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Biomedical subjects

Francis Q Almeda

Publications and source records attributed to Francis Q Almeda.

At least 19 recordsLinked to original sources
PubMed2005

Clopidogrel (Plavix) desensitization: a case series.

Clopidogrel (Plavix) is a thiopyridine that inhibits the ADP-dependent pathway for platelet activation and has been shown in numerous trials to be effective for a wide variety of patients with cardiovascular disease, particularly those who have undergone coronary stent implantation and who present with acute coronary syndromes. Allergic rashes are one of the common side effects of clopidogrel, which leads to its discontinuation. Type I (Gell and Combs classification) allergic reactions to drugs may be amenable to drug desensitization, allowing safe and prolonged use of the drug. This case series describes a protocol for clopidogrel desensitization over an 8-hr period using 15 doubling doses of clopidogrel given by mouth to achieve a maintenance dose of 75 mg a day. This case series suggests that patients who have had type I drug allergy to clopidogrel may be rapidly desensitized using this protocol. Further studies enrolling a larger number of patients are indicated to confirm the safety and efficacy of this regimen.

Aged↗
PubMed2005

Coronary revascularization in multivessel disease. Which is better, stents or surgery?

Coronary artery disease (CAD) remains the major cardiovascular health issue in contemporary clinical practice. Treatment options for multivessel CAD include medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Here, the authors review the most recent data that compare intracoronary stenting to CABG in multivessel disease. They address therapeutic issues surrounding proper selection of the optimal revascularization strategy and give special consideration to high-risk populations, such as patients with diabetes.

Angioplasty, Balloon, Coronary↗
PubMed2004

Silent myocardial ischemia: concepts and controversies.

Silent myocardial ischemia is a relatively common, but poorly understood, clinical entity. The most accurate means of detecting silent myocardial ischemia and the precise treatment endpoints remain unclear. However, the amount of ischemic myocardium appears to correlate with the likelihood of future adverse cardiac events. Evidence suggests that patients at highest risk of severe myocardial ischemia, even in the absence of symptoms, derive the greatest benefit from an aggressive diagnostic and therapeutic approach. This paper reviews the diagnosis and treatment of silent myocardial ischemia, and its clinical implication in select patient groups: those without coronary artery disease, those with coronary artery disease, diabetic patients, postrevascularization patients, and women.

Angioplasty, Balloon↗
PubMed2004

Noncardiac applications of glycoprotein IIb/IIIa inhibitors.

Platelet activation and aggregation have become increasingly recognized as the primary processes involved in the cascade that leads to thrombus formation in atherosclerotic vascular disease. Glycoprotein IIb/IIIa receptor inhibitors (GPI) favorably impact thrombus formation and distal embolization by inhibiting the final common pathway of platelet aggregation. Glycoprotein IIb/IIIa inhibitors have been used effectively in a wide variety of clinical scenarios including unstable angina, non-ST segment elevation myocardial infarction, ST segment elevation myocardial infarction, and low and high risk percutaneous coronary interventions with and without intracoronary stenting, however there is limited data regarding the use of these potent antiplatelet agents in the setting of extracardiac vascular disease. This article will review the non-cardiac applications of glycoprotein IIb/IIIa inhibitors in the setting of acute ischemic stroke, carotid and vertebral angioplasty and stenting, acute critical limb ischemia, and percutaneous interventions in peripheral arterial occlusive disease.

Acute Disease↗
PubMed2004

Spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia with complex pathophysiology. This paper reviews the major diagnostic and therapeutic issues of this rare but important disease. The diagnosis of SCAD should be strongly considered in any patient who presents with symptoms suggestive of acute myocardial ischemia, particularly in young subjects without traditional risk factors for coronary artery disease (especially in young women during the peripartum period or in association with oral contraceptive use). Urgent coronary angiography is indicated to establish the diagnosis and to determine the appropriate therapeutic approach. The decision to pursue medical management, percutaneous coronary intervention, or surgical revascularization is based primarily on the clinical presentation, extent of dissection, and amount of ischemic myocardium at risk.

Aortic Dissection↗
PubMed2003

Alternative therapeutic strategies for patients with severe end-stage coronary artery disease not amenable to conventional revascularization.

Although there have been remarkable advances in medical therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery, complete revascularization remains a challenge given the more complex coronary artery disease prevalent in contemporary practice. The lack of donors for cardiac transplantation will fuel the search for effective alternative strategies for dealing with patients with severe ischemic heart disease not amenable to conventional revascularization techniques. Percutaneous laser revascularization clearly diminishes anginal symptoms; however, the blinded trials have provided conflicting results, with one study showing a definite decrease in angina and another suggesting that the placebo effect may play a major role in this modality. Similarly, surgical transmyocardial laser revascularization is limited by the lack of consistent improvement in objective measurements of ischemia and the potential confounding mechanisms of denervation and the placebo effect, and thus should be reserved for only the most highly selected patients. Although enhanced external counterpulsation is associated with an improvement in anginal symptoms and exercise tolerance, this modality is limited by its availability, tolerability, and rigid exclusion criteria. Of the alternative strategies available, therapeutic angiogenesis holds the most promise. However, the long-term results of ongoing randomized clinical trials require further scrutiny. Novel methods for vascular reconstruction are evolving techniques, but should be viewed currently as mainly experimental methods. The common goals of these new treatment options would be to reduce symptoms, decrease morbidity, and potentially improve mortality by reducing ischemia through favorably impacting myocardial oxygen supply and demand. The optimal management of patients with severe end-stage coronary artery disease not amenable to conventional revascularization techniques will continue to remain a challenge for the clinician and will be the main focus of basic cardiovascular research and clinical trials in the new millennium.

Angioplasty, Laser↗
PubMed2003

Correlates of failure following treatment with Sr-90 beta irradiation for in-stent restenosis.

We sought to determine the correlates of failure following intracoronary radiation therapy (IRT) with Sr-90 using the Novoste Beta-Cath system for the treatment of in-stent restenosis (ISR) in a broad range of patients. IRT has been shown to be more efficacious compared to placebo for the treatment of ISR in large randomized trials. However, even in patients treated with IRT, major adverse cardiac events occur in approximately 20% of cases on follow-up. This trial sought to elucidate the correlates of failure following successful IRT for ISR. To determine the correlates of IRT failure, we retrospectively compared the demographics, lesion characteristics, and clinical outcomes of 102 consecutive patients with ISR treated with Sr-90 from September 1998 to July 2001. IRT failure was defined as death, myocardial infarction (MI), or target vessel revascularization (TVR) due to repeat ISR on follow-up. A comparison of the clinical and angiographic profile of IRT failures (n = 16) vs. IRT successes (n = 86) revealed that a history of smoking (75% vs. 40%; P = 0.012), current use of calcium channel blockers (84% vs. 45%; P = 0.013), ostial location of target lesion (44% vs. 16%; P = 0.020), and mean posttreatment minimal luminal diameter (MLD; 1.64 +/- 0.19 vs. 2.21 +/- 0.29 mm; P < 0.001), respectively, were correlated with failure using univariate analysis. After multivariate regression analysis, the correlates of failure that remained significant were treatment of an ostial lesion (OR = 31.2; 95% CI = 2.6-382.7; P = 0.007) and final posttreatment MLD (P < 0.001). Ostial location of target lesion and smaller posttreatment MLD are correlated with subsequent death, MI, and TVR following therapy with Sr-90 for ISR.

Aged↗
PubMed2003

Comparison of echocardiography using tissue harmonics and contrast harmonics with radionuclide angiography for the assessment of left ventricular function.

BACKGROUND: Left ventricular ejection fraction (LVEF) is a significant predictor of morbidity and mortality; however, the optimal noninvasive modality for the quantitative determination of LVEF is not apparent. HYPOTHESIS: We verified the hypothesis that the various echocardiographic methods of assessing LVEF using the Method of Discs with contrast (Optison human albumin microspheres; Amersham Health, Princeton, NJ) and visual assessment of LVEF using tissue harmonics and contrast harmonics compare favorably with radionuclide angiography (RNA). METHODS: In a prospective analysis, 24 consecutive patients scheduled to undergo RNA had an echocardiogram using tissue harmonics and contrast harmonics on the same day. LVEF was assessed by RNA by an experienced, blinded reader using manual determination of the region of interest. LVEF was calculated using the Method of Discs (Simpson's Rule) by a blinded sonographer. LVEF was visually estimated by two blinded readers using echocardiography with tissue harmonics and contrast harmonics on separate occasions. RESULTS: By linear regression analysis, LVEF determination by echocardiography with contrast using the Method of Discs correlated well with RNA (r = .835, p < .0005). Using Bland-Altman analysis, the second echocardiogram reader had excellent agreement with RNA, whereas the first reader had a mean difference of 5.25% (CI 1.3-9.2; p = .012) with visual assessment using tissue harmonics and a mean difference of 4.67% (CI 0.4-8.8; p = .031) with visual assessment using contrast harmonics compared with RNA. Thus, a small difference in agreement between RNA and echocardiographic visual estimation was noted that appeared to be primarily reader dependent. CONCLUSIONS: LVEF determination with echocardiography with contrast using the Method of Discs correlated well with RNA and provided agreement across a range of cardiac functions. Visual echocardiographic assessment of LVEF with both tissue harmonics and contrast harmonics correlated well with RNA, but contrast harmonics did not appear to offer an advantage over tissue harmonics alone.

Adult↗
PubMed2003

Update on therapy for acute and chronic heart failure. Applying advances in outpatient management.

Care of patients with heart failure is often challenging and involves proper therapeutic selection from the pharmacologic, interventional, and mechanical options available. In this article, Drs Almeda and Hollenberg discuss the latest approaches and guidelines to treatment of acute and chronic heart failure in patients with left ventricular systolic dysfunction. They review the benefits, risks, and myriad considerations that physicians need to assess before making choices about best medical management.

Acute Disease↗
PubMed2003

Improved in-hospital outcomes in acute coronary syndromes (unstable angina/non-ST segment elevation myocardial infarction) despite similar TIMI risk scores.

BACKGROUND: The Thrombolysis In Myocardial Infarction (TIMI) Risk Score has been shown to predict prognosis in acute coronary syndromes (ACS) comprised of unstable angina (UA) and non-ST segment elevation myocardial infarction (STEMI). We sought to evaluate the impact of newer antiplatelet and antithrombotic therapies for ACS, such as glycoprotein IIb/IIIa inhibitors (GPI) and low molecular weight heparin (LMWH), on in-hospital outcomes over time in patients (pts) with similar TIMI risk scores. METHODS: The baseline demographics and clinical outcomes of pts with ACS (UA and non-STEMI) in 1998 (Group 1998) and 2000 (Group 2000) at a single large university medical center were compared using a prospectively collected database. In-hospital major adverse cardiac events (MACE) included death, MI, or recurrent angina that resulted in urgent revascularization. Risk was estimated by utilizing the TIMI Risk Score, which uses 7 predictor variables: age > 65 years, at least 3 risk factors for coronary artery disease, prior coronary stenosis of 50%, ST segment deviation on EKG, severe angina, prior aspirin use, and elevated cardiac biomarkers. RESULTS: Comparing Group 1998 (n = 563) and Group 2000 (n = 604), there was no difference between the mean TIMI Risk Score (2.90 1.52 vs. 2.91 1.52; p = 0.97), demonstrating a similar risk profile. Nevertheless, significant improvement in in-hospital MACE (9.1% vs. 2.8%; p < 0.001) was noted. The improvement in MACE was due to differences in rates of recurrent angina, without significant differences in death and myocardial infarction. This occurred temporally in association with a significant increase in GPI (1.0% vs. 8.3%; p < 0.01) and LMWH (0.0% vs. 15.6%; p < 0.001) use within 24 hours of presentation, and the increased utilization of intracoronary stenting (46.6% vs. 64.6%; p = 0.005), findings which were confirmed with multivariate analysis. CONCLUSION: Despite similar TIMI Risk Scores, the in-hospital outcomes of pts with ACS have improved over time. This temporal change is associated with the greater use of newer antiplatelet and antithrombotic therapies and increased utilization of intracoronary stenting.

Aged↗
PubMed2002

Frequency of abrupt vessel closure and side branch occlusion after percutaneous coronary intervention in a 6.5-year period (1994 to 2000) at a single medical center.

The aims of this study were to analyze the contemporary trends in the changing incidence of abrupt vessel closure (AVC) after percutaneous coronary intervention (PCI), to determine the impact of intracoronary stenting and glycoprotein IIb/IIIa inhibitors (GPIs) on complication rates and etiologies, and to determine the incidence of side branch occlusion (SBO) as the etiology of AVC in the stent era, complications occurring during 3,300 consecutive PCIs performed from April 1994 to December 2000 at a single referral institution. In this consecutive patient cohort of PCI cases collected over a 6.5-year period, AVC occurred in 103 of 3,300 cases (3.12%). Linear regression analysis over this time frame documented a steadily decreasing incidence of AVC from 5.9% in 1994 to 1.1% in 2000 (-0.76%/per year, 95% confidence interval -0.99 to 0.52, p <0.05). Analysis using Pearson's correlation showed that the decreasing incidence of AVC was inversely correlated with the increasing percentage of intracoronary stents placed over this time period (r = -0.94, p <0.001). Additionally, GPI use increased from 0% in 1995 to 36.0% in 2000 (p = 0.009). The absolute incidence of SBO of a major branch vessel remained relatively stable over this 6.5-year period. However, SBO appeared to be increasing as the etiology of AVC, and accounted for 9.0% of AVC in 1995 compared with 28.0% of AVC in 2000. This increasing trend of the percentage of SBO as the etiology of AVC appeared to correlate with the increased use of stents (r = 0.85, p = 0.015). Thus, the incidence of AVC steadily decreased over the 6.5-year time period, and was associated with the increased use of stents and GPIs; conversely, SBO accounted for an increasing percentage of AVC over this time period.

Academic Medical Centers↗