Coronary-artery stenting.
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Angioplasty, Balloon, Coronary↗
Biomedical subjects
R Holubkov
Publications and source records attributed to R Holubkov.
Contemporary practice of coronary revascularization in U.S. hospitals and hospitals participating in the bypass angioplasty revascularization investigation (BARI).
OBJECTIVES: To assess generalizability of the Bypass Angioplasty Revascularization Investigation (BARI), we conducted a separate study comparing revascularization in U.S. and BARI hospitals. BACKGROUND: The BARI trial is a multicenter investigation comparing initial revascularization with percutaneous transluminal coronary angioplasty and coronary bypass graft surgery in patients with symptomatic multivessel coronary disease. METHODS: All revascularization procedures during 5 consecutive workdays were surveyed at 75 U.S. hospitals offering coronary angioplasty and bypass surgery and at all BARI hospitals. Data collected were demographics, extent of disease and type of current and previous revascularization. RESULTS: At both U.S. and BARI hospitals, 57% of all revascularization procedures were coronary angioplasty and 43% were bypass surgery. The U.S. hospitals had more patients with single-vessel disease, acute myocardial infarction and primary procedures. Other characteristics were similar. The majority of revascularization procedures were angioplasty for single-vessel disease (U.S. 32% vs. BARI 25%) and bypass surgery for triple-vessel disease (U.S. 31% vs. BARI 31%). Overall, the choice between bypass surgery and angioplasty was similar in BARI and U.S. hospitals (adjusted odds ratio [OR] 1.0, p = 0.914). However, older patients were more likely and younger patients less likely to undergo bypass surgery in BARI versus U.S. hospitals (older patients: adjusted OR 1.6, p = 0.031; younger patients: adjusted OR 0.6, p = 0.028). The BARI protocol would have excluded 65% of all candidates for revascularization, for whom indications already exist for angioplasty or bypass surgery, and another 23%, for whom angioplasty would be contraindicated for individual lesions. CONCLUSIONS: Patients undergoing coronary revascularization in BARI and U.S. hospitals were generally similar, as was the choice between types of revascularization. Results from the BARI trial apply to approximately 300 (12%) candidates for coronary revascularization/workday.
Aged↗
Classification and regression trees (CART) for prediction of function at 1 year following head trauma.
A cohort of 514 hospitalized head-injury survivors was identified based on their injury and 448 (87%) of them were followed for 1 year. Comprehensive neurobehavioral testing was performed 1 month and 1 year after injury. The authors developed predictions of six neuropsychological and two psychosocial outcomes 1 year after head injury. Prediction trees are presented for verbal IQ, Halstead's Impairment Index, and work status at 1 year. Early predictors of neurobehavioral outcome in survivors are similar to previously reported predictors of mortality. Extent (both depth and length) of coma and age are the medical and demographic variables most predictive of late outcome. Adding 1-month scores substantially improves prediction of neuropsychological variables. The classification and regression tree is a useful technique for predicting long-term outcome in patients with head injury. The trees are simple enough to be used in a clinical setting and, especially with 1-month scores, predictions are accurate enough for clinical utility.
Adolescent↗
Human peripheral lymphocytes as indicators of microsomal epoxide hydrolase activity in liver and lung.
In this study, we have applied an improved assay for the determination of microsomal epoxide hydrolase activity to assess enzymatic levels in human lung, liver, and blood lymphocytes. The assay is fluorescence-based and monitors the epoxide hydrolase-mediated conversion of (+/-)-benzo[a]pyrene-4,5-epoxide to (+/-)-trans-benzo[a]pyrene-4,5-dihydrodiol, using a high pressure liquid chromatography separation system. Approximately a 40-fold range in microsomal epoxide hydrolase activities was detected in blood lymphocytes collected from 70 individual donors. In 38 individuals who were sampled twice after a 3-month interval, the repeatability of an individual's lymphocyte epoxide hydrolase activity was highly correlated (r = 0.80, p < 0.02). In addition, within the same individual there appeared to be a strong correlation between lymphocyte and liver epoxide hydrolase activity (r = 0.92, p = 0.02), and some correlation between liver and lung activity (r = 0.58, p = 0.05). Activities were assessed in lymphocytes from a styrene-exposed worker population but no significant associations between blood concentrations of styrene and epoxide hydrolase activity levels were observed. Neither were any correlations detected in these workers between epoxide hydrolase activities and age, years on the job, alcohol consumption, sex, or smoking status. The results of our study suggest that blood lymphocytes are a useful sentinel cell for epoxide hydrolase activity determinations in individuals, as these measures are relatively stable over time and appear to reflect activity levels in other target organs.
Adult↗
Results of percutaneous transluminal coronary angioplasty in women. 1985-1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry.
BACKGROUND: The National Heart, Lung, and Blood Institute (NHLBI) Percutaneous Transluminal Coronary Angioplasty (PTCA) 1978-1981 Registry cohort indicated that PTCA risk was higher and efficacy was lower in women. Data from the 1985-1986 PTCA Registry are used to address the question of whether compared with men, women still have a worse outcome after PTCA. METHODS AND RESULTS: The 1985-1986 NHLBI PTCA Registry collected data on consecutive, first-PTCA cases at 16 centers. Initial results are reported for 2,136 patients, 546 of whom were women. Four-year follow-up status was available on 95% of the cohort. Although women were an average of 4.5 years older than the male patients and had more cardiovascular risk factors and more severe angina, their coronary artery disease as assessed by angiography was not more extensive. Rates of angiographic success on a per-lesion basis were similar for women and men (89% versus 88%), and the clinical success rates (79%) were the same. Women had more initial complications (29% versus 20%, p < 0.001) and a considerably higher procedural mortality rate (2.6% versus 0.3%, p < 0.001). For patients who survived the initial procedure, 4-year survival was similar for men and women. At 4 years, women had slightly fewer events (myocardial infarction, repeat PTCA, and/or coronary artery bypass grafting). Despite the higher proportion of women reporting the presence of angina and medication use at 4 years, the proportion reporting improvement in symptomatic status was similar to that of men. CONCLUSIONS: Women undergoing PTCA have a higher procedural mortality risk than men; this is explained in part by their worse cardiovascular risk factor profile. Otherwise, the success rate and long-term prognosis after PTCA are excellent, and PTCA should be considered for women in need of revascularization.
Aged↗
Strategy of complete revascularization in patients with multivessel coronary artery disease (a report from the 1985-1986 NHLBI PTCA Registry).
Percutaneous transluminal coronary angioplasty (PTCA) is increasingly performed in patients with multivessel coronary artery disease (CAD) despite reports showing relatively low rates of complete revascularization and poorer long-term prognosis for patients with significant residual narrowings. Reasons for incomplete revascularization were assessed in 618 patients with multivessel CAD in the 1985-1986 National Heart, Lung, and Blood Institute (NHLBI) PTCA Registry. The PTCA operator was asked to describe the treatment plan and outcome for each of the 1,942 significant lesions (greater than or equal to 50% luminal diameter stenosis) in the Registry patients. Although all significant narrowings were considered amenable to balloon angioplasty in 77% of patients, complete correction was intended only for 34% of them. It was attempted in 28% and successful in 19%. Only 63% of total occlusions were considered amenable to PTCA and only 54% of those attempted were successfully dilated. PTCA was intended for 38% with 50 to 69% stenoses versus 80% with 70 to 89% stenoses and for greater than 85% with narrowings greater than or equal to 90%. Dilatation in narrowings of the left circumflex and left anterior descending artery systems was intended less frequently than in lesions of the right coronary artery. Finally, there was wide variability in operator strategy among the different Registry sites.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon, Coronary↗
Results of coronary angioplasty of chronic total occlusions (the National Heart, Lung, and Blood Institute 1985-1986 Percutaneous Transluminal Angioplasty Registry).
There has been increasing application of coronary angioplasty to patients with chronic total occlusions. The acute and long-term outcome in 271 patients after coronary angioplasty (142 single and 129 multiple stenoses) of a total occlusion was compared with 1,429 patients undergoing angioplasty of subtotal (less than or equal to 99% stenosis) occlusions (885 single and 544 multilesion) participating in the 1985-1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Baseline characteristics were similar for each lesion group except for a higher incidence of prior myocardial infarction and left ventricular dysfunction (ejection fraction less than 50%) in patients with total occlusion. Major complications (death, myocardial infarction or emergency bypass surgery) were similar (p = not significant) between patients with total and subtotal occlusions for single (6 vs 7%) and multilesion angioplasty (9 vs 6%). At 2 years, after making adjustments for baseline variables, patients with a total occlusion had a significantly increased risk of death compared with those with subtotal occlusion. There were no significant differences in cumulative event rates for myocardial infarction or bypass surgery. Approximately three-fourths of patients in each group were free of angina at 2 years. In conclusion, angioplasty of chronic total occlusions is associated with a similar acute complication rate. Despite similar relief of anginal symptoms, patients in the total occlusion group have a higher 2-year mortality.
Aged↗
Short and long term outcome of percutaneous transluminal coronary angioplasty in unstable versus stable angina pectoris: a report of the 1985-1986 NHLBI PTCA Registry.
In a cohort of 1,720 consecutive patients from the National Heart, Lung, and Blood Institute, Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry (August 1985-May 1986), we compared 768 patients (45%) with stable angina and 952 patients (55%) with unstable angina pectoris. Unstable angina patients exhibited at least one of the following characteristics: new onset angina, rapidly progressing angina, angina at rest, angina refractory to medication, variant angina, acute coronary insufficiency, or angina recurring shortly after an acute myocardial infarct. The distribution of single- and multi-vessel disease was similar among stable and unstable angina patients; multi-vessel disease predominated. Average severity of stenosis and incidence of tubular and diffuse stenosis morphology were higher among patients with unstable angina (both p less than 0.001). Patient success rates were similar in stable and unstable patients. However, on a per lesion basis, overall angiographic success rate and average reduction of severity of stenosis in successfully dilated lesions were significantly higher among patients with unstable angina (both p less than 0.001). Incidence of major patient complications (p less than 0.01) and of emergency coronary bypass surgery (p less than 0.05) were also higher in patients with unstable angina but consistent with their more precarious clinical condition and stenosis morphology. During a two year follow-up, the cumulative distributions of death, myocardial infarct, repeat PTCA, and coronary bypass surgery were not significantly different in patients with stable angina compared to patients with unstable angina. Comparison of the current PTCA Registry cohort with the cases reported in the 1979-1982 Registry revealed a 19% higher success rate for both stable and unstable angina patients. Major complication rates decreased between time periods for stable but not for unstable angina patients. Incidence of emergency bypass surgery decreased more for stable than for unstable angina patients. Coronary angioplasty is indicated in properly selected patients with unstable angina and both single- and multi-vessel coronary disease.
Aged↗
A relation between childhood sun exposure and dysplastic nevus syndrome among patients with nonfamilial melanoma.
We studied 117 patients with nonfamilial melanoma to determine whether melanoma patients with dysplastic nevus syndrome might be distinguished, on the basis of solar exposure, from melanoma patients without dysplastic nevus syndrome. Study participants were interviewed and received a skin examination, which included a total count of nevi, a standardized assessment of clinically atypical nevi, and the excision of each patient's clinically most atypical nevus. Based on the histologic review of the clinically most atypical nevus, each patient was classified as to whether dysplastic nevus syndrome was present or absent. Childhood sunburn with blistering and childhood recreational sun exposure were found to be associated with dysplastic nevus syndrome. The results suggest that childhood sun exposure increases risk of melanoma by initiating the melanoma precursor syndrome.
Adult↗
Results of percutaneous transluminal coronary angioplasty in patients greater than or equal to 65 years of age (from the 1985 to 1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry).
The 1985 to 1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry series of 1,801 initial procedures included 486 patients age greater than or equal to 65 years (elderly). In comparison to younger patients, a greater proportion of elderly patients were women and had unstable angina. Elderly patients had more history of hypertension and more history of congestive heart failure. Although the elderly had more extensive vessel disease, the numbers of lesions and vessels attempted with PTCA were similar in the older and younger cohorts. Angiographic success rates were similar for all age groups. Although complication rates in the catheterization laboratory did not differ, patients greater than or equal to 65 years were much more likely to require emergency coronary artery bypass graft surgery (CABG) (5.4 vs 2.8%, p less than 0.05) or elective CABG (3.9 vs 1.6%, p less than 0.01). The in-hospital death rate was considerably higher among the elderly (3.1 vs 0.2%, p less than 0.01). At 2-year follow-up, symptomatic status and cumulative rates of myocardial infarction, CABG and repeat PTCA were similar for elderly and younger patients. The death rate after 2 years was higher among elderly patients (8.8% of patients greater than or equal to 65 years vs 2.9% of patients less than 65 years, p less than 0.01). When the relative risk of death for the elderly was adjusted for factors more prevalent among those greater than or equal to 65 years (history of congestive heart failure, multivessel disease, unstable angina, history of hypertension and female gender), the relative risk remained significant but was substantially reduced (from 3.3 to 2.4).
Aged↗
Coronary angioplasty: a German/US comparison.
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Aged↗
Incidence and consequences of periprocedural occlusion. The 1985-1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.
Of 1,801 patients in the 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry, 122 (6.8%) had periprocedural occlusion (4.9% in the catheterization laboratory, 1.9% outside the laboratory). Baseline patient factors independently associated with increased occlusion rates included triple-vessel disease, high risk status for surgery, and acute coronary insufficiency. Lesion characteristics showing significant positive association included severe stenosis before PTCA, diffuse or multiple discrete morphology, thrombus, and collateral flow from the lesion. Intimal tear and dissection were also very strongly associated with occlusion. Sixty patients (49%) had a transient occlusion that was reopened with PTCA, 43 (35%) were not redilated and managed with bypass surgery, and 19 (16%) were not redilated and managed medically. In-hospital mortality was 5% in each of these treatment groups, compared with 1% in occlusion-free patients. In-hospital infarction rates ranged from 27% in patients with transient occlusion to 56% in the patients managed with surgery, compared with 2% in patients without occlusion. During 2 years of follow-up, somewhat increased mortality continued in patients with occlusion, whereas follow-up infarction rates were comparable for all patients regardless of occlusion. Patients with an occlusion that was reopened or managed medically had increased rates of surgery during follow-up. Rates of repeat PTCA were comparable (about 23% by 2 years) in patients with transient occlusion and those without occlusion. Occlusion remains a serious complication of angioplasty and is associated most strongly with major events and surgical procedures that occur during the in-hospital period.
Aged↗
One-year follow-up results of the 1985-1986 National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty Registry.
In 1,801 patients in the 1985-1986 Percutaneous Transluminal Coronary Angioplasty Registry, overall 1-year mortality was 3.2%, the 1-year myocardial infarction rate was 7.2%, and the 1-year coronary artery bypass surgery rate was 13.2%. In the 78% of the cohort with all lesions successfully dilated and without major procedural complications (successful patients), the corresponding rates were 1.9%, 2.6%, and 6.4%. Nearly 20% of all deaths, 40% of all infarctions, and 25% of all bypass operations occurred in the small subset of patients (6.8%) who sustained periprocedural occlusion. Event rates were higher in patients with multivessel disease than in those with one-vessel disease. At 1 year, angina-free status was reported by approximately three fourths of all surviving patients, regardless of initial success. However, compared with successful patients, unsuccessful patients underwent intervening bypass surgery (42% vs. 6%) to achieve asymptomatic status more frequently. Comparison of the 1-year event rates in the 1985-1986 registry with those in the 1977-1981 registry indicated reductions in all major untoward events. These reductions became apparent after controlling for the more extensive disease of the 1985-1986 registry patients. In contrast, use of repeat angioplasty has increased by 50%. We conclude that the improved initial results reported in the 1985-1986 registry cohort were maintained at 1-year follow-up.
Angina Pectoris↗
Percutaneous transluminal coronary angioplasty in 1985-1986 and 1977-1981. The National Heart, Lung, and Blood Institute Registry.
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. 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 vs. 25 percent, P less than 0.001), poor left ventricular function (19 vs. 8 percent, P less than 0.001), previous myocardial infarction (37 vs. 21 percent, P less than 0.001), and previous coronary bypass surgery (13 vs. 9 percent, P less than 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 in the new cohort was better. Angiographic success rates according to lesion increased from 67 to 88 percent (P less than 0.001), and overall success rates (measured as a reduction of at least 20 percent in all lesions attempted, without death, myocardial infarction, or coronary bypass surgery) increased from 61 to 78 percent (P less than 0.001). In-hospital mortality for the new cohort was 1 percent, and the nonfatal myocardial infarction rate was 4.3 percent. Both rates are similar to those for the old registry. The long-term efficacy of current angioplasty remains to be determined.
Age Factors↗
Comparison of complications during percutaneous transluminal coronary angioplasty from 1977 to 1981 and from 1985 to 1986: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.
Because the effects of changing technology in percutaneous transluminal coronary angioplasty, increased operator experience and use of the procedure in patients with extensive disease are unknown in regard to complication patterns, the initial 1977-1981 cohort and the recent 1985-1986 cohort of the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry were analyzed with respect to complications. Compared with the initial cohort of 1,155 patients, the 1,801 new cohort patients were older and had an increased prevalence of multivessel coronary artery disease, depressed left ventricular function and prior infarction. Overall complication rates in the recent cohort were either unchanged or decreased from the rates in the initial cohort despite a higher risk patient population. The most significant decreases were in the incidence of coronary spasm (p less than 0.001) and the need for emergency coronary bypass surgery (p less than 0.01). Overall in-hospital mortality was low but was dependent on the extent of vessel disease--0.2% for single vessel disease, 0.9% for double vessel disease and 2.2% for triple vessel disease (p less than 0.001 for linear trend). Acute coronary complications of branch occlusion, dissection or abrupt closure were associated with increased rates of death, nonfatal infarction or need for emergency surgery. Factors showing a multivariate association with increased mortality included a history of congestive heart failure (p less than 0.001), age greater than or equal to 65 years (p less than 0.01), triple vessel or left main coronary artery disease (p less than 0.05), female gender (p less than 0.05) and new onset angina.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon↗
Weighted likelihood, pseudo-likelihood and maximum likelihood methods for logistic regression analysis of two-stage data.
General approaches to the fitting of binary response models to data collected in two-stage and other stratified sampling designs include weighted likelihood, pseudo-likelihood and full maximum likelihood. In previous work the authors developed the large sample theory and methodology for fitting of logistic regression models to two-stage case-control data using full maximum likelihood. The present paper describes computational algorithms that permit efficient estimation of regression coefficients using weighted, pseudo- and full maximum likelihood. It also presents results of a simulation study involving continuous covariables where maximum likelihood clearly outperformed the other two methods and discusses the analysis of data from three bona fide case-control studies that illustrate some important relationships among the three methods. A concluding section discusses the application of two-stage methods to case-control studies with validation subsampling for control of measurement error.
Adult↗