Emergency bypass surgery for failed coronary interventions.
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Angina Pectoris↗
Biomedical subjects
G Vetrovec
Publications and source records attributed to G Vetrovec.
Effect of thromboxane A2 blockade on clinical outcome and restenosis after successful coronary angioplasty. Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART II)
BACKGROUND: Antithromboxane therapy with aspirin reduces acute procedural complications of coronary angioplasty (PTCA) but has not been shown to prevent restenosis. The effect of chronic aspirin therapy on long-term clinical events after PTCA is unknown, and the utility of more specific antithromboxane agents is uncertain. The goal of this study was to assess the effects of aspirin (a nonselective inhibitor of thromboxane A2 synthesis) and sulotroban (a selective blocker of the thromboxane A2 receptor) on late clinical events and restenosis after PTCA. METHODS AND RESULTS: Patients (n = 752) were randomly assigned to aspirin (325 mg daily), sulotroban (800 mg QID), or placebo, started within 6 hours before PTCA and continued for 6 months. The primary outcome was clinical failure at 6 months after successful PTCA, defined as (1) death, (2) myocardial infarction, or (3) restenosis associated with recurrent angina or need for repeat revascularization. Neither active treatment differed significantly from placebo in the rate of angiographic restenosis: 39% (73 of 188) in the aspirin-assigned group, 53% (100 of 189) in the sulotroban group, and 43% (85 of 196) in the placebo group. In contrast, aspirin therapy significantly improved clinical outcome in comparison to placebo (P = .046) and sulotroban (P = .006). Clinical failure occurred in 30% (49 of 162) of the aspirin group, 44% (73 of 166) of the sulotroban group, and 41% (71 of 175) of the placebo group. Myocardial infarction was significantly reduced by antithromboxane therapy: 1.2% in the aspirin group, 1.8% in the sulotroban group, and 5.7% in the placebo group (P = .030). CONCLUSIONS: Thromboxane A2 blockade protects against late ischemic events after angioplasty even though angiographic restenosis is not significantly reduced. While both aspirin and sulotroban prevent the occurrence of myocardial infarction, overall clinical outcome appears superior for aspirin compared with sulotroban. Therefore, aspirin should be continued for at least 6 months after coronary angioplasty.
Angioplasty, Balloon, Coronary↗
Laser for optical thrombolysis and facilitation of balloon angioplasty in acute myocardial infarction following failed pharmacologic thrombolysis.
This report discusses a new indication for the use of holmium:YAG laser. It includes facilitation of thrombolysis and plaque ablation in acute myocardial infarction after failure of thrombolytic agents. Further study is required to define optimal utilization and integration of this novel device for patients who fail to respond to thrombolytic agents.
Angioplasty, Balloon, Laser-Assisted↗
Coronary collateral circulation in the transplanted heart.
BACKGROUND: The concept that coronary collateral (CC) circulation can develop in cardiac transplant recipients (CTR) is controversial. Indeed, a decreased occurrence of CC in CTR has been previously reported. METHODS AND RESULTS: We reviewed 102 coronary angiograms in 73 CTR to evaluate the presence and significance of CC in denervated human hearts. These angiograms were compared with angiograms of 70 nontransplanted patients. Twenty-six CTR who had undergone at least two coronary angiograms, thus allowing comparative evaluations, form the basis for this study. Angiograms were analyzed using a modification of CC classification (Rentrop et al) from grade 0 for complete absence to grade 4 representing mature collateral with clear filling of epicardial vessels. Coronary artery disease was classified according to the scheme reported by Gao et al. For the purpose of this study, all type A lesions were grouped as large vessel disease (LVD), and types B1, B2, and C were collectively grouped as small vessel (epicardial) disease (SVD). The presence of CC circulation in all 73 CTR was grade 0, 7 (10%); grade 1, 41 (56%); grade 2, 33 (45%); grade 3, 30 (41%); and grade 4, 5 (7%). However, in control nontransplanted subjects grades 0, 1, 2, 3, and 4 were found in 47 (67%), 22 (31%), 4 (6%), 11 (15%), and 16 (20%) patients, respectively. The presence of mature collaterals (grade 4) in both groups were associated with type A lesions and was frequent in nontransplanted hearts. In contrast, grade 2 and grade 3 vascular channels probably representing CC with "myocardial blush" was more frequent in CTR and was mostly associated with small vessel coronary arteriopathy. CONCLUSIONS: These results suggest the presence of atypical CC in patients with cardiac allograft arteriopathy. It is speculated that this atypical form of CC with "blush pattern" may represent an angiogenic response to microvascular ischemia due to allograft coronary arteriopathy.
Adult↗
Frequency of coronary artery disease and left ventricle dysfunction in cocaine users.
To evaluate the spectrum of coronary artery disease (CAD) in cocaine users, coronary angiograms obtained from 33 patients (26 men [79%] and 7 women [21%], mean age 37 years) with history of cocaine use and cardiac symptoms were retrospectively reviewed. Clinical indications for coronary angiograms included chest pain (n = 28), congestive failure (n = 4) and complete heart block (n = 1). Coronary angiograms were reviewed independently by 2 angiographers unaware of patient's clinical status. Thirteen patients (40%) had normal coronary angiograms, and 20 (60%) had CAD; 7 (21%) had mild CAD (less than or equal to 70% diameter stenosis), and 13 (40%) had significant CAD (greater than 70% diameter stenosis). Of 13 patients with significant CAD, 7 had 1-vessel, 4 had 2-vessel and 2 had 3-vessel CAD. There was enzymatic evidence of myocardial infarction in 12 of 33 patients (36%); all 12 had CAD (10 with significant and 2 with mild CAD). Mean age and number of risk factors (serum total cholesterol, cigarette smoking, systemic hypertension, diabetes mellitus, family history of CAD, and obesity) in patients with CAD (mild or significant) and with normal coronary angiograms were not statistically different. Left ventricular ejection fraction was normal in 15 patients (45%) and depressed in 18 (55%). All patients with CAD and low ejection fractions (n = 12) had regional wall motion abnormalities, whereas all those with normal coronary arteries and low ejection fraction (n = 6) had global hypokinesia.
Adult↗
Immediate and long-term results of delayed recanalization of occluded acute myocardial infarction-related arteries using coronary angioplasty.
Recent evidence suggests that late reperfusion of an occluded infarct-related artery after acute myocardial infarction (AMI) may convey a better prognosis. The clinical outcome of percutaneous transluminal coronary angioplasty (PTCA) as a means of mechanical reperfusion in this particular setting has not been clearly delineated. Ninety-seven patients with AMI underwent PTCA of the occluded infarct-related artery after the acute phase of the AMI (48 hours to 2 weeks, mean 8 +/- 4 days). The study consisted of 72 men (74%) (mean age 56.5 +/- 12 years) and 25 women. Seventy-seven patients (79%) had a Q-wave AMI and 20 patients (21%) a non-Q-wave AMI. Seventy-six patients (79%) had angina after AMI and 4 had previously undergone coronary bypass surgery. Clinical success was achieved in 85 patients (87%). Angiographic success was obtained in 90 of the 97 occluded arteries (93%) and was similar for all 3 major vessels: right coronary 97%, left anterior descending 93% and circumflex 85% (p = not significant). Major complications (AMI, emergency bypass and death) occurred in 3 patients (3.1%). Long-term follow up (3.7 +/- 0.8 years) revealed symptomatic recurrence in 20 (23%), whereas 51 (58%) remained asymptomatic. Most recurrences (16 of 20) were in the form of restenosis rather than reocclusion, with a high success rate for repeat dilation (93%). These results indicate that mechanical reperfusion of an occluded infarct artery, performing PTCA 48 hours to 2 weeks after AMI, has a high success rate, a low complication rate and low symptomatic restenosis.
Adult↗
Adverse reactions of low osmolality contrast media during cardiac angiography: a prospective randomized multicenter study.
A multicenter study was performed to determine the incidence of adverse reactions to two contrast media with similar low osmolality during cardiac angiography. The study was of a randomized double-blind design comparing ioxaglate (an ionic dimer) and iopamidol (a nonionic compound) and included 500 patients; 250 patients received ioxaglate and 250 iopamidol. There were 58 adverse reactions attributed to the contrast media in the ioxaglate group and 29 in the iopamidol group (p less than 0.001). Chest pain occurred in 11 patients in the ioxaglate group compared with 5 in the iopamidol group (p = 0.123). Nausea or vomiting was present in 20 and 2 patients, respectively (p less than 0.0003). Allergic adverse reactions, such as bronchospasm, urticaria and itching, occurred in 15 of the ioxaglate group and only 1 of the patients receiving iopamidol (p less than 0.0007). Fifty-two patients in the ioxaglate group had a known allergic history (not to contrast medium) or asthma, whereas 77 receiving iopamidol had a similar history. Seven of the 52 ioxaglate-treated patients developed an allergic adverse reaction compared with none of the 77 in the iopamidol group (p = 0.001). Of 41 patients receiving ioxaglate who were premedicated with diphenhydramine, 4 had an allergic adverse event. In the iopamidol group 45 patients received similar premedication and none had an allergic adverse reaction (p less than 0.03). Thus, this multicenter study shows that adverse reactions occur more often with ioxaglate than with iopamidol and that patients with an allergic history have a greater risk with ioxaglate therapy compared with iopamidol.
Adult↗
Multi-Hospital Eastern Atlantic Restenosis Trial. II: A placebo-controlled trial of thromboxane blockade in the prevention of restenosis following coronary angioplasty.
Since platelet interactions appear to play an important role in the development of restenosis, attenuation of thromboxane-mediated reactions may improve the long-term outcome following coronary angioplasty. Phase II of the Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART) is a prospective, randomized, placebo-controlled study of thromboxane blockade in the prevention of restenosis following successful coronary angioplasty. Two forms of thromboxane blockade are evaluated: aspirin (a nonspecific inhibitor of thromboxane synthesis) and sulotroban (a specific thromboxane receptor antagonist). The design of this multicenter trial and the rationale for use of sulotroban in the prevention of restenosis are reviewed in this report.
Angioplasty, Balloon, Coronary↗
Clinical and angiographic determinants of primary coronary angioplasty success. M-HEART Investigators.
Clinical and anatomic determinants of the initial success of percutaneous transluminal coronary angioplasty were prospectively evaluated in 826 patients enrolled in the Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART). The 639 men and 187 women ranged in age from 31 to 85 years. Successful angioplasty (residual stenosis less than 50% and no major complications) was achieved in 886 (88.6%) of 1,000 lesions. Success rates were uniform among the eight individual centers. Outcome was not influenced by gender, age or other clinical features, including severity and duration of angina, prior myocardial infarction, rest pain, transient ST segment elevation, history of smoking or diabetes. In contrast, procedural outcome was significantly associated with lesion-specific angiographic factors. Stenoses 60% to 74%, 75% to 89%, 90% to 99% and 100% were associated with success rates of 96%, 90%, 84% and 69%, respectively (p less than 0.001). Angioplasty was less successful in calcified than in noncalcified lesions (82% versus 90%, p less than 0.01), in thrombotic than in nonthrombotic lesions (82% versus 90%, p less than 0.05) and in lesions in the right coronary artery than in other vessels (84% versus 90%, p less than 0.01). Outcome was not related to other anatomic variables, including lesion location (proximal versus distal), vessel size, eccentricity, stenosis length or translesional gradient. By multivariate logistic regression, preangioplasty percent stenosis, right coronary artery location and lesion calcification were demonstrated to be significant independent predictors of angioplasty success. Alternative clinical and angiographic variables did not contribute to this regression model.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon, Coronary↗
Restenosis after coronary angioplasty: a multivariate statistical model to relate lesion and procedure variables to restenosis. The M-HEART Investigators.
The Multi-Hospital Eastern Atlantic Restenosis Trial group obtained follow-up angiography in 510 patients with 598 successfully dilated coronary lesions who were enrolled in a controlled trial of the effects of a single dose of 1 g of methylprednisolone on restenosis after coronary angioplasty. The overall restenosis rate was 39.6%. The strongest univariate relations to the restenosis rate were found for lesion location (saphenous vein graft, 68%; left anterior descending artery, 45%; left circumflex artery and right coronary artery, 32%; p = 0.002); lesion length (less than or equal to 4.6 mm, 33%; greater than 4.6 mm, 45%; p = 0.001); percent stenosis before angioplasty (less than or equal to 73%, 25%; greater than 73%, 43%; p = 0.005), percent stenosis after angioplasty (less than or equal to 21%, 33%; greater than 21%, 46%; p = 0.017) and arterial diameter (less than 2.9 mm, 44%; greater than or equal to 2.9 mm, 34%; p = 0.036). Two multivariate models to predict restenosis probability were developed with use of stepwise logistic regression. The preprocedural model, which included only variables whose values were known before angioplasty, entered lesion length, vein graft location, left anterior descending artery location, percent stenosis before angioplasty, eccentric lesion and arterial diameter. The postprocedural model, which also included variables whose values were known after angioplasty was performed, was similar to the preangioplasty model except that it also entered postangioplasty percent stenosis and "optimal" balloon sizing but did not enter eccentric lesion. These data indicate that the probability of restenosis after angioplasty is determined predominantly by the characteristics of the lesion being dilated. They are consistent with the known intimal proliferative mechanism of restenosis, offer a means of identifying lesions at unusually high or low risk of restenosis, and of predicting the likelihood that a particular lesion will restenose after angioplasty and provide a rationale for stratification by restenosis probability in the design of future studies of restenosis.
Angioplasty, Balloon, Coronary↗
Patient-related variables and restenosis after percutaneous transluminal coronary angioplasty--a report from the M-HEART Group.
As part of a randomized prospective study designed to investigate the restenosis process after percutaneous transluminal coronary angioplasty (PTCA), the relation between patient-related variables and restenosis rate was examined. A total of 722 patients had successful PTCA. Angiographic follow-up was scheduled for 6 +/- 2 months after the procedure and achieved in 510 patients (71%), yielding 598 lesions for analysis. The overall restenosis rate was 40%. The rate was higher in patients undergoing early restudy for a clinical event than in those undergoing routinely scheduled follow-up restudy (71 vs 22%, p less than 0.0001). Age, sex, cigarette smoking history, diabetes mellitus and history of previous myocardial infarction were not associated with restenosis rate. Angina duration and severity before PTCA were also unrelated to restenosis rate. In summary, these variables, many of which have been previously implicated in restenosis, were not found to be predictors of restenosis. The decision to perform PTCA in individual patients should not be negatively influenced by the presence of these factors.
Adult↗
Multi-Hospital Eastern Atlantic Restenosis Trial: design, recruitment, and feasibility. M-HEART Investigators.
A randomized control trial was set up to examine factors that influence restenosis and determine the effects of corticosteroids on restenosis following successful PTCA. The rationale for the study agent chosen, design, recruitment, and feasibility, as well as initial patient demographic data and initial results are presented.
Adult↗
Aortic pseudoaneurysm occurring after cardiac transplantation.
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Aortic Aneurysm↗
A controlled trial of corticosteroids to prevent restenosis after coronary angioplasty. M-HEART Group.
A multicenter, double-blind, placebo-controlled trial was conducted to determine if corticosteroids influence the development of restenosis after successful percutaneous transluminal coronary angioplasty (PTCA). Either placebo or 1.0 g methylprednisolone (steroid) was infused intravenously 2-24 hours before planned PTCA in 915 patients. The PTCA patient success rate was 87% (mean) in the eight centers. There were no differences in clinical or angiographic baseline variables between the two groups. End-point analysis (angiographic restenosis, death, recurrent ischemia necessitating early restudy, and coronary artery bypass graft surgery) showed that there was no significant difference comparing placebo- with steroid-treated patients. Angiographic restudy showed the lesion restenosis rate to be 39% (120 of 307 lesions) after placebo and 40% (117 of 291) after steroid treatment (p = NS). We conclude that pulse steroid pretreatment does not influence the overall restenosis rate after successful PTCA.
Angioplasty, Balloon, Coronary↗
P&T Committee review of nifedipine GITS: new modality for angina and hypertension.
The nifedipine gastrointestinal therapeutic system (GITS) was recently approved for use in the treatment of angina and hypertension. According to the experts in this roundtable discussion, the GITS formulation provides continuous delivery of nifedipine, ensuring relatively constant drug levels and 24-hour efficacy with a once-daily dosage regimen. Nifedipine GITS also has a favorable side-effects and drug-interaction profile. This formulation will be useful for both inpatients and outpatients and may benefit patients in whom therapeutic levels previously could not be reached due to side effects.
Angina Pectoris↗
Angiographic morphology of coronary artery stenoses in prolonged rest angina: evidence of intracoronary thrombosis.
Previous clinical and angiographic/histopathologic correlative studies have demonstrated that angiographic findings of occlusive thrombus, intraluminal filling defects and complex lesion morphology indicate the presence of intracoronary thrombosis. The purpose of this study was to determine whether the presence of these descriptors of intracoronary thrombosis is associated with the syndrome of prolonged rest angina. The coronary angiograms of 50 patients with prolonged rest angina without myocardial infarction (group I) and 42 concurrent patients with stable angina (group II) were reviewed without knowledge of the clinical syndrome. Patients with prior myocardial infarction, coronary angioplasty or coronary artery bypass graft surgery were excluded, as were patients with important aortic stenosis. Each coronary artery stenosis in a major epicardial vessel was evaluated for the presence or absence of intracoronary thrombus (defined using standard criteria), complex lesion morphology (defined as the presence of haziness, a smudged appearance or irregular lesion margins) and eccentricity, and the frequency of each of these findings in groups I and II was compared. Intracoronary thrombus was present significantly more often in group I patients (42%) than in group II patients (17%) (chi 2 5.77; p less than 0.02). Complex lesion morphology was also present significantly more often in group I (44%) than in group II (14%) patients (chi 2 8.17; p less than 0.01). Either standard criterion for intracoronary thrombus or complex morphology was present in 70% of group I but only 21% of group II patients (chi 2 19.7; p less than 0.001). These results support a strong association of the angiographic descriptors of intraluminal thrombosis with the clinical syndrome of prolonged rest angina.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Hemodynamic and electrophysiologic effects of amlodipine, a new long-acting calcium antagonist: preliminary observations.
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Adult↗
Effect of bepridil in patients with chronic stable angina: results of a multicenter trial.
The effects of bepridil, a calcium antagonist with a half-life of approximately 42 hr, were assessed in a double-blind, randomized, placebo-controlled crossover trial. Forty-four patients (39 men, five women) with exercise-induced angina pectoris and ST segment depression with exercise testing (modified Bruce protocol) were studied. Compared with placebo bepridil (400 mg daily) increased total exercise time, time to onset of angina, time to 1 mm of ST segment depression, time to 2 mm of ST segment depression, and total work achieved (all p less than or equal to .001). Both frequency of angina and nitroglycerin consumption decreased during the bepridil compared with the placebo period (p = .02 and .03, respectively). Minor side effects were noted during both the bepridil and placebo phases. Four patients experienced side effects that limited therapy (dizziness in three and abnormal results of liver function tests in one) and one patient died during the bepridil phase. This study suggests that bepridil, 400 mg daily, is effective for the treatment of exercise-induced myocardial ischemia and angina pectoris.
Angina Pectoris↗