Comparison of six-month outcomes of percutaneous transluminal coronary angioplasty in patients > or =75 with those <75 years of age (the ROSETTA registry).
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Age Factors↗
Biomedical subjects
D Schechter
Publications and source records attributed to D Schechter.
Use of routine functional testing after percutaneous transluminal coronary angioplasty: results from the ROSETTA Registry.
BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for exercise testing suggest that only selected groups of high-risk patients should undergo routine functional testing after percutaneous transluminal coronary angioplasty (PTCA) for the detection of restenosis. OBJECTIVES: Our purpose was (1) to document the patterns of use of post-PTCA functional testing and (2) to determine whether the choice of functional testing strategy is related to clinical characteristics of patients or whether physicians use a similar strategy for all their patients. METHODS: The Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) Registry is a prospective study examining the use of functional testing among 788 patients at 13 centers in 5 countries. RESULTS: During the 6-month period after a successful PTCA, 49% of patients underwent functional testing (range among centers 10%-81%). Among patients who underwent functional testing, 39% had a clinical indication and 61% had functional testing as a routine follow-up. The first functional test was performed a median of 7 weeks after PTCA, with 13% of patients having second tests at a median of 14 weeks and 4% having additional tests at a median of 20 weeks. Univariate and multivariate analyses demonstrated that the chief determinant of the use of routine functional testing was clinical center. Aside from age (P <.0001), no baseline clinical or procedural characteristics were consistently associated with the use of routine functional testing after PTCA. CONCLUSIONS: Physicians do not appear to be adhering to the ACC/AHA guidelines for exercise testing regarding the routine use of post-PTCA functional testing. None of the clinical characteristics identified by the ACC/AHA guidelines were associated with the routine use of post-PTCA functional testing, and the primary determinant of functional testing was the location of the center at which the patient had the PTCA.
Angioplasty, Balloon, Coronary↗
Coronary stenting in diabetic patients: Results from the ROSETTA registry.
OBJECTIVE: Diabetes mellitus is associated with high rates of restenosis and adverse outcomes after percutaneous transluminal coronary angioplasty (PTCA). It is unclear whether coronary stenting reduces adverse events in diabetic patients after PTCA. Our purpose was to determine whether coronary stenting improves clinical event rates in diabetic patients after PTCA. METHODS: The Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry was a prospective multicenter observational study examining functional testing and adverse outcomes after successful PTCA. RESULTS: Among the 791 patients enrolled, 180 were diabetic. A total of 90 diabetics received stents while the remaining 90 patients did not. Baseline clinical characteristics were similar between the 2 groups of patients. However, patients with stents were more likely to have complex lesions, whereas those without stents were more likely to undergo atherectomy and have greater residual coronary stenosis. At 6-month follow-up, the composite end point defined as cardiac death, unstable angina, myocardial infarction, need for repeat PTCA, or coronary artery bypass graft surgery (CABG) occurred in 25.0% of stented and 22.2% of nonstented diabetic patients (P not significant [NS]). A multivariate logistic regression analysis showed that coronary stenting was not associated with a reduced incidence of the composite end point among diabetic patients (odds ratio 0.97, 95% CI 0.46-2.05, P NS). CONCLUSION: Coronary stenting does not improve clinical event rates in diabetic patients after PTCA.
Angioplasty, Balloon, Coronary↗
Tc-99m mercaptoacetyltriglycine clearance: comparison of camera-assisted methods.
PURPOSE: To compare the accuracy of three camera-assisted methods for the measurement of Tc-99m mercaptoacetyltriglycine (MAG3) clearance. MATERIALS AND METHODS: MAG3 renal scintigraphy was performed in 21 adults with different degrees of renal function. Posterior views were obtained that included the heart and the kidneys in the camera field of view. The syringe for injection was imaged before and after injection. Blood samples were drawn 24 and 43 minutes after injection and plasma radioactivity was measured. Three camera-assisted techniques to measure MAG3 clearance were tested: 1) Biexponential fitting of the left ventricular curve, normalized to plasma activity at 24 minutes; 2) calculation of clearance by relating the integral of the plasma curve (normalized to plasma activity) to the kidney activity using the Rutland-Patlak space method; and 3) a regression equation measuring clearance from the percentage of the injected dose accumulating in the kidneys during the 1- to 2.5-minute period. The camera-assisted clearances were compared with the single-sample MAG3 clearances calculated using the Russell equation. Linear regression analysis was used to measure the correlation between the camera-based methods and the single-sample techniques. RESULTS: Correlation with r > 0.900 was found for all three techniques. The difference in correlation coefficients between the three methods was not significant; however, the regression line of method 3 was significantly closer to the line of identity (P = 0.005). CONCLUSION: Method 3 most closely fits the line of identity and is probably the most practical because no blood sample is needed.
Adult↗
Preoperative dipyridamole-thallium scanning, selective coronary revascularization and long-term survival in patients with critical lower limb ischemia.
BACKGROUND: A large proportion of patients with critical limb ischemia have advanced, often asymptomatic coronary artery disease which is associated with increased perioperative risk and decreased long-term survival. METHODS: We evaluated retrospectively the short and long-term effect of routine dipyridamole-thallium cardiac scanning (DTS) and selective coronary revascularization in 113 consecutive patients who were scheduled for revascularization of the lower extremity. RESULTS: DTS was abnormal in 60 (53.1%) patients and demonstrated a moderate-severe reversible defect in 26 (23.0%) patients. On the basis of DTS and clinical evaluation 33 (29.2%) patients were referred for coronary catheterization. Of these, 9 underwent PTCA and 4 underwent coronary artery bypass, without complications. Surgical revascularization of the limbs was performed in all but two patients. Two (1.8%) patients died postoperatively, three (2.7%) sustained nonfatal postoperative myocardial infarctions. None of the patients who underwent preoperative coronary revascularization suffered a cardiac complication after the peripheral vascular operation. During mean follow-up of 31.7 months, 30 (28.0%) patients died. A moderate-severe reversible defect on DTS was the strongest predictor for shortened survival (Exp(b)=0.61, CI 95%=0.42-0.88; p=0.006). Patients who underwent preoperative coronary revascularization followed a survival curve approaching those without a reversible defect on DTS (mean survival 61+/-8 vs 63+/-4 months; NS) which was significantly better than those with such a defect who did not undergo coronary revascularization (mean survival 34+/-5 months; p=0.03). CONCLUSIONS: While the perioperative benefits of routine preoperative DTS screening in patients with critical limb ischemia, remain debatable, it provides an opportunity for identification and treatment of life-limiting coronary artery disease and improving survival.
Aged↗
Tips to help take the hassle out of inpatient utilization review.
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Attitude of Health Personnel↗
Results of a routine exercise treadmill testing strategy early after percutaneous transluminal coronary angioplasty.
BACKGROUND: Some physicians use routine exercise treadmill testing early after percutaneous transluminal coronary angioplasty (PTCA), yet there have been few prospective studies examining the results of such a functional testing strategy. OBJECTIVES: To examine the results of a routine post-PTCA exercise treadmill testing strategy, and to explore the impact of such a strategy on follow-up functional tests and cardiac procedures. PATIENTS AND METHODS: Functional test results were examined from a cohort of 226 patients who underwent PTCA at a single institution in which a routine functional testing strategy is used. Tests were defined as 'routine' if they were performed solely because the patient had a prior PTCA. Tests were defined as 'selective' if they were done for a clinical indication or if there was no functional testing during the six-month follow-up. RESULTS: A total of 183 patients (81%) underwent at least one functional test during the six-month period after PTCA. Of these patients, 150 (82%) underwent routine functional testing, the majority (73%) of which were exercise treadmill tests. Sixty-seven per cent of patients who had routine functional testing had their first functional test less than seven weeks after their PTCA. Most routine exercise treadmill tests were found to be electrically or clinically indeterminate (46%), but a substantial number were either electrically or clinically positive (28%), or electrically and clinically negative (39%). Of patients who had electrically or clinically positive routine tests, 57% had repeat functional testing and 23% had repeat revascularization. Of patients who had electrically and clinically negative tests, 53% had repeat functional testing and 10% had repeat revascularization. Of the patients who had electrically or clinically indeterminate tests, 53% had repeat functional testing and 14% had repeat revascularization. The rate of clinical events was less than 4%, irrespective of the results of the exercise treadmill tests. CONCLUSIONS: Routine exercise treadmill testing early after PTCA is associated with a low clinical yield. Most routine exercise treadmill testing results in indeterminate and negative tests, which often lead to more functional tests with little difference in clinical outcome. These results call into question the use of a routine post-PTCA functional testing strategy.
Angioplasty, Balloon, Coronary↗
SPECT attenuation artifacts in normal and overweight persons: insights from a retrospective comparison of Rb-82 positron emission tomography and TI-201 SPECT myocardial perfusion imaging.
PURPOSE: Myocardial perfusion imaging can be performed using SPECT or positron emission tomography (PET). SPECT has lower specificity than PET, largely as a result of attenuation artifacts; however, it is more widely available. The authors describe a study of the effect of sex and body weight on the incidence of SPECT attenuation artifacts using a retrospective comparison of TI-201 SPECT and Rb PET. METHODS: One hundred sixty-one persons (101 men, 60 women; 81 normal weight, 80 overweight) underwent TI-201 SPECT and Rb PET. The incidence of observed perfusion defects was studied in territories of the three major coronary arteries. SPECT and PET results were also compared with those of angiography in a subset of 75 patients. RESULTS: One hundred fourteen defects were reported on Rb PET compared with 176 defects with TI-201 SPECT. Excess TI-201 SPECT defects occurred in male and female, normal-weight and overweight persons. The average specificity was 64% for TI-201 SPECT and 84% for Rb PET, reflecting this difference. CONCLUSIONS: Attenuation artifacts in TI-201 SPECT occur frequently and are not confined to easily identifiable subgroups of patients. Therefore, measures to improve specificity of SPECT (e.g., prone or gated imaging) or alternative imaging techniques such as PET have potential advantages for everyone, not simply for obese patients and women with large breasts. In addition, awareness of the prevalence of SPECT attenuation artifacts, in both sexes and all weight categories, may contribute to improved accuracy of interpretation.
Artifacts↗
Long-term outcome of patients with very long stents for treatment of diffuse coronary disease.
OBJECTIVES: The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents. BACKGROUND: New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet. METHODS: Fifty-seven consecutive patients in whom 67 long stents (>/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization. RESULTS: Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P <. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent. CONCLUSIONS: Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually <40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.
Aged↗
Selection of 'normal' control subjects for psychiatric research: update on a model for centralized recruitment.
A recruitment program for 'normal' control subjects is evaluated with regard to the yield of 'healthy' subjects, the degree to which subjects remain healthy over a number of years, and the rate of subject participation in research. Only 22.4% had no lifetime history of mental illness (Never Mentally III), 6.8% met the criteria for one episode of a minor mental disorder (MMD), 41.6% were currently healthy but had a more serious history of mental illness and 29.9% were currently mentally ill. Diagnostic follow-up found that subjects in the NMI and MMD categories did not differ with regard to the rate of interval episodes in themselves or in family members over an average of 27 months. However, subjects in the MMD category were more likely to have a positive family history of mental illness (chi2(1) = 21.34; P < 0.001). The longitudinal course of mental health in a combined group of NMI and MMD subjects was predicted by sex of the subject (chi2(1) = 4.04; P < 0.05), but not by age or family history of mental illness. These findings suggest that investigators selecting 'healthy' control subjects consider the probability that a currently healthy individual will have episodes of mental illness in the future.
Adult↗
Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation.
We studied the effect of central line catheters on thrombus formation in the right atrium (RA), including the incidence and echocardiographic characteristics of the catheter-associated thrombus as well as possible clinical implications in patients. We prospectively studied 55 patients by transesophageal echocardiography within 1 week after Hickman catheter implantation and on a follow-up study at 6 to 8 weeks. We succeeded in imaging the catheter tip in 48 of the 55 patients (87%). In the baseline study 13 had the tip placed in the RA, eight at the superior vena cava-atrium junction, and 27 in the superior vena cava. An abnormal mass, consistent with a thrombus, was found in 12.5% of the patients, all of which were seen within the 13-patient (46%) group with the Hickman catheter tip placed in the RA. Hickman catheter insertion is associated with high incidence (12.5%) of early formation of RA thrombus. The formation of these thrombi is asymptomatic and highly associated (p < 0.001) with the catheter tip position in the RA, in contrast to their positioning in the superior vena cava or in its junction with the right atrium. On the basis of these findings, we recommend that special attention and effort be given to placing of the catheter tip in the superior vena cava and avoiding the RA during the implantation procedure.
Adult↗
The expression of the urinary forms of human luteinizing hormone beta fragment in various populations as assessed by a specific immunoradiometric assay.
Human gonadotrophins undergo metabolic transformations which result in the presence of several smaller, structurally and immunologically related forms of gonadotrophins in the urine. For luteinizing hormone (LH), a beta core fragment (LHbeta cf) has been isolated from the pituitary and characterized. The corresponding urinary fragment is inferred from mass spectral and immunochemical analysis of chromatographically separated urinary forms. Physicochemical characteristics, primarily mass spectral and chromatographic, indicate that the pituitary and urinary forms of LHbeta cf have a different structure, probably in the carbohydrate moieties. This communication characterizes the expression of LHbeta cf in the urine of both reproductive and post-reproductive age women and in men, employing assays highly specific for the pituitary form of the fragment. It was found that LHbeta cf is the predominant LH associated molecular form in the urine during peri-ovulatory period, peaking 1-3 days later than intact LH and reaching a concentration of approximately 600 fmol/mg creatinine, 7-fold higher than either LH or LH free beta subunit. Corresponding concentrations of human chorionic gonadotrophin (HCG) beta cf were <1% that of LHbeta cf. LHbeta cf cross-reaction with some LH or LHbeta monoclonal antibodies may well interfere with the accurate estimation of the day of the LH surge when urinary tests are utilized.
Adolescent↗
Heart rate variability as a marker of myocardial perfusion.
RR variability (HRV), an independent predictor of death following myocardial infarction, may also be related to other features of coronary artery disease. We evaluated its ability to differentiate among sedentary patients with chest pain >/=45 years of age demonstrating either normal or abnormal myocardial perfusion with rest and exercise thallium-210 tomographic imaging. The major HRV difference between 48 men and 50 women with normal perfusion was a significantly higher high frequency power in women. No significant differences in mean HRV values were found between the 57 men with abnormal perfusion scans and the 48 men with normal perfusion. In both men and women with normal perfusion scans, duration of exercise was significantly related to age. In men with abnormal scans, impaired myocardial perfusion alters the relationship between exercise duration and age, and a group of individuals with diminished HRV and low levels of physical fitness, regardless of age, can be identified. Despite these latter selective findings, we conclude that HRV is not a sensitive indicator to differentiate patients with normal and abnormal myocardial perfusion.
Age Factors↗
Preoperative thallium scanning, selective coronary revascularization, and long-term survival after carotid endarterectomy.
BACKGROUND AND PURPOSE: Long-term survival in patients after carotid endarterectomy (CEA) is determined mainly by their concomitant cardiac disease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA. METHODS: Two hundred twenty-six of 255 consecutive patients (88%) undergoing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 groups: group 1, normal or mild defects on PTS; group 2, moderate-severe fixed and/or reversible defects in patients who did not undergo CR; group 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Perioperative data were prospectively recorded, and data on long-term survival and cardiac and neurological complications were collected. RESULTS: Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combined CEA+CABG in 10, and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had perioperative nonfatal myocardial infarction and 8 had stroke. During the follow-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac disease and 4 (8.5%) from stroke. Independent predictors of long-term overall mortality were diabetes mellitus, preoperative T-wave inversion on ECG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3. 5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, and 0.04, respectively]. In addition, preoperative moderate-severe thallium defect without CR (group 2) independently predicted long-term cardiac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and significantly better than that of group 2 (P=0. 02). CONCLUSIONS: PTS predicts long-term survival, and selective CR based on the thallium results improves the survival rate of patients undergoing CEA.
Aged↗
Noncardiogenic pulmonary congestion following bone marrow transplantation.
We report a 36-year-old female who developed acute pulmonary congestion as the first presenting sign of venoocclusive disease (VOD), complicating an otherwise successful bone marrow transplantation (BMT). Left ventricular function was normal by echocardiography. Conservative therapy included oxygen, Lasix, and low dose dopamine. Hepatic toxicity, the typical presenting feature of VOD, occurred in our patient 72 h after pulmonary congestion. VOD occurs in 20-50% of BMT patients and is the result of widespread endothelial damage as a result of chemoradiotherapy. The dominating clinical feature is liver toxicity. Pulmonary manifestations of VOD have not been described as presenting features, and in fact have been noted as rare and late sequelae of BMT. Therefore, in the setting of preserved left ventricular function, acute pulmonary congestion early after BMT may represent the onset of VOD.
Adult↗
[Treatment of concomitant coronary and carotid disease].
The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.
Aged↗
"Normal" control subjects are hard to find: a model for centralized recruitment.
A central program for recruiting "normal" control subjects is examined by considering the yield of subjects who meet criteria for "healthy" as defined by their personal and family histories of mental disorders. Of the 267 applicants, 30.3% have no lifetime diagnoses, 41.2% are currently healthy with a history of mental illness, and 27.7% are currently mentally ill. Only 16.1% met Research Diagnostic Criteria for "never mentally ill" and reported no family history of mental disorders. Benefits of a central recruitment program for studies of mental disorders include increased information on a large subject pool and decreased volunteer bias.
Adult↗