Functional evaluation of lipid-lowering therapy by pravastatin.
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Angina Pectoris↗
Biomedical subjects
F C Schoebel
Publications and source records attributed to F C Schoebel.
[Internal thoracic artery bypass--basic principles of Doppler ultrasound for pre- and postoperative diagnosis].
During the last 25 years the internal thoracic artery has become a well established conduit for coronary revascularization. Next to angiography, duplex-sonography is increasingly used as a non-invasive imaging procedure for the evaluation of this graft vessel. Preoperative investigation in 117 patients has yielded a high level of agreement between angiography and duplex-sonography. While the preoperative flow-pattern is dominated by systolic flow as it is typical for vessels supplying skeletal muscle, the postoperative findings show an adaptation to the coronary vascular bed as the diastolic flow increases. These non-invasive measurements are well matched with invasive intravascular recordings. Coronary angiography and duplex-sonography of the internal thoracic artery yielded comparable findings in respect to the procedural result. Considering the increasing use of the internal thoracic artery in coronary artery bypass surgery, this non-invasive method should gain increasing relevance.
Blood Flow Velocity↗
[Antithrombotic therapy in chronic coronary syndromes--value of thrombocyte aggregation inhibition, anticoagulation and chronic thrombolysis].
Antithrombotic therapy is a basic part in the treatment of acute as well as chronic coronary syndromes. The rationale is an enhanced platelet activity with predomination of procoagulatory mechanisms in coronary artery disease. The current status of antiplatelet drugs, anticoagulation, and chronic thrombolysis used in the treatment of chronic coronary syndromes is discussed. It is concluded that low-dose aspirin is the current drug of choice for long term oral treatment in patients with stable chronic coronary artery disease. In contrast, oral anticoagulation with coumadin should be considered in patients with higher risk for atrial or ventricular thrombosis. The impact of long-term intermittent urokinase therapy in patients with end-stage coronary artery disease and refractory angina pectoris leads to a marked improvement of clinical symptoms. Oral blockade of platelet membrane glycoprotein IIb/IIIa receptor and clinical trials regarding antiischemic effects of low-molecular weight heparins in chronic coronary syndromes are expected for the future.
Anticoagulants↗
[Assessment of the anti-ischemic effect in patients with therapy refractory angina pectoris in end-stage coronary heart disease--results of chronic intermittent urokinase therapy].
Patients with refractory angina pectoris and end-stage coronary artery disease represent an increasing clinical problem. Numbers of these patients will increase in the future for improved survival due to effective secondary prevention of coronary artery disease. Next to the evaluation of clinical symptoms non-invasive objective parameters of myocardial ischemia are of major relevance before initiation of alternative treatment modalities and for verification of antiischemic effectiveness. Based on our own experience it can be shown that in these patients testing which is mainly based on the patients physical exercise capacity is only of limited value due to the early occurrence of clinical symptoms. Furthermore diffuse perfusion abnormalities reduce the sensitivity of electrocardiographic and scintigraphic detection of ischemic changes. In contrast indirect measures of ischemia relating to the systolic or diastolic function of the left ventricle like doppler-echocardiography and radionuclide ventriculography seem to be promising approaches. This is confirmed by the results from the application of long-term intermittent urokinase therapy. Long-term intermittent urokinase therapy leads to an absolute enhancement of myocardial perfusion, which makes this approach superior to other medical interventions which are mainly based on a reduction of cardiac work-load.
Angina Pectoris↗
[Coronary heart disease in patients with end-stage kidney failure].
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Angioplasty, Balloon, Coronary↗
[Formation, therapy and prevention of false aneurysm of the femoral artery following diagnostic and interventional heart catheterization].
OBJECTIVE: As pseudoaneurysm of the femoral artery after catheter introduction is a frequent complication, its causes and therapeutic options were investigated in a large patient collective. PATIENTS AND METHODS: In a prospective study with colour-Doppler duplex sonography of 6928 patients after diagnostic and of 3764 after interventional cardiac catheterisation, pseudoaneurysms were diagnosed in 80 patients (0.75%), 46 after diagnostic (0.66%) and 34 after interventional (0.9%) catheterisation. RESULTS: The incidence was higher in women than men (1.33% vs 0.58%; P < 0.05). Anticoagulation after sheath removal was the leading risk factor (n = 55, 68.8%), especially after interventional coronary intervention 85.3 vs 56.5%, P < 0.05). Local compression under duplex sonography monitoring was undertaken in 69 patients (86.3%), achieving aneurysmal obliteration in 53 (76.8%). Spontaneous thrombosis occurred in 15 of the remaining 27 patients, and surgical closure became necessary in 12. CONCLUSIONS: These data indicate a risk profile for the occurrence of pseudoaneurysm after cardiac catheterisation which can be dealt with by preventive measures. Local compression under duplex sonographic monitoring was the treatment of choice with a high success rate and low incidence of complications.
Aged↗
[Blood vessel occlusion in acute and chronic coronary syndromes--significance of PTCA].
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Acute Disease↗
[Conservative therapeutic approaches in terminal coronary heart disease. Chronic intermittent urokinase therapy].
Despite progress in the invasive revascularization procedures and even though conventional antianginal treatment has improved the quality of life in patients with symptomatic coronary artery disease considerably, an increasing number of patients suffers from end-stage coronary artery disease and refractory angina pectoris. For these refractory patients long-term intermittent urokinase therapy was developed as an antithrombotic intervention, which is based on its capacity to enhance thrombolysis and blood rheology, and may possibly lead to plaque regression. The coronary syndrome of refractory angina pectoris is characterized by a mismatch of severe coronary insufficiency and a relatively large amount of viable myocardium as indicated by an only moderately impaired left ventricular function. Prior to initiation of long-term intermittent urokinase therapy all potential measures to improve myocardial perfusion have to be considered in each patient. These supportive measures include rigorous reduction of LDL-cholesterol, which has proven antiischemic properties due to an improved endothelial function of epicardial conductance vessels possibly resulting in an antianginal effect. Apart from the proven antiischemic properties of long-term intermittent urokinase therapy in patients with refractory angina pectoris, objective signs of ischemic myocardial heart failure improve. Follow-up studies demonstrated a significant increase of left ventricular ejection fraction as evaluated with multi-gated blood pool analysis. Furthermore, left ventricular diastolic function normalized after a treatment period of 12 weeks. As the clinical effects last well beyond the actual treatment period and as they are accompanied by a remarkable increase in the quality of life, a complex approach as this one is justified in this highly symptomatic patient group.
Angina Pectoris↗
[Transmyocardial laser revascularization--morphologic, pathophysiologic and historical principles of indirect revascularization of the heart muscle].
Under normal conditions the coronary system of the human heart is not hermetically isolated from the surrounding structures nor the ventricles, but is in various ways connected to the adjacent arteries and the cardiac chambers. These natural connections have been models for most surgical efforts to revascularize the myocardium. Numerous anastomoses between the aorta and the coronary branches functionally resemble aorto-coronary bypass grafts. Coronaro-ventricular anastomoses do also exist in the myocardium and therefore transmyocardial laser revascularization should allow blood to penetrate from the ventricle into the myocardium. This process should not be called "reptilization" of the human heart, as in large reptilian hearts the nutrition of an extensive amount of myocardium only by diffusion is highly unlikely. Transmyocardial laser revascularization results in a relevant reduction of clinical symptoms and an increase of exercise capacity in approximately two thirds of the patients treated. Objective data of enhanced myocardial perfusion as assessed by positron emission tomography and stress echocardiography has up to now only been presented by smaller studies. Open laser channels are rarely visualized by conventional ventriculography for the limited resolution of the technique. Possibly contrast-echocardiography may offer a more appropriate option to proof the systolic filling of the laser channels, as recently reported in patients. This would allow a correlation between clinically successful revascularization and functioning channels in contrast to an early or late failure due to the closure of the channels. As to the current opinion, transmyocardial laser revascularization is no alternative to established medical, interventional or surgical therapies but may in conjunction with bypass surgery or as a sole procedure offer a new option for those patients, who were recently considered to be refractory to conventional treatment. Experimental studies in particular should contribute to the understanding of therapeutic mechanisms and lead to standardized indications in the surgical treatment of end-stage coronary heart disease. Even though in transmyocardial laser revascularization the perioperative risk depends mainly on the degree of cardiac disease and the overall state of the patient, and impaired left ventricular function is per se no exclusion criterium, if viable myocardium is detectable. Many questions concerning indications, long-term prognosis and pathophysiological mechanisms are still open to discussion and have to be answered in order to find standardized applications for treatment of end-stage coronary artery disease.
Animals↗
[Incidence and therapy of peripheral arterial vascular complications after heart catheter examinations].
We analyzed the incidence and management of major vascular complications at the arterial puncture site following diagnostic or interventional cardiac catheterization. 27387 cardiac catheterization procedures were performed for diagnostic (n = 19581) or interventional (n = 7806) purposes at our institution during a 7-year study period. A total number of 114 major vascular complications (0.42%) were identified. In 36 (0.13%) patients an arterial occlusion at the puncture site was detected, 34 patients (0.12%) had severe hematoma (blood transfusion or surgical repair necessary), 32 patients (0.12%) developed false aneurysms, 9 patients (0.03%) with av-fistulas and 3 patients (0.01%) had other complications. The following factors were predictive for a significant increase in the incidence of major vascular complications: Female gender, interventional catheterization using larger introducer sheaths and necessitating effective perioperative doses of heparine, and peripheral vascular disease. Operative repair was necessary in 62 patients (54%), 34 patients (30%) were treated conservatively. In 18 patients (17%) acute vascular occlusion could be managed by percutaneous transluminal balloon dilatation and intravascular thrombolysis of the obstruction, in 3 patients additional stent-implantation was necessary in the presence of a large occlusive dissection. Overall the rate of clinically significant major vascular complications is low. In the future a greater number of vascular complications at the entry site for cardiac catheterization will be treated with nonoperative methods (e.g. manual compression of pseudoaneurysms or catheter-based techniques for recanalization of acutely occluded vessels.
Adult↗
[Rate of restenosis after PTCA in patients with terminal renal failure. A quantitative coronary angiography study].
Patients with end-stage renal disease (ESRD) have a high incidence of coronary artery disease. In 30-60% of these patients coronary artery disease can be demonstrated by coronary angiography often prompting myocardial revascularization. Previous studies on PTCA in patients with ESRD have suggested a high rate of procedural complications and restenosis. We studied the rate of restenosis after PTCA in 23 patients with chronic renal failure (17 males, 6 females, age: 52.5 +/- 18.3 years). After primarily successful PTCA all patients were restudied angiographically within 6-12 months. Using quantitative coronary angiography 13 patients (56%) demonstrated restenosis (stenosis > 50% luminal diameter). In 11 of these patients further revascularization therapy was indicated (6 x PTCA, 5 x CABG). Before follow-up angiography 12 patients demonstrated recurrence of angina pectoris, the sensitivity of clinical symptoms for angiographic restenosis was 69%. High concentrations of triglycerides (265 +/- 160 mg/dl), total cholesterol (258 +/- 53 mg/dl) with low HDL-levels (34 +/- 14 mg/dl) as well as elevated plasma levels of fibrinogen (481 +/- 114 mg/dl) were measured before PTCA. The mechanisms contributing to the high rate of coronary restenosis in patients with ESRD remain unclear, influence of lipid abnormalities, hemostatic factors and fibrinolytic state as well as primarily uremic factors have to be discussed. Prospective interventional studies are needed to address the relevance of PTCA for myocardial revascularization in this patient group.
Adult↗
Refractory angina pectoris in end-stage coronary artery disease: evolving therapeutic concepts.
Refractory angina pectoris in coronary artery disease is defined as the persistence of severe anginal symptoms despite maximal conventional antianginal combination therapy. Further, the option to use an invasive revascularization procedure such as percutaneous coronary balloon angioplasty or aortocoronary bypass grafting must be excluded on the basis of a recent coronary angiogram. This coronary syndrome, which represents end-stage coronary artery disease, is characterized by severe coronary insufficiency but only moderately impaired left ventricular function. Almost all patients demonstrated severe coronary triple-vessel disease with diffuse coronary atherosclerosis, had had one or more myocardial infarctions, and had undergone aortocoronary bypass grafting (70% of cases). We present three new approaches with antiischemic properties: long-term intermittent urokinase therapy, transcutaneous and spinal cord electrical nerve stimulation, and transmyocardial laser revascularization.
Aged↗
Relevance of conventional cardiovascular risk factors for the prediction of coronary artery disease in diabetic patients on renal replacement therapy.
BACKGROUND: Diabetic patients undergoing renal replacement therapy have a high cardiovascular mortality. As the rate of patients with diabetic nephropathy rises, adequate risk stratification subsequent to renal transplantation is warranted. It was the aim of our study to elucidate whether conventional risk factors are valid predictors of coronary artery disease in this group of patients with chronic renal failure subsequent to transplantation. METHODS AND RESULTS: Between 1989 and 1993, 105 consecutive diabetic patients (70 men, 35 women, 77 type I and 28 type II diabetics, mean age 43 +/- 12 years) were examined during the first six months of dialysis treatment. Coronary angiography was performed in all patients regardless of clinical symptoms of coronary artery disease (CAD). In 38 patients (36%) CAD was documented (single-vessel disease: 17 patients, double-vessel disease: 6 patients, triple-vessel disease: 15 patients). Manifestations of coronary atherosclerosis were seen in 49 patients (47%). Angina pectoris was present in 9 out of 38 patients (24%), the sensitivity to detect CAD was 43% and 52% for ST-segment depression assessed at rest. Risk factors for atherosclerosis like hypertension, smoking, cholesterol (total cholesterol, HDL-,LDL-cholesterol), triglycerides as well as concentrations of lipoprotein (a) and fibrinogen were not significantly different in patients with or without coronary artery disease. Atherosclerotic manifestations of cerebral and peripheral arteries as well as manifestations of diabetic microangiopathy like retinopathy did not correlate with the prevalence of CAD. In 11 out of 38 patients (29%) cardiac interventions (3 x CA BG, 8 x PTCA) were performed. All of them were defined as transplantable after myocardial revascularisation. CONCLUSIONS: Clinical symptoms as well as the cardiovascular risk profile are not valid predictors of CAD in diabetic patients with chronic renal failure. Therefore coronary angiography should be performed in all diabetic patients prior to renal transplantation.
Adult↗
Antithrombotic treatment in stable coronary syndromes: long-term intermittent urokinase therapy in end-stage coronary artery disease and refractory angina pectoris.
Interventions that modify lipid metabolism and blood coagulation have been shown to favourably influence the natural course of coronary artery disease in terms of the primary prevention and treatment of acute cardiovascular events. Various findings suggest that such interventions may also preserve and enhance myocardial perfusion in the chronic stage of the disease. Long-term intermittent urokinase therapy was developed for patients with end-stage coronary artery disease and refractory angina pectoris. A dose of 500,000 IU of urokinase given intravenously as a bolus three times a week for of 12 weeks reduced symptoms by 70% and was accompanied by objective improvements in myocardial perfusion and an increase of ergometric exercise capacity. The possible therapeutic mechanisms of long-term intermittent urokinase therapy-improvement of rheological blood properties mediated by fibrinogen reduction, thrombolysis of non-occlusive subclinical thrombi, and regression of atherosclerotic plaques-are discussed in the context of other antithrombotic approaches.
Angina Pectoris↗
Restenosis after elective coronary balloon angioplasty in patients with end stage renal disease: a case-control study using quantitative coronary angiography.
OBJECTIVE: To assess the rate of angiographic restenosis in patients with end stage renal disease after elective coronary angioplasty. DESIGN: A retrospective case-control study of 20 patients with end stage renal disease and 20 sex and age matched controls without renal disease, who had undergone primarily successful coronary angioplasty. Control coronary angiography was performed regardless of worsening or renewed incidence of anginal symptoms. MAIN OUTCOME MEASURES: Group comparison of coronary morphology, as evaluated by quantitative coronary angiography, and of cardiovascular risk factors. RESULTS: The rate of angiographic restenosis was 60% in patients with renal disease and 35% in controls. In patients with end stage renal disease the following differences (mean (SD) were found versus controls: raised plasma fibrinogen (483 (101) v 326 (62) mg/dl, p < 0.001); raised plasma triglyceride (269 (163) v 207 (176) mg/dl, p < 0.01); smaller diameter of the coronary reference segment (2.59 (0.87) v 2.90 (0.55) mm, p < 0.10); smaller minimum luminal diameter of the dilated stenosis (0.77 (0.46) v 0.97 (0.27) mm, p < 0.05). Discriminant analysis showed that minimum luminal diameter before angioplasty (r = -0.79) and fibrinogen (r = +0.34) had the highest statistical association with restenosis. CONCLUSIONS: The high rate of angiographic restenosis in patients with end stage renal disease seems to be related to the size of the vessel dilated and to an increased prothrombotic risk, as indicated by higher fibrinogen concentrations.
Angioplasty, Balloon, Coronary↗
[Therapy refractory end stage angina pectoris in coronary heart disease--a clinical and scientific challenge].
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Angina Pectoris↗
[Coronary vasomotion in coronary heart disease--significance of epicardial and microcirculatory vessels for myocardial perfusion].
The most important function of the coronary vasculature is the effective regulation of coronary blood flow according to the metabolic needs of the myocardium. Under physiological conditions, coronary blood flow is regulated by a balance of vasoconstricting and -dilating components which can be differentiated with regard to the site (macro- vs. microcirculation), compartment (endothelium vs. vascular smooth muscle), and mechanism of action (receptor dependent vs. independent). This balance includes on the one hand the ability of the coronary circulation to maintain a relatively constant blood flow at any given oxygen demand irrespective of perfusion pressure (coronary autoregulation). On the other hand, coronary blood flow can be increased rapidly and effectively several-fold when myocardial oxygen demand increases. Previous investigations have demonstrated that the coronary endothelium plays a key role in the development of arteriosclerotic vascular lesions. In the time course of arteriosclerosis, functional alterations in endothelium dependent vasodilatation alterations are already present before angiographically demonstrable morphologic lesions. In the present manuscript, the diagnostic methods used to assess clinically the coronary macro- and microcirculation with regard to endothelium and smooth muscle dependent vasomotion are reviewed. In addition, present pharmacotherapeutic strategies to improve myocardial perfusion in coronary artery disease are discussed.
Animals↗
[Significance of coronary thrombosis for chronic myocardial ischemia].
Apart from the relevance of disorders of lipid metabolism for the clinical and morphological progression of coronary artery disease, coronary thrombosis has received increasing attention in recent years. It is undoubtedly the decisive factor in the pathogenesis of acute coronary syndromes, which is underlined by the therapeutic success of various antithrombotic interventions. Furthermore coronary thrombosis is regarded to be a key factor for morphological disease progression also in stable coronary syndromes, which eventually may lead to critical limitation of myocardial perfusion. This is caused by the formation of subclinical coronary thrombi, which either undergo endogenous lysis or become morphologically fixed as they are incorporated into the plaque. Besides local factors, systemic disturbances of hemostasis and endogenous thrombolysis are of relevance. The concept of thrombotic progression of coronary thrombosis is supported by data on the reduction of morphological disease progression or antiischemic effectiveness of anti-thrombotic interventions like aspirin, low-molecular weight heparin and low-dose intermittent urokinase therapy. Percutaneous transluminal coronary angioplasty results in deep mechanical injury of the vessel wall, which is accompanied by secondary coronary thrombosis in the majority of the cases, not necessarily leading to abrupt vessel closure. Particularly, dilatation of primary thrombus as it has been described as the substrate of the culprit lesion in unstable coronary syndromes, promotes release of thrombin and activation of platelets, which in turn furthers the proliferative processes in the pathogenesis of restenosis. Even though data on the reduction of the rate of restenosis by the use of platelet aggregation inhibitors like aspirin, ticlopidin and dipyridamole have not consistently supported this concept, the EPIC. Study has shown that even in patients with stable angina pectoris clinical restenosis rate may be reduced by a platelet-IIb/IIIa-antagonist.
Angina Pectoris↗