with lower frequency compared to younger patients.1517 The treatment of cardiovascular risk factors in elderly patients is as important as in younger patients. This is mainly due to the fact that cardiovascular disease is more prominent and the risk of acute complications is increased. The treatment includes a combination of lifestyle interventions with optimal medical therapy.

Quantification of coronary atherosclerosis for cardiovascular risk assessment the hole in the doughnut

A tomographical section of a diseased coronary artery, which is characterized by the central lumen and the surrounding thickened vessel wall, roughly resembles a doughnut. Depending on the imaging modality used, this basic coronary anatomy is described from different perspectives. Angiographical techniques described the size and characteristics of the lumen. In contrast, tomographical techniques, including intravascular ultrasound (IVUS), computed tomography (CT), and magnetic resonance imaging (MRI), describe the plaque and the vessel wall. If the overall diameter of the coronary arteries were fixed (as is the case in a pipe of a water faucet), changes in plaque size would always be reflected in luminal dimensions. However, it has become obvious that coronary pathophysiology is far more complex than reflected in the historical comparison of diseased arteries with rusty pipes. This has important implications for the quantitative assessment of coronary artery disease. The following...

Imaging in the Evaluation of the Patient with Suspected Acute Coronary Syndrome

Over the last decade, major advances have been made in the treatment of acute coronary syndromes (ACSs). However, effective implementation of these treatments requires timely and accurate identification of the high-risk patient among all those presenting to the emergency department (ED) with symptoms suggestive of ACS. In the patient population presenting with a diagnostic ECG or those who have typical chest pain and a history of coronary disease, the initial triage and treatment strategies are straight-forward and guideline driven. However, for most patients the diagnosis is not clear-cut and further evaluation is required. The population of patients considered low risk after the initial evaluation accounts for nearly two thirds of ED chest pain patients 1,2 , representing as many as 4 million patients a year in the United States. An additional consideration is that the opportunity for improving outcomes is time-dependent, so that early identification of the patient who has true ACS...

Cardiovascular Disease

The most common cause of death in the community, and of sudden death particularly, is cardiac disease, and within this group, those deaths recorded as resulting from ischemic heart disease or coronary atheroma are the most common. The exact definitions and criteria for the pathological diagnosis of significant ischemic heart disease (8) are not within the scope of this chapter. Although there is a clear increase in the incidence of this cause of death with age (9), it is important to remember that a small percentage of people in the younger age groups, most commonly those with hypercholesterolemia and hyperlipidemia, may also have significant coronary artery disease, and because the younger age groups are more likely to be arrested by the police, these few individuals may assume great significance. Individuals suffering from significant myocardial hypertrophy resulting from chronic hypertension are also at greater risk during periods of stress. Once again, it is the older age groups...

The Causes of Exercise Intolerance in Cardiovascular Diseases

Exercise intolerance is a key feature of most cardiovascular diseases. Its value for describing the stage of the disease is so important that standardized classification systems of exercise limitation (i.e. the New York Heart Association Classification) were developed more than half a century ago. While the symptoms of reduced maximal exercise capacity may be similar, the underlying mechanisms causing exercise limitations are fundamentally different between major disease entities In stenotic coronary artery disease (CAD) the patient is limited by the mismatch between myocardial perfusion and oxygen demand during physical exertion. The onset of relative myocardial ischemia determines the exercise capacity and is typically characterized by the development of angina pectoris. However, coronary stenoses are not the only source of myocardial ischemia - frequently they only become hemodynamically relevant in the presence of endothelial dysfunction, where an additional vasoconstriction can...

Association ofLpPLA2 With Cardiovascular Risk

Initial evidence for an association of Lp-PLA2 with cardiovascular risk came from the West of Scotland Coronary Prevention Study (WOSCOPS), a large primary prevention trial of men at high risk that was primarily initiated to evaluate the effect of pravastatin therapy on reduction of CHD (26). Of6595 middle-aged men with hypercholesterolemia and no preexisting CHD, 580 with subsequent coronary events (nonfatal myocardial infarction MI , CHD death, or coronary revascularization procedure) that occurred during a 4.9-yr follow-up were enrolled as case subjects and compared with 1160 event-free participants, matched for age and smoking. Elevated Lp-PLA2 concentrations at baseline were associated with an increased risk of subsequent coronary events. The relative risk (RR) associated with an increase ofone standard deviation (SD) in Lp-PLA2 was 1.18 (95 confidence interval CI 1.05-1.33 p 0.005) after controlling for traditional risk factors and was independent of various other biomarkers...

Cardiovascular Diseases

Several studies have demonstrated that natural deaths at the wheel are fairly uncommon and that the risk for other persons is not significant (5,6). Even so, requirements for commercial drivers are generally much more rigid than for individuals, and in the United States, the Federal Highway Administration prohibits drivers with angina or recent infarction from driving. The length of prohibition varies from state to state. Restrictions for noncommercial car driving after first acute myocardial infarction are 4 weeks in United Kingdom but only 2 weeks in Australia. In the United States, they are entirely at the discretion of physicians. In general, ischemia itself is not considered an absolute disqualification, provided treadmill stress testing demonstrates that moderate reserves are present (7). Similarly, individuals with controlled hypertension are usually considered fit to drive, although physicians, no matter what country they are in, must give serious thought to just what sort of...

Association of sPLA2II With Cardiovascular Risk

The concentration of circulating sPLA2-II in blood has been demonstrated to predict coronary events. Among 142 consecutive patients with angiographically proven, stable coronary artery disease (CAD) and 93 control subjects, significantly higher sPLA2-II levels were seen in case patients compared with control subjects (63). A strong and positive correlation between sPLA2-II and CRP was also observed (r 0.53). Furthermore, patients with CAD were followed for a mean duration of17.2 mo, during which 48 coronary events occurred. Kaplan-Meier analysis as well as Cox models revealed that subjects with higher levels of sPLA2-II (> 366 ng dL) had a significantly higher risk of developing future coronary events such as coronary revascularization, MI, and coronary death than those with the lowest concentration (< 246 ng dL). This prognostic value of sPLA2-II was independent of traditional cardiovascular risk factors and various biochemical markers, including CRP (odds ratio OR 3.3 95 CI,...

Association ofoxLDL With Cardiovascular Risk

To date, a number of cross-sectional studies have examined the involvement of oxidative modification of LDL in subjects with clinical evidence of CVD. Clinical studies (72, 73) have demonstrated that patients with both stable CHD and acute coronary syndrome (ACS) have elevated plasma levels of oxLDL compared with apparently healthy control subjects. A positive association between oxLDL and severity of ACS was found by Ehara et al. (74), who reported that oxLDL concentrations were significantly higher in patients with MI than in patients with unstable or stable angina pectoris or age-matched control subjects. Findings from other studies suggest that plasma levels of oxLDL represent a more sensitive marker for the presence of CAD than the Global Risk Assessment Score

Association of LPL With Cardiovascular Risk

Epidemiological evidence on the potential role of LPL in CHD remains scarce and controversial. The association between LPL activity and mass and the presence of CAD were studied in a large cohort of patients with CAD participating in the Regression Growth Evaluation Statin Study (124). Patients with the lowest LPL activity reported more severe angina pectoris according to New York Heart Association classification, compared with patients in the highest quartile ofthe LPL distribution. The results of a small case-control study from Japan also showed considerably lower levels of preheparin serum LDL mass in patients with coronary atherosclerosis, compared with those in healthy men (125). Another case-control study (126) included 194 patients with and without angiographically proven CAD (n 158 and 36, respectively) and demonstrated no differences in LPL activity or concentration between these groups. In addition, no association between LPL quartile distribution and severity and extension...

Box 2 Unique factors in patients with a history of coronary artery disease that affect stress test results

Diabetic patients represent a group with increased risk and a high rate of atypical symptoms for CAD. Cardiovascular disease is the leading cause of death in diabetic patients, and the prevalence of CAD in some diabetic populations is over 50 23 . Detection of CAD and risk stratification is often confounded by several unique features, including the markedly increased risk in female diabetics, lower predictive value of LDL cholesterol, and high rate of silent myocardial ischemia. In addition, diabetic patients often have poor exercise tolerance and nonspecific ST segment alterations that can result in nondiagnostic or false-positive exercise testing (Box 3) 41 .

Ischemic Heart Disease and Systemic Atherosclerosis Including Stroke and PostAMI Therapy

Against this background, a new era in cholesterol intervention research began, namely, the principle of head-to-head comparisons between different statins. The three most important studies performed with this aim were the PROVE-IT,23 Treating to New Targets (TNT),24 and the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL)25 studies. In the PROVE-IT trial23 more than 4000 patients with acute coronary syndrome were randomized to pravastatin 40 mg daily or atorvastatin 80 mg daily, and followed for 2.5 years. While the group treated with pravastatin achieved a mean LDL cholesterol reduction to about 2.5mmol L, the atorvastatin group achieved a mean LDL cholesterol level of 2.0mmol L. Notably, after only 30 months of follow-up, the study showed that the risk of death or cardiovascular events in the ator-vastatin group was significantly reduced by 16 compared to the pravastatin group. Amidst this intriguing development came the publication of the IDEAL study,25...

Valvular Heart Disease

Pharmacotherapy in prevention and rehabilitation applies also for patients with valvular heart disease. The main purpose is the prevention of infective endocarditis. This is a disease of valves and neighboring endovascular intracardiac struc tures due to infection with microorganisms. The primary preventive principle is a prophylactic antibiotic course in all patients at risk in whom bacteremia is expected.63 These include patients with prosthetic heart valves, patients with surgically corrected congenital cardiac abnormalities, and patients with moderate to severe congenital or acquired valvular heart disease. This includes patients with mitral valve prolapse if substantial mitral incompetence is present, patients with bicuspid aortic valves, as well as patients with a previous history of infective endocarditis.

Plasma Proteomics in Cardiovascular Disease

The plasma proteome is unique in that it does not represent a particular cellular genome but, instead, reflects the collective expression of all cellular genomes. It has thus far been poorly characterized. Twenty-two of the most abundant proteins, including albumin and the immunoglobulins, comprise 99 ofthe plasma proteome mass. Many of the biologically interesting molecules relevant to cardiovascular disease (CVD) are low-abundance proteins. For example, cardiac markers such as troponin are found in the nanomolar range, insulin in the picomolar range, and tumor necrosis factor-a in the femtomolar range. In all, there are an estimated 10,000 unique proteins in the plasma, with concentrations spanning a dynamic range over 9 orders of magnitude (Fig. 5). However, some hypothesize that the entire set ofmore than 300,000 estimated human polypeptide species resulting from splice variants and posttranslational modifications is potentially represented in the plasma proteome. This is possible...

Prophylactic Use of PBlockers in Myocardial Infarction

Randomized, controlled clinical trials have demonstrated that -adrenergic blockade decreases not only the incidence of ventricular fibrillation (VF) within the first few days of acute myocardial infarction (ISIS Collaborative Group 1988 Ryden et al. 1983), but also late sudden arrhythmic death mortality up to 1-3 years after infarction primarily (Anonymous 1981 Anonymous 1982). In pooled data from 18,000 patients treated over long-term post-infarct periods with several different P-blockers, sudden death was reduced 32 -50 (Yusuf et al. 1985). Moreover, a recent report showed that in pooled data from two post-myocardial infarction trials (Cairns et al. 1997 Julian et al. 1997), total mortality rate reduction was greater when P-blockers were administered along with the broad-spectrum antiarrhythmic amiodarone compared with amiodarone alone (Boutitie et al. 1999). This result indicates that amiodarone, which has non-competitive P-antagonist properties, does not replace P-blockers, and it...

PBlockers in Patients with Other Structural Heart Diseases and Ventricular Arrhythmias

Patients who survive life-threatening ventricular tachyarrhythmias, such as sustained monomorphic ventricular tachycardia (VT), polymorphic VT or VF, are at high risk for recurrent arrhythmias. When these tachyarrhythmias occur in the setting of structural heart disease, they can usually be provoked by programmed electrical stimulation. In most patients, P-blockers have little effect in preventing inducibility of the arrhythmia or in terminating VT. The anti-fibrillatory mechanisms by which P-blockers reduce sudden death in ischemic heart disease and CHF are not understood completely. However, in experimental and clinical studies, P-blockers increase VF threshold and reduce dispersion of repolarization in the ischemic myocardium (Reiter and Reiffel 1998). Moreover, P-blockers attenuate ventricular remodeling (Eichhorn and Bristow 1996 St John and Ferrari 2002), indicating the role of modification of development of the substrate for lethal ventricular arrhythmias. Other structural...

Exercise testing in the prognostic evaluation of patients with lung and heart diseases

Exercise tolerance is a well recognised predictor of mortality in healthy subjects 1-3 , as well as in patients with pulmonary and cardiovascular disease 4 . In clinical practice, physiological measurements obtained during the most commonly used exercise protocols, such as cardiopulmonary exercise testing (CPET) and the 6-min walking test (6MWT), are proving more useful than resting physiological measurements in the prognostic evaluation of these patients. CPET and 6MWT also represent the tests of choice for the selection of candidates for therapeutic procedures, such as transplantation and thoracic surgery. The aim of the present chapter is to focus on the main cardiac and respiratory diseases for which exercise tolerance evaluation is indicated, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), interstitial lung disease (ILD), primary pulmonary hypertension (PPH), chronic heart failure (CHF) and congenital heart disease (CHD). This chapter also focuses on...

Coronary Artery Disease

The patient who presents with chest pain needs to be thoroughly evaluated. A complete history and physcial is first undertaken, taking special care to note the presence of cardiac risk factors history of premature family history of CAD, hypertension, diabetes, obesity, hypercholesterolemia and smoking. A physical examination should focus on the cardiovascular system, followed by laboratory assessment of cardiac enzymes (troponin, CPK and MB), a chest x-ray and electrocardiogram. Suspicion of an acute coronary syndrome (unstable angina or acute myocardial infarction) requires oxygen therapy, nitrates and aspirin therapy (unless contraindicated), blood pressure therapy (first line therapy of acute coronary syndromes is beta-blockers) and serial electrocardiograms and cardiac enzymes. Evidence of an acute myocardial infarction by either enzyme analysis or electrocardiogram usually requires immediate therapy with either thrombolytics or angioplasty. Currently there are several...

Transplantation Of Nt2n Cells In Stroke Patients

The preclinical studies (see above) demonstrating successful implantation of human-derived NT2N neurons into rat brains paved the way for limited clinical trials. The target stroke patients chosen were at a chronic stage because laboratory data indicated the possibility of reversing motor symptoms associated with a stable stroke. The Food and Drug Administration approved phase I clinical trials of transplantation of NT2N neurons to evaluate this therapy in patients with stable stroke. NT2N cells were transplanted into patients with basal ganglia stroke and fixed motor deficits, including 12 patients ages 44-75 yr, with an infarct of 6 mo to 6 yr who were stable for at least 2 mo (62). Serial evaluations at 12-18 mo showed no adverse cell-related serologic or imaging-defined effects. These results suggest that transplantation of NT2N cells is feasible in patients with motor infarction. The intracranial transplantation of certain stem cell lines has been shown to induce tumor formation...

Definition of nonstelevation acute coronary syndrome

Although acute coronary syndrome (ACS) constitutes a continuum, it is usually divided into ST-elevation ACS (STEACS) and non-ST-elevation ACS (NSTEACS) according to the electrocardiogram (ECG) changes at presentation (Fig. 1). Patients presenting with symptoms of acute cardiac ischemia and ST-elevation on the ECG are referred to as having STEACS. Owing to the high specificity of ST-elevation, STEACS is, in practice, equivalent to ST-elevation myocardial infarction (STEMI). Patients presenting with new left bundle branch block, which prevents evaluation of the ST-segment, should be treated similarly to those with ST-elevation. Patients with other or no ischemic ECG changes are referred to as having non-STEACS. The NSTEACS group is further divided into non-ST-elevation myocardial infarction (NSTEMI) and unstable angina, based on the presence or absence of myocardial necrosis.

Blood Lipids and Heart Disease

Inulins and fructooligosaccharides help maintain the health of the cardiovascular system and may reduce the risk of heart disease. A key factor in this is the maintenance or improvement of blood lipid composition, through decreases in triglycerides (triacylglycerols), and the lowering of cholesterol and homocysteine levels (Hidaka et al., 2001 Luo et al., 1996 Tungland, 2003). Convincing lipid-lowering effects have been demonstrated in animals (e.g., Delzenne et al., 1993 Fiordaliso et al., 1995 Kok et al., 1998 Trautwein et al., 1998). Rats on inulin-rich diets, for example, had lower blood cholesterol and total lipid levels than control animals, while reductions in serum triglycerides were reported for rats on diets containing 5 to 20 fructooligosaccharides (Roberfroid, 1993). However, the situation is less clear-cut for humans, where higher inulin doses (over 30 gday-1) can produce adverse gastrointestinal symptoms (Williams, 1999). Some human studies have found no effects, while a...

Pathogenesis of Heart Disease and Targets for Gene Therapy

Damage initiated during ischemia (61-63). In time, the left ventricle undergoes a process of remodeling characterized by myocyte hypertrophy, interstitial fibrosis, chamber dilatation, and increased propensity for contractile dysfunction that ultimately leads to ventricular failure (64). The remodeling process is complex and highly dependent on the activity of matrix metalloproteinases (MMPs), a group of zinc-dependent proteases that are involved in extracellular matrix degradation (65). Chronic ischemic heart disease is also characterized by heightened inflammatory state and oxidative stress (66,67). The increased levels of proinflammatory cytokines depress myocardial contractility and activate neurohormonal systems such as the renin-angiotensin system, which promote ventricular fibrosis and remodeling.

Coronary angioplasty with or without stent implantation for acute myocardial infarction

Grines CL, Cox DA, Stone GW, et a ., The Stent Primary Angioplasty in Myocardial Infarction Study Group BACKGROUND Coronary-stent implantation is frequently performed for treatment of acute myocardial infarction. However, few studies have compared stent implantation with primary angioplasty alone. METHODS We designed a multicenter study to compare primary angioplasty with angioplasty accompanied by implantation of a heparin-coated Palmaz-Schatz stent. Patients with acute myocardial infarction underwent emergency catheterization and angioplasty. Those with vessels suitable for stenting were randomly assigned to undergo angioplasty with stenting (452 patients) or angioplasty alone (448 patients). RESULTS The mean ( SD) minimal luminal diameter was larger after stenting than after angioplasty alone (2.56 0.44mm vs. 2.12 0.45mm, p < 0.001), although fewer patients assigned to stenting had grade 3 blood flow (according to the classification of the Thrombolysis in Myocardial Infarction...

Cardiac Malformations and Coronary Artery Disease

Coronary Artery Disease GENICA Study The GENICA Study identified novel risk factors for coronary artery disease. It has recently been reported that the C allele at the T-786C endothelial nitric oxide synthase (eNOS) polymorphism is associated with a higher risk of multivessel coronary artery disease in Caucasians (73). Although an impaired endothelium-dependent vasodilation (74) is associated with accelerated atherosclerosis, such as arterial hypertension, cigarette smoking, diabetes mellitus, hypercholesterolemia, hyperhomocysteinemia and aging (75,76), a blunted nitric oxide (NO)-mediated endothelium-dependent vasodila-tion was found to predict cardiovascular events independently of the common risk factors (77). NO is involved in atherogenesis (78-80), development of heart failure, and congenital septal defects and vascular remodeling, as shown by data from mice lacking the eNOS gene (79,81). NO, by blunting the activity of the nuclear factor-KB family of transcription...

Selective cine coronary arteriography correlation with clinical findings in 1000 patients

In the absence of definite electrocardiographic diagnosis of myocardial infarction, clinical diagnosis of coronary disease has been dependent principally on the elicitation and proper evaluation of the history, and therefore, the accuracy has varied with the care, ability, and experience of the physician. In other fields of medicine in which clinical diagnosis can be compared with those based on objective criteria, it is evident that errors in clinical diagnoses are common. The development of selective cine coronary arteriography has made possible the correlation of clinical syndromes and evidence of arterial obstruction during life. If this method of study is valid, there should be a close relationship between the typical clinical syndromes (angina pectoris and myocardial infarction) and the presence of significant arteriographic abnormality. that mild degrees of obstruction rarely cause angina pectoris or myocardial infarction. Arterio-graphical evidence of obstruction is almost...

Relation of arterial geometry to luminal narrowing and histological markers for plaque vulnerability the remodeling

Yamagishi M, Terashima M, Awano K, et al. Morphology of vulnerable coronary plaque insights from follow-up of patients examined by intravascular ultrasound before an acute coronary syndrome. J Am Coll Cardiol 2000 35 106-111. 3. Kotani J, Mintz GS, Castagna MT, et al. Intravascular ultrasound analysis of infarct-related and non-infarct-related arteries in patients who presented with an acute myocardial infarction. Circulation 2003 107 2889-2893. Both plaque and vessel area were geometrical determinants of the presence of markers related to plaque vulnerability. The type of arterial remodelling may have a dual impact on luminal narrowing. Compensatory enlargement will retard chronic luminal narrowing, but it might enhance the risk of plaque rupture and, hence, acute luminal narrowing or occlusion. Conversely, paradoxical shrinkage will accelerate chronic luminal narrowing, but it might reduce the risk of plaque rupture and, hence, acute luminal narrowing or occlusion. Future studies...

Andersen HR Nielsen TT Rasmussen K et al for the DANAMI2 Investigators Reference

BACKGROUND For the treatment of myocardial infarction with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities. Whether this benefit is maintained for patients who require transportation from a community hospital to a center where invasive treatment is available is uncertain. METHODS We randomly assigned 1572 patients with acute myocardial infarction to treatment with angioplasty or accelerated treatment with intravenous alteplase 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 invasive-treatment centers. The primary study end point was a composite of death, clinical evidence of reinfarction, or disabling stroke at 30 days. RESULTS Among patients who underwent randomization at referral hospitals, the primary end point was reached in 8.5 percent of the patients in the angioplasty group, as compared with 14.2 percent of those in the fibrinolysis group (p 0.002)....

Zijlstra F Patel A Jones M et al Reference

AIMS We examined the clinical characteristics and outcome of patients with early (< 2h), intermediate (2-4 h) and late (> 4 h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction. METHODS AND RESULTS We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n 1302) vs thrombolytic therapy (n 1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories early presentation (< 2h), intermediate presentation (2-4 h), and late presentation ( 4h). At 30 days the combined rate of death, nonfatal reinfarction and stroke in patients presenting early was 5.8 in the angioplasty group vs 12.5 in the thrombolysis group, in patients with intermediate...

De Feyter PJ Serruys PW Arnold A et al Reference

This study is a retrospective analysis of the efficacy of percutaneous transluminal coronary angioplasty (PTCA) of the ischaemia-related vessel in patients with unstable angina. Forty-three patients had multivessel disease with dilatation of the ischaemia related vessel only (group I partial revascularization) while 111 patients had single vessel disease only (group II total revascularization). The initial success rate in both groups was identical (88 versus 88 ). The need for emergency coronary artery bypass surgery was similar in the two groups (group I 12 versus group II 9 NS). The total post PTCA myocardial infarction rate (despite urgent CABG) was also similar in the two groups (group I 9 versus group II 10 NS). The results of electrocardiographic exercise testing and Thallium-201 scintigraphy provide objective evidence for incomplete revascularization in group I. The maximum workload achieved was lower, and the frequency of exercise induced angina, ST-segment depression and...

Klein LW Kramer BL Howard E Lesch M Reference

This study examined procedural details and in-hospital events in a series of elective angio-plasties to establish the significance of post-angioplasty creatinine kinase (CK) and CK-MB elevation. All patients with major in-hospital events after angioplasty (death, cardiac arrest, Q wave myocardial infarction (Ml) and emergency coronary artery bypass grafting, CABG) were excluded. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q wave myocardial infarction. Results of the TIMI IIIB trial. Thrombolysis in myocardial ischemia

The Timi Iiib Investigators Reference

BACKGROUND Although coronary thrombosis plays a critical role in the pathogenesis of unstable angina and non-Q-wave myocardial infarction (NQMI), the effects of thrombolytic therapy in these disorders is not clear. Also, the role of routine early coronary angiography followed by revascularization has not been established. METHODS AND RESULTS Patients (n 1473) seen within 24 hours of ischemic chest discomfort at rest, considered to represent unstable angina or NQMI, were randomized using a 2 x 2 factorial design to compare (1) TPA versus placebo as initial therapy and (2) an early invasive strategy (early coronary arteriography followed by revascularization if initial medical therapy failed). All patients were treated with bedrest, anti-ischemic medications, aspirin, and heparin. The primary end point for the TPA-placebo comparison (death, myocardial infarction, or failure of initial therapy at 6 weeks) occurred in 54.2 of the TPA-treated patients and 55.5 of placebo-treated patients...

The EPIC Investigators Reference

BACKGROUND Platelets are believed to play a part in the ischemic complications of coronary angioplasty, such as abrupt closure of the coronary vessel during or soon after the procedure. Accordingly, we evaluated the effect of a chimeric monoclonal-antibody Fab fragment (c7E3 Fab) directed against the platelet glycoprotein IIb IIIa receptor, in patients undergoing angioplasty who were at high risk for ischemic complications. This receptor is the final common pathway for platelet aggregation. METHODS In a prospective, randomized, double-blind trial, 2099 patients treated at 56 centers received a bolus and an infusion of placebo, a bolus of c7E3 Fab and an infusion of placebo, or a bolus and an infusion of c7E3 Fab. They were scheduled to undergo coronary angio-plasty or atherectomy in high-risk clinical situations involving severe unstable angina, evolving acute myocardial infarction, or high-risk coronary morphologic characteristics. The primary study end point consisted of any of the...

Cannon CP Weintraub WS Demopoulos L et al for the TACTlCS Thrombolysis in Myocardial lnfarction 18 lnvestigators

BACKGROUND There is continued debate as to whether a routine, early invasive strategy is superior to a conservative strategy for the management of unstable angina and myocardial infarction without ST-segment elevation. METHODS We enrolled 2220 patients with unstable angina and myocardial infarction without ST-segment elevation who had electrocardiographic evidence of changes in the ST segment or T wave, elevated levels of cardiac markers, a history of coronary artery disease, or all three findings. All patients were treated with aspirin, heparin, and the glycoprotein IIb IIIa inhibitor tirofiban. They were randomly assigned to an early invasive strategy, which included routine catheterization within 4 to 48 hours and revascularization as appropriate, or to a more conservative (selectively invasive) strategy, in which catheterization was performed only if the patient had objective evidence of recurrent ischemia or an abnormal stress test. The primary end point was a composite of death,...

Highrisk coronary intervention a selective literature review of highrisk subsets

The use of percutaneous coronary intervention (PCI) to treat ischaemic coronary artery disease (CAD) has expanded dramatically over the past 25 years. From its incipience as an alternative to coronary bypass surgery in selected patients with single-vessel disease, PCI has evolved into the preferred revascularization strategy in the 900,000 patients who undergo this procedure annually in the USA. The safety and durability of PCI have improved dramatically since 1979 1 , due to continual technological improvements (e.g. drug-stents, distal protection devices), refinements in peri-procedural adjunctive pharmacology (e.g. glycoprotein lib Ilia GP lib Ilia inhibitors, alternative thrombin inhibitors), and a better understanding of early and late outcomes associated with low- and high-risk patients. This review will focus on the pivotal literature that describes the clinical outcomes of patients undergoing high-risk coronary intervention. We begin with a description of the percutaneous...

Best PJ Lennon R Ting HH et al Reference

Renal insufficiency is a strong predictor of death and subsequent cardiac events in a dose-dependent fashion during and after percutaneous coronary intervention (PCI). Patients with renal insufficiency have more baseline cardiovascular risk factors, but renal insufficiency is associated with an increased risk of death and other adverse cardiovascular events, independent of all other measured variables.

Cowley MJ Mullin SM Kelsey SF et al Reference

To assess whether gender influenced the outcome of percutaneous transluminal coronary angioplasty (PTCA), early outcomes were compared in 705 women and 2374 men enrolled in the NHLBI PTCA Registry. Women were older (p < 0.01) and had more unstable angina (p < 0.01), and class 3 or 4 angina (p < 0.01). Men had more multivessel disease (p < 0.01), prior bypass surgery (p < 0.01), and abnormal left ventricular function (p < 0.05). Women had a lower angiographic success rate (60.3 versus 66.2 in men p < 0.01) and had a lower clinical success rate (56.6 versus 62.2 in men p < 0.01). More women had complications (27.2 versus 19.4 in men p < 0.01), but overall frequency of major complications (death, myocardial infarction, emergency surgery) was not different (9.8 versus 9.3 in men). Women had a higher incidence of coronary dissection (p < 0.05) and higher in-hospital mortality (1.8 versus 0.7 in men p < 0.01). PTCA-related mortality was nearly six times higher in women...

Kip KE Faxon DP Detre KM Yeh W Kelsey SF Currier JW Reference

Patients with diabetes mellitus are at increased risk for cardiovascular disease. Data on baseline clinical and angiographic characteristics and short- and long-term outcomes of 281 diabetic and 1833 nondiabetic PTCA patients in the multicenter National Heart, Lung, and Blood Institute 1985-1986 PTCA Registry were analyzed. Diabetic patients were older, were more likely to be female, and had more co-morbid baseline conditions, triple vessel disease, and atherosclerotic lesions. Angiographic success and completeness of revascularization did not differ significantly, yet diabetic patients experienced more in-hospital death (women) and nonfatal myocardial infarction. Nine-year mortality was twice as high in diabetic patients (35.9 versus 17.9 ). Similarly, 9-year rates of nonfatal myocardial infarction (29.0 versus 18.5 ), bypass surgery (36.7 versus 27.4 ), and repeat PTCA (43.7 versus 36.5 ) were higher in diabetics than in nondiabetics. In multivariate analysis, diabetes remained a...

Holmes DR Detre KM Williams DO Kent KM King SB Yeh W Steenkiste A Reference

Coronary revascularization with bypass has been shown to improve survival in patients with coronary artery disease and left ventricular dysfunction. The purpose of this investigation was to characterize the outcome of angioplasty in patients with decreased left ventricular function and contrast it with the results in patients with normal left ventricular function. In the 1985-1986 National Heart, Lung, and Blood Institute's percutaneous transluminal coronary angioplasty (PTCA) Registry, of 1802 patients undergoing PTCA, 244 patients (13.5 ) had an ejection fraction of 45 (mean, 39.6). These patients had a higher incidence of prior infarction, a longer and worse history of manifestations of coronary disease, and more extensive coronary artery disease than patients with well-preserved function 88 and 91 , respectively, had successful dilation of at least one lesion (non-significant difference). However, patients with decreased left ventricular function had a decreased frequency of...

Detre K Holubkov R Kelsey S et al Reference

In August 1985, the Percutaneous Transluminal Coronary Angioplasty Registry of the National Heart, Lung, and Blood Institute reopened at its previous sites to document changes in angioplasty strategy and outcome over time. The new registry entered 1802 consecutive patients who had not had a myocardial infarction in the 10 days before angioplasty. Patient selection, technical outcome, and short-term major complications were compared with those of the 1977 to 1981 registry cohort. The new-registry patients were older and had a significantly higher proportion of multivessel disease (53 versus 25 , p < 0.001), poor left ventricular function (19 versus 8 , p < 0.001), previous myocardial infarction (37 versus 21 , p < 0.001), and previous coronary bypass surgery (13 versus 9 , p < 0.01). The new-registry cohort also had more complex coronary lesions, and angioplasty attempts in these patients involved more multivessel procedures. Despite these differences, the in-hospital outcome...

Platko WP Hollman J Whitlow PL Franco I Reference

Percutaneous transluminal angioplasty was used to treat 101 patients with saphenous vein bypass graft stenosis at a mean of 50.1 months (range 2 to 196) after coronary artery bypass surgery. The patients presented between March 1981 and April 1987. A total of 107 saphenous vein grafts were dilated at 117 sites. The primary success rate was 91.8 . The incidence of cardiac complications was 7.1 . There were no cardiac complications in 53 patients with grafts implanted less than 36 months before angioplasty (Group 1). The 48 patients with grafts implanted for greater than 36 months (Group 2) had a 12.5 incidence rate of myocardial infarction, a 4 incidence rate of emergent bypass surgery and a 4 incidence rate of death for an overall cardiac complication rate of 14.9 (p less than 0.01). Follow-up was obtained at a mean of 16.8 13.9 months (range 1 to 54) in 87 patients (97 of successful cases). Repeat coronary angiography was performed in 49 patients and revealed restenosis in 30...

Holmes DR Vlietstra RE Reeder GS et al Reference

Percutaneous transluminal coronary angioplasty was attempted without streptokinase in 24 patients with total coronary artery occlusion but without acute transmural myocardial infarction. The maximal duration of occlusion was estimated to be 1 week or less in 10 patients, more than 1 to 4 weeks in 6, more than 4 to 12 weeks in 3 and more than 12 weeks in 5. Dilation of the occluded artery was attempted in the left anterior descending coronary artery in 17 patients, in the right coronary artery in 4 and in the circumflex coronary artery in 3. Angioplasty was successful in 13 patients (54 ) left anterior descending coronary artery in 59 , right coronary artery in 50 and circumflex coronary artery in 33 . In patients with successful dilation, there was a mean decrease in coronary artery stenosis from 100 to 23 . In the 19 patients whose occlusion was estimated to be of 12 weeks' duration or less, angioplasty was successful in 68 . In the five patients whose occlusion was estimated to be...

Sigwart U Puel J Mirkovitch V Joffre F Kappenberger L Reference

In this paper, the investigators describe their experience deploying self-expanding stents in peripheral and coronary arteries. The authors used a canine model to demonstrate the feasibility of deploying self-expanding stents in the femoral and coronary arteries of mongrel dogs. Examination of the stents and arterial segments at 9 months demonstrated endothelialization of stent struts with a smooth neointimal layer. The authors then turned their attention to human subjects. In coronary arteries, procedural success was over 90 . In the four patients who received a stent for failed angioplasty, successful delivery of a stent restored coronary blood flow and averted the need for emergency coronary bypass surgery. During follow-up three patients developed stent thromboses (17 ) and one patient died (6 ). There were no cases of in-stent restenosis, though two patients developed new, symptomatic stenoses at sites remote from the coronary stent.

Jeptha P Curtis John F Setaro

Subsequent studies demonstrated the utility of stents in a variety of patients and lesion subgroups including acute myocardial infarction, diabetics, total occlusions, saphenous vein grafts, and long lesions. Simultaneously, stent manufacturers have continuously improved their technology, creating stents with thinner struts, increased radial support, and improved deliverability. Undoubtedly the most important advance since the original introduction of coronary stents has been the development and approval of drug-eluting stents which have dramatically decreased the incidence of clinical and angiographical restenosis.

Serruys PW Unger F Sousa JE Jatene A Bonnier HJRM Schnberger JPAM Buller N Bonser R van den Brand MJB van Herwerden LA

BACKGROUND The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease. METHODS A total of 1205 patients were randomly assigned to undergo stent implantation or bypass surgery when a cardiac surgeon and an interventional cardiologist agreed that the same extent of revascularization could be achieved by either technique. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at one year. The costs of hospital resources used were also determined. RESULTS At one year, there was no significant difference between the two groups in terms of the rates of death, stroke, or myocardial infarction. Among patients who survived without a stroke or a myocardial infarction, 16.8 percent of those in the stenting group underwent a second...

Stone GW Grines CL Cox DA et al for the Controlled Abciximab and Device Investigation to Lower Late Angioplasty

BACKGROUND As compared with thrombolytic therapy, primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction reduces the rates of death, reinfarc-tion, and stroke, but recurrent ischemia, restenosis, and reocclusion of the infarct-related artery remain problematic. When used in combination with PTCA, coronary stenting and platelet glycoprotein IIb IIIa inhibitors may further improve outcomes. METHODS Using a 2-by-2 factorial design, we randomly assigned 2082 patients with acute myocardial infarction to undergo PTCA alone (518 patients), PTCA plus abciximab therapy (528), stenting alone with the MultiLink stent (512), or stenting plus abciximab therapy (524). RESULTS Normal flow was restored in the target vessel in 94.5 to 96.9 percent of patients and did not vary according to the reperfusion strategy. At six months, the primary end point - a composite of death, reinfarction, disabling stroke, and ischemia-driven revascularization of the target vessel...

Widimsky P Budesinsky T Vorac D et al Prague Study Group Investigators Reference

BACKGROUND Primary percutaneous coronary intervention (PCI) is shown to be the most effective reperfusion strategy in acute myocardial infarction (AMI). The aim of this multicentre national randomized mortality trial was to test whether the nationwide change in treatment guidelines (transportation of all patients to PCI centres) was warranted. METHODS The PRAGUE-2 study randomized 850 patients with acute ST elevation myocardial infarction presenting within < 12 h to the nearest community hospital without a catheter laboratory to either thrombolysis in this hospital (TL group, n 421) or immediate transport for primary percutaneous coronary intervention (PCI group, n 429). The primary end-point was 30-day mortality. Secondary end-points were death reinfarction stroke at 30 days (combined end-point) and 30-day mortality among patients treated within 0-3 h and 3-12 h after symptom onset. Maximum transport distance was 120 km. RESULTS Five complications (1.2 ) occurred during the...

Moses JW Leon MB Popma JJ et a for the Sirius Investigators Reference

BACKGROUND Preliminary reports of studies involving simple coronary lesions indicate that a sirolimus-eluting stent significantly reduces the risk of restenosis after percutaneous coronary revascularization. METHODS We conducted a randomized, double-blind trial comparing a sirolimus-eluting stent with a standard stent in 1058 patients at 53 centers in the United States who had a newly diagnosed lesion in a native coronary artery. The coronary disease in these patients was complex because of the frequent presence of diabetes (in 26 percent of patients), the high percentage of patients with longer lesions (mean, 14.4 mm), and small vessels (mean, 2.80 mm). The primary end point was failure of the target vessel (a composite of death from cardiac causes, myocardial infarction, and repeated percutaneous or surgical revascularization of the target vessel) within 270 days. RESULTS The rate of failure of the target vessel was reduced from 21.0 percent with a standard stent to 8.6 percent with...