PubMed Health⌕ Search

Biomedical subjects

R M Steingart

Publications and source records attributed to R M Steingart.

At least 19 recordsLinked to original sources
PubMed2000

Interventional therapy in heart failure management.

The incidence and prevalence of congestive heart failure are rapidly increasing because of the progressive decrease in age-adjusted mortality rates for coronary artery disease and hypertensive heart disease, together with the progressive aging of the US population. Despite great advances in maximal medical therapy, most patients with symptomatic congestive heart failure can expect functional impairment, interludes of worsening symptomatology, and a shortened life span. Thus, it is appropriate to ask whether the interventional revolution that is under way for the management of ischemic cardiovascular disease can be applied with benefit to the management of congestive heart failure. The use of interventional therapies for the treatment of elderly patients with congestive heart failure caused by coronary artery disease, valvular heart disease, or renal vascular disease is addressed.

Aged↗
PubMed1997

Intracoronary Doppler assessment of moderate coronary artery disease: comparison with 201Tl imaging and coronary angiography. FACTS Study Group.

BACKGROUND: Coronary angiography may not reliably predict whether a stenosis causes exercise-induced ischemia. Intracoronary Doppler ultrasound may enhance diagnostic accuracy by providing a physiological assessment of stenosis severity. The goal of this study was to compare intracoronary Doppler ultrasound with both 201Tl imaging and coronary angiography. METHODS AND RESULTS: Fifty-five patients with 67 stenotic coronary arteries underwent coronary angiography with intracoronary Doppler ultrasound and had exercise 201Tl testing within a 1-week period. Coronary flow reserve was measured, and analyses were performed by independent core laboratories. The mean stenosis was 59+/-12%; 51 of 67 stenoses were intermediate in severity (40% to 70%). A coronary flow reserve < 1.7 predicted the presence of a stress 201Tl defect in 56 of 67 stenoses (agreement=84%; kappa=0.67; 95% CI=0.48 to 0.86). In the patients who achieved 75% of their predicted maximum heart rate, the Doppler and 201Tl imaging data agreed in 46 of 52 stenoses (agreement=88%; kappa=0.77; 95%CI=0.57 to 0.97). Scatter was evident when angiography was compared with coronary flow reserve (r=.43), and the angiogram did not reliably predict the results of the 201Tl stress test (kappa=0.21; agreement=57% to 63%). CONCLUSIONS: Doppler-derived coronary flow reserve accurately predicts the presence of exercise-induced ischemia on stress 201Tl imaging, and coronary angiography does not reliably assess the physiological significance of an intermediate coronary stenosis.

Aged↗
PubMed1997

Relation between ambulatory electrocardiographic monitoring and myocardial perfusion imaging to detect coronary artery disease and myocardial ischemia: an ACIP ancillary study. The Asymptomatic Cardiac Ischemia Pilot (ACIP) Investigators.

OBJECTIVES: This study sought to explore the relation between markers of ischemia detected by ambulatory electrocardiographic (AECG) monitoring and stress myocardial perfusion single-photon emission computed tomography (SPECT). BACKGROUND: Stress myocardial SPECT and AECG monitoring are both utilized in evaluating patients with coronary artery disease. However, information is limited regarding the relation between the presence and extent of ischemia as detected by these two modalities. METHODS: This was an ancillary study of the Asymptomatic Cardiac Ischemia Pilot (ACIP) trial. One hundred six patients with previous coronary angiography underwent AECG monitoring and stress SPECT within a close temporal time period. The frequency and duration of ischemia as assessed by AECG monitoring and the total and ischemic stress-induced myocardial perfusion defect sizes as assessed by SPECT were quantified in separate core laboratories. Multivariate logistic regression and linear regression analysis were used to determine associations between AECG and SPECT abnormalities with regard to angiographic, demographic and treadmill exercise variables. RESULTS: Seventy-four percent of patients with significant (> or = 50%) coronary artery stenosis had SPECT abnormalities, whereas 61% had ischemia by AECG monitoring. The most important predictors of SPECT abnormalities were severity (p < 0.001) of coronary artery stenosis, followed by total exercise duration (p = 0.016) and patient age (p = 0.04). The only predictor of AECG abnormalities was the presence of ST segment depression on the initial exercise treadmill test (p = 0.021). Only a 50% concordance for normalcy or abnormalcy was observed between the SPECT and AECG results, and no relation was observed between the frequency or duration of AECG ischemia and the quantified total or ischemic myocardial perfusion defect size as assessed by SPECT. CONCLUSIONS: Ischemia as detected by AECG monitoring does not correlate with the presence and extent of ischemia as quantified by stress SPECT. Because these techniques appear to detect different pathophysiologic manifestations of ischemia, they may be complementary in more fully defining the functional significance of coronary artery disease and, in particular, which patients are at highest risk for adverse cardiac events.

Adult↗
PubMed1997

Clinical value of electron-beam computed tomography in the diagnosis and prognosis of coronary artery disease.

Electron-beam computed tomography (EBCT) is a relatively new imaging modality that provides transaxial cardiac images with excellent spatial and temporal resolution. At present EBCT is used primarily to detect and quantify the extent of coronary calcification. In autopsy studies, increasing areas of classification are associated with the increasing likelihood of more advanced atherosclerosis, but the relationship is not linear, with large confidence limits, and EBCT may underestimate the total plaque burden. Compared with angiography, EBCT has a high sensitivity to detect coronary classification and a high negative predictive value to rule out a significant stenosis. But it may miss atherosclerotic plaque, including unstable plaque. Recent studies have aimed at improving the characterization of individual plaques by EBCT. Despite validation against autopsy and angiography, the clinical utility of EBCT still is not well defined. Additional data on reproducibility and better consensus on criteria for abnormality for coronary calcification are advised.

Angiography↗
PubMed1996

Factors limiting the enrollment of women in a randomized coronary artery disease trial. The Asymptomatic Cardiac Ischemia Pilot Study (ACIP) Investigators.

BACKGROUND AND HYPOTHESIS: Although it is recognized that women have been underrepresented in clinical trials of cardiovascular disease, the reasons for their limited enrollment have not been elucidated. METHODS: A prospective tracking system was established in the Asymptomatic Cardiac Ischemia Pilot study (ACIP) to monitor recruitment and identify protocol issues that interfered with the recruitment of women. Patients with stress test evidence for ischemia during the course of routine clinical care were screened for asymptomatic ischemia with an ambulatory electrocardiogram (ECG). RESULTS: Those with at least one episode of asymptomatic ischemia and angiographic evidence of coronary artery disease suited for revascularization could be randomized. Women comprised only 17% of the 1,820 patients screened for asymptomatic ischemia, and only 14% of the 558 patients randomized. The limited number of women screened for ischemia was largely due to the limited number of women (25% of all patients) found to have test evidence for ischemia or coronary artery disease suited for revascularization during the course of routine clinical care. Once patients were identified as having ischemia on stress test and ambulatory ECG, the major difference in eligibility was the difference in disqualifying angiograms, occurring 21/2 times as frequently in women as in men (p < 0.001). CONCLUSION: The percentage of women recruited was lower than the prevalence of ischemic heart disease in the general population because at participating centers (1) women were found to have ischemia less often than men during the course of routine clinical care, and (2) screening tests for ischemia were less predictive of protocol-defined coronary disease in women than in men.

Analysis of Variance↗
PubMed1993

Can further benefit be achieved by adding flosequinan to patients with congestive heart failure who remain symptomatic on diuretic, digoxin, and an angiotensin converting enzyme inhibitor? Results of the flosequinan-ACE inhibitor trial (FACET).

BACKGROUND: Angiotensin converting enzyme inhibitors, diuretics, and digoxin are each effective in treating congestive heart failure, but many patients remain symptom-limited on all three medications. This trial was designed to determine whether the addition of oral flosequinan, a new direct-acting arterial and venous vasodilator with possible dose-dependent positive inotropic effects, improves exercise tolerance and quality of life in such patients. METHODS AND RESULTS: In a randomized, double-blind multicenter trial, 322 patients with predominantly New York Heart Association class II or III congestive heart failure and left ventricular ejection fractions of 35% or less, who were stabilized on a diuretic, angiotensin converting enzyme inhibitor, and digoxin, were treated with 100 mg flosequinan once daily, 75 mg flosequinan twice daily, or matching placebo. Efficacy was evaluated with serial measurements of treadmill exercise time, responses to the Minnesota Living With Heart Failure Questionnaire (LWHF), and clinical assessments during a baseline phase and a 16-week treatment period. After 16 weeks, 100 mg flosequinan once daily produced a significant increment in median exercise time (64 seconds at 16 weeks) compared with placebo (5 seconds), whereas the higher-dose flosequinan group did not show a statistically significant increase. Flosequinan (100 mg once daily) also improved the overall LWHF score significantly compared with placebo; both active therapies decreased the physical component, but 75 mg flosequinan twice daily was associated with a trend toward worsening of the emotional component. Most clinical assessments tended to improve on active therapy. CONCLUSIONS: These results indicate that additional symptomatic benefit can be attained by adding flosequinan to a therapeutic regimen already including a converting enzyme inhibitor. Because in the future most patients will fall into this category, flosequinan is a potential adjunctive agent in the management of severe congestive heart failure. However, because recent evidence indicates that the flosequinan dose studied in the present trial has an adverse effect on survival, the benefit-to-risk ratio must be assessed in individual patients.

Adult↗
PubMed1992

Prognosis in ischemic heart disease. Can you tell as much at the bedside as in the nuclear laboratory?

BACKGROUND--While the resting left ventricular ejection fraction (LVEF) predicts prognosis in ischemic heart disease, clinical evaluation is also useful. METHODS--To compare the prognostic value of LVEF by resting radionuclide ventriculography with that of clinical signs and symptoms of congestive heart failure (CHF), 170 patients with suspected ischemic heart disease were followed up in this prospective study. Patients had a standardized history and physical examination performed by a study cardiologist immediately before the nuclear scan. Chest roentgenography and radionuclide ventriculography were performed in a standard manner. The diagnosis of CHF was made by validated clinicoradiographic criteria based on the Framingham study. Mortality was determined by means of the National Death Index; median follow-up time was 3 years. RESULTS--There was CHF at baseline in 70 patients, and baseline LVEF was low (< or = 0.4) in 63 patients. Low LVEF was significantly associated with CHF. During follow-up, 55 of the subjects died (overall mortality, 32%). Subjects with CHF had a significantly higher risk of death than those without CHF, and subjects with low LVEF had a higher mortality than those with preserved LVEF. Both CHF and LVEF were independent predictors of mortality. In a Cox model, each percentage increase in LVEF was associated with a 2% decreased mortality, while subjects with CHF had a mortality 2.5 times higher than that of those without CHF. Also, CHF with preserved LVEF had a better prognosis than CHF with depressed LVEF, but this prognosis was worse than that in subjects without CHF. CONCLUSIONS--The clinical diagnosis of CHF, based on clinical evaluation and chest roentgenogram, is a valid predictor of mortality and provides information independent of the radionuclide LVEF in determining prognosis in patients with ischemic heart disease.

Aged↗
PubMed1991

Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators.

BACKGROUND: Despite the fact that coronary artery disease is the leading cause of death among women, previous studies have suggested that physicians are less likely to pursue an aggressive approach to coronary artery disease in women than in men. To define this issue further, we compared the care previously received by men and women who were enrolled in a large postinfarction intervention trial. METHODS: We assessed the nature and severity of anginal symptoms and the use of antianginal and antiischemic interventions before enrollment in the 1842 men and 389 women with left ventricular ejection fractions less than or equal to 40 percent after an acute myocardial infarction who were randomized in the Survival and Ventricular Enlargement trial. RESULTS: Before their index infarction, women were as likely as men to have had angina and to have been treated with antianginal drugs. However, despite reports by women of symptoms consistent with greater functional disability from angina, fewer women had undergone cardiac catheterization (15.4 percent of women vs. 27.3 percent of men, P less than 0.001) or coronary bypass surgery (5.9 percent of women vs. 12.7 percent of men, P less than 0.001). When these differences were adjusted for important covariates, men were still twice as likely to undergo an invasive cardiac procedure as women, but bypass surgery was performed with equal frequency among the men and women who did undergo cardiac catheterization. CONCLUSIONS: Physicians pursue a less aggressive management approach to coronary disease in women than in men, despite greater cardiac disability in women.

Angina Pectoris↗
PubMed1991

Nuclear exercise testing and the management of coronary artery disease.

Three hundred seventy-eight patients referred for nuclear exercise testing were classified using demographics and symptoms into low, intermediate, and high coronary disease likelihood categories. These likelihood groups constituted 15%, 41%, and 15% of referrals, respectively. Patients with prior infarction or disease at angiography (proven disease) made up the remaining 29% of patients. Only 2% of low likelihood patients had typical angina, but physicians diagnosed coronary disease in 64%, prescribed antianginal therapy in 50%, and were considering catheterization in 28% of these patients, all as frequently as for patients with intermediate or high likelihoods for disease. Patients with proven disease were treated differently in that 79% were receiving antianginal therapy and 56% were considered for catheterization (p less than 0.001). Nuclear exercise test results reduced the perceived need for catheterization in all groups, on average by 49%. Nuclear exercise tests are a standard by which patients are managed, sometimes substituting for the traditional role of the history in physician decision making.

Bayes Theorem↗
PubMed1989

Effects of intravenous metoprolol on global and regional left ventricular function after coronary arterial reperfusion in acute myocardial infarction.

Coronary reperfusion in myocardial infarction improves infarct zone motion, but its effect on the global ejection fraction has been less consistent. The directional movement of the ejection fraction is determined by the opposing influences of improved infarct zone motion and diminishing hyperkinesia in the noninfarct zone. Noninfarct zone hyperkinesia has been attributed to catecholamine stimulation, the Frank-Starling mechanism or intraventricular interactions that unload noninfarcted segments. To investigate the influence of catecholamine stimulation, 9 men presenting with a first myocardial infarction (mean age 53 +/- 13 years) were studied. Coronary reperfusion was accomplished less than 4 hours after the onset of myocardial infarction. Radionuclide ventriculography was then performed before and immediately after the intravenous administration of 15 mg of metoprolol. End-diastolic volume did not change, but end-systolic volume increased 28% after metoprolol (p = 0.041). The ejection fraction decreased from 55 +/- 13% before metoprolol to 45 +/- 14% after its administration (p = 0.002). There was no effect of intravenous metoprolol on infarct zone motion, whereas motion in the noninfarcted segment decreased (p = 0.002). The patients underwent repeat ventriculography after receiving metoprolol, 100 mg orally twice a day for 9 days. Infarct zone motion improved (p less than 0.002) and the ejection fraction increased to 55 +/- 12% (p less than 0.02). Normal zone motion did not change. Thus, compensatory hyperkinesia is at least in part caused by catecholamine stimulation. Conclusions regarding the effects of reperfusion on global ventricular performance can be influenced by the timing of ejection fraction determinations relative to metoprolol therapy.

Adult↗
PubMed1988

The clinical use of nuclear exercise tests.

In the mid-1970s, after decades of clinical use, the utility of electrocardiographic exercise testing for the evaluation of patients with suspected ischemic heart disease was critically examined and questioned. Concurrent with this critique, two sophisticated, more expensive and powerful "nuclear" exercise tests were introduced sequentially for clinical use: myocardial perfusion imaging with thallium-201 and radionuclide ventriculography with technetium 99m. The published indications for the two tests are similar, and both have been shown to offer advantages over ECG stress testing in selected populations. However, few data are available regarding the comparative utility of thallium versus ventriculographic imaging. As part of a prospective study to assess the efficacy of cardiovascular nuclear medicine studies, we undertook the present analysis to assess the clinical evolution of these tests and to elucidate factors responsible for clinicians' choice for the often competing examinations. The study examined 213 consecutive patient referrals for thallium scintigraphy and 183 referrals for ventriculography, ranging from patients with no symptoms or highly non-specific chest pain syndromes (21% of referrals) to patients with proven coronary disease (28% of the referrals). Twenty-one percent of patients were referred to confirm the clinical impression that the patient did not have coronary disease, 40% to confirm its presence, and 37% to determine its severity. Analyses were undertaken to determine the factors that dictated a preference for thallium scintigraphy rather than ventriculography; only the physician's intent in testing and level of training were significant predictors for a particular nuclear test.

Coronary Disease↗
PubMed1988

The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria.

There is no uniformly accepted clinical definition for congestive heart failure (CHF), although criteria have been published by various groups. There is also no reference standard for CHF, although left ventricular ejection fraction (LVEF) gives a quantitative assessment of systolic function and is useful in predicting prognosis. To determine the relationship between LVEF and clinically diagnosed CHF, we compared resting LVEF determined by radionuclide ventriculography with diagnosis of CHF by clinical criteria in 407 patients, based on clinical data collected by a cardiology fellow. Of 153 patients with a low LVEF (less than or equal to 0.40), 30 (20%) met none of the criteria for CHF. Conversely, of 204 patients with normal LVEF (greater than or equal to 0.50), 105 (51%) met at least one of the criteria. We conclude that different criteria for CHF will have varying utility depending on the population being examined, and that a combination of clinical features and an objective measure of cardiac performance is needed to diagnose CHF.

Female↗
PubMed1987

Nuclear scans: a clinical decision making tool that reduces the need for cardiac catheterization.

We have assessed the impact of cardiovascular nuclear medicine studies (CVNMS) on physicians' decisions to send patients with suspected ischemic heart disease (N = 439) on to cardiac catheterization at three Bronx hospitals. A change in management plans with respect to catheterization was observed in 31% of cases. Catheterization rates were reduced by 25% among patients referred for resting studies and by 49% for exercise studies (thallium perfusion or exercise wall motion studies). Results of CVNMS had little impact on catheterization decisions for resting study patients (N = 192). Among exercise study patients (N = 247), those with normal results had a relative reduction in catheterization post-CVNMS of 82% vs 27% for patients with abnormal results (p less than 0.001). However, impact of exercise CVNMS test results on post-CVNMS catheterization rates obtained for men only; women with abnormal exercise study results were much less likely to undergo subsequent catheterization (7.7%) than men with abnormal results (41.9%), p less than 0.005, independent of age. The apparent discrepancy in referral for catheterization based on sex needs to be investigated further.

Adolescent↗