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PubMed2002

Preoperative prediction of early mortality in redocoronary artery surgery.

OBJECTIVES: Construct a predictive model for early mortality in coronary reoperations (RECABG). METHODS: Five hundred and forty one RECABG (1987-1998) were studied by univariate and multivariate analysis. Stepwise selective procedure (p<0.05) was used to identify a subset of variables with prognostic value for early mortality. This subset was used to calculate a prognostic score 'S' and a predicted probability 'P' for early mortality, P=1/1+e(-S). Sensitivity analysis was used for evaluation. RESULTS: The best predictive variables for early mortality were diabetes, vascular-, lung-disease, a myocardial infarction between the primary and the RECABG, acute- and emergency operation and the operative period. The prognostic accuracy (receiver operating characteristics curve (ROC) area) was 80%. Observed probabilities compare well with the predicted probabilities, and patients were classified in low risk (5%), intermediate risk (15%), high risk (30%) and very high risk (40%). A predicted probability of > or =0.40 was used as cut-off point for the prognostic test. The specificity of this test was 97%, sensitivity 33%, predictive value of a positive test 63% and 90% for a negative test. CONCLUSIONS: The results show that individual patients presented for RECABG, can be stratified according to their early mortality risk. This information can be used to inform the patient, and also to discus the opportunity of the RECABG.

Adult↗

PubMed2006

Fenofibrate therapy and cardiovascular protection in diabetes: recommendations after FIELD.

PURPOSE OF REVIEW: The aim of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study was to provide valuable information on the ability of fibrates to reduce cardiovascular risk in type 2 diabetes. The purpose of this review is to analyse results from FIELD and to see whether they may lead to modify the recommendations for treatment of diabetic dyslipidemia. RECENT FINDINGS: In FIELD, fenofibrate therapy was associated with a nonsignificant 11% reduction in the primary endpoint (coronary heart disease death, nonfatal myocardial infarction), corresponding to a significant 24% reduction in nonfatal myocardial infarction (P = 0.010) and a nonsignificant 19% increase in CHD mortality. Fenofibrate reduced CHD events only in patients in primary prevention, but not in secondary prevention. Fenofibrate treatment was associated with less albuminuria progression and less retinopathy needing laser treatment. SUMMARY: FIELD's results are somewhat disappointing. The relatively low cardiovascular risk population from FIELD and the 'pollution' by statin therapy may not totally explain the weak results of fenofibrate in the reduction in CHD events. The significant increase in plasma homocysteine observed with fenofibrate could partly explain not only the higher number of venous thrombotic events, but also the poor effect of fenofibrate in reducing clinical outcomes, more particularly in patients with previous cardiovascular disease.

Cardiovascular Diseases↗

PubMed2000

Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST)

OBJECTIVES: To evaluate the long-term outcome of patients randomized to coronary bypass surgery or coronary angioplasty. BACKGROUND: The Emory Angioplasty versus Surgery Trial (EAST) is a single center randomized comparison of a strategy of initial coronary angioplasty (n = 198) or coronary bypass surgery (n = 194) for patients with multivessel coronary artery disease. The primary end point (death, myocardial infarction or a large ischemic defect at 3 years) was not different, and repeat revascularization was significantly greater in the angioplasty group. Subsequently, the National Heart, Lung and Blood Institute supported a five-year extension of the trial. METHODS: After the three year anniversary visit, annual questionnaires, telephone contact and examination of medical records were accomplished until death or the eight year anniversary in 100% of the patients surviving at 3 years. RESULTS: Survival at 8 years is 79.3% in the angioplasty group and 82.7% in the surgical group (p = 0.40). Patients with proximal left anterior descending stenosis and those with diabetes tended to have better late survival with surgical intervention although not reaching statistical significance. After the first 3 years, repeat interventions remained relatively equal for both treatment groups. CONCLUSIONS: Long-term survival is not significantly different between angioplasty and surgery, and late (three to eight year) revascularization procedures were infrequent. Patients without treated diabetes had similar survival in both groups.

Aged↗

PubMed2004

Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial.

CONTEXT: Despite decades of use and considerable research, the role of estrogen alone in preventing chronic diseases in postmenopausal women remains uncertain. OBJECTIVE: To assess the effects on major disease incidence rates of the most commonly used postmenopausal hormone therapy in the United States. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind, placebo-controlled disease prevention trial (the estrogen-alone component of the Women's Health Initiative [WHI]) conducted in 40 US clinical centers beginning in 1993. Enrolled were 10 739 postmenopausal women, aged 50-79 years, with prior hysterectomy, including 23% of minority race/ethnicity. INTERVENTION: Women were randomly assigned to receive either 0.625 mg/d of conjugated equine estrogen (CEE) or placebo. MAIN OUTCOME MEASURES: The primary outcome was coronary heart disease (CHD) incidence (nonfatal myocardial infarction or CHD death). Invasive breast cancer incidence was the primary safety outcome. A global index of risks and benefits, including these primary outcomes plus stroke, pulmonary embolism (PE), colorectal cancer, hip fracture, and deaths from other causes, was used for summarizing overall effects. RESULTS: In February 2004, after reviewing data through November 30, 2003, the National Institutes of Health (NIH) decided to end the intervention phase of the trial early. Estimated hazard ratios (HRs) (95% confidence intervals [CIs]) for CEE vs placebo for the major clinical outcomes available through February 29, 2004 (average follow-up 6.8 years), were: CHD, 0.91 (0.75-1.12) with 376 cases; breast cancer, 0.77 (0.59-1.01) with 218 cases; stroke, 1.39 (1.10-1.77) with 276 cases; PE, 1.34 (0.87-2.06) with 85 cases; colorectal cancer, 1.08 (0.75-1.55) with 119 cases; and hip fracture, 0.61 (0.41-0.91) with 102 cases. Corresponding results for composite outcomes were: total cardiovascular disease, 1.12 (1.01-1.24); total cancer, 0.93 (0.81-1.07); total fractures, 0.70 (0.63-0.79); total mortality, 1.04 (0.88-1.22), and the global index, 1.01 (0.91-1.12). For the outcomes significantly affected by CEE, there was an absolute excess risk of 12 additional strokes per 10 000 person-years and an absolute risk reduction of 6 fewer hip fractures per 10 000 person-years. The estimated excess risk for all monitored events in the global index was a nonsignificant 2 events per 10 000 person-years. CONCLUSIONS: The use of CEE increases the risk of stroke, decreases the risk of hip fracture, and does not affect CHD incidence in postmenopausal women with prior hysterectomy over an average of 6.8 years. A possible reduction in breast cancer risk requires further investigation. The burden of incident disease events was equivalent in the CEE and placebo groups, indicating no overall benefit. Thus, CEE should not be recommended for chronic disease prevention in postmenopausal women.

Aged↗

PubMed2006

Safety of single versus multi-vessel angioplasty for patients with acute myocardial infarction and multi-vessel coronary artery disease: report from the New York State Angioplasty Registry.

BACKGROUND: The conventional strategy for primary angioplasty during acute myocardial infarction is angioplasty of the infarct-related vessel, even in patients with multi-vessel disease. Patients, however, often have significant lesions in multiple coronary arteries and a strategy for multi-vessel angioplasty during acute myocardial infarction has not been explored. The purpose of this study was to examine whether multi-vessel angioplasty is as safe as infarct-related vessel angioplasty in patients with multi-vessel coronary artery disease during acute myocardial infarction. METHODS: Using the 2000-2001 New York State Angioplasty Registry database, we compared the in-hospital clinical outcomes of patients with multi-vessel disease (>70% stenosis in at least two major coronary arteries), who underwent either multi-vessel angioplasty (n=632) or infarct-related vessel angioplasty (n=1350) within 24 h of acute myocardial infarction. Patients with previous myocardial infarction, angioplasty, bypass surgery, or cardiogenic shock were excluded. RESULTS: Patients in the multi-vessel angioplasty group were less likely to be female, to have peripheral vascular disease or diabetes. They had more complex lesions and were more likely to receive stents. In-hospital mortality was three-fold lower (0.8 versus 2.3%, P=0.018) in the multi-vessel angioplasty group. No differences were observed in other ischemic complications, renal failure, or length of stay. After multivariate analysis, multi-vessel angioplasty remained a significant predictor of lower in-hospital death (odds ratio=0.27, 95% confidence interval=0.08-0.90, P=0.03). CONCLUSIONS: Despite the added complexity of multi-vessel angioplasty, patients in this group had significantly lower in-hospital mortality. Therefore, a strategy of multi-vessel angioplasty during acute myocardial infarction may be safe compared with infarct-related angioplasty in selected patients.

Angioplasty, Balloon, Coronary↗

PubMedDate not supplied

Primary and secondary prevention of myocardial infarction.

The prevention of coronary artery disease (CHD) and particularly of myocardial infarction (MI) is based on some well designed strategies aimed at treating both asymptomatic high-risk patients (primary prevention) and patients with established CHD (secondary prevention). A positive impact from primary prevention can be basically achieved trough a reduction in high blood pressure and by correcting dyslipidemia. The benefit can be substantially increased by smoking cessation, increasing physical exercise, reduction of body weight, use of post-menopausal oestrogen, moderate alcohol consumption and use of high doses of vitamin E in those patients who are compliant with the specific strategies. Secondary prevention of MI can be again obtained by controlling blood pressure and reducing serum cholesterol in patients surviving acute MI who can also benefit from the administration of beta-blockers, aspirin and probably ace-inhibitors particularly in presence of left ventricular dysfunction. We suggest that in both arms of prevention, significant results can be achieved mainly by a multifactorial approach capable of correcting all the modifiable risk factors that contribute to the rather complex pathogenesis of CHD.

Adrenergic beta-Antagonists↗

PubMed1999

Persistent ST segment elevation: a new ECG finding in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy is a primary disease of myocardium resulting in myocardial hypertrophy without any inciting pressure or volume overload. The typical triad of symptoms includes exertional angina, syncope, and shortness of breath. Sudden cardiac death, the most dreadful complication of this disorder, can be the first manifestation of the disease and is more common in young patients. Elderly patients, on the other hand, may have a relatively benign course with normal or near-normal life span. The electrocardiogram (ECG) and echocardiography are the two most useful measures to diagnose hypertrophic cardiomyopathy. The electrocardiographic features of hypertrophic cardiomyopathy are numerous, including ST segment elevation that may simulate other ST segment elevation syndromes, including acute myocardial infarction, variant angina pectoria, acute pericarditis, bundle branch blocks, ventricular paced rhythm, dyskinetic ventricular segment, ventricular aneurysm, left ventricular hypertrophy, Wolff-Parkinson-White syndrome, and early repolarization syndrome. This report describes a case of an asymptomatic patient who presented with ST segment elevation of acute injury type and, therefore, was admitted to rule out silent myocardial infarction. Myocardial infarction was ruled out by cardiac enzyme levels, but ST segment elevation remained persistent in all of the subsequent ECGs. Echocardiography was performed, which clearly showed hypertrophic cardiomyopathy with left ventricular outflow tract obstruction and a high intracavity pressure gradient. Subsequently, retrieval of old ECGs showed a similar type of ST segment elevation in the patient's previous ECGs.

Cardiomyopathy, Hypertrophic↗

PubMed2001

Cardiac rehabilitation and survival in patients with left ventricular systolic dysfunction.

BACKGROUND: Exercise training, the major component of cardiac rehabilitation (CR), has been shown in previous trials to improve many pathophysiologic changes found in patients with left ventricular systolic dysfunction. It remains unproven whether exercise training improves survival. METHODS: By using the Duke Databank for Cardiovascular Disease, we identified patients with an ejection fraction < or = 40% and no recent myocardial infarction, congenital heart disease, or primary valvular disease who survived > or = 30 days after a cardiac catheterization (n = 1902). Participation in CR (n = 70) was identified through computer billing records. We developed a multivariable Cox proportional hazards regression model to estimate survival by using variables known to be independent predictors of survival in patients with systolic dysfunction. RESULTS: Patients participating in CR were less likely to be female or black and more likely to have a history consistent with ischemic cardiomyopathy. Participation in CR was associated with significantly improved survival after adjustment for baseline characteristics (hazard ratio, 0.39; 95% confidence interval, 0.15 to 0.62, P < .0001). Survival increased when patients participated in > 6 CR sessions (hazard ratio, 0.10; 95% confidence interval, 0.03 to 0.39; P < .0001). CONCLUSIONS: Participation in CR was associated with improved survival for patients with cardiomyopathy. There appears to be a dose response with improved survival benefit for patients with left ventricular systolic dysfunction participating in cardiac rehabilitation.

Aged↗

PubMed2004

EUROPA: has anything new been learned with angiotensin-converting enzyme inhibitors?

The European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA) involved 12,218 patients with stable coronary artery disease. Patients in this trial were randomized to the angiotensin-converting enzyme inhibitor perindopril (8 mg/d) or placebo in addition to optimized conventional therapy and followed for an average of 4 years. Perindopril reduced the primary end points of cardiovascular disease, myocardial infarction, and cardiac arrest by 20% (p=0.0003). Moreover, the angiotensin-converting enzyme inhibitor reduced the rate of fatal and nonfatal myocardial infarction by 24% (p=0.001). The results from EUROPA complement those observed in the Heart Outcomes and Prevention Evaluation (HOPE) study and provide further support for the concept of angiotensin-converting enzyme inhibitors conferring cardiovascular protection as a class effect.

Adult↗

PubMed1998

Identification of a new missense mutation in MyBP-C associated with hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy is a primary cardiac disease, characterised by idiopathic myocardial hypertrophy, and is caused by defects in sarcomeric protein encoding genes. One of these genes is cardiac myosin binding protein C (MyBP-C), in which a number of splice site and duplication mutations causing HCM have been described. During mutation screening of a South African HCM population by PCR-SSCP, a missense mutation, Arg654His, was detected in one proband. Although the mutation was present in his three adult children, only the proband himself was markedly affected. This is the first report of a disease associated missense mutation in MyBP-C which does not affect the myosin or titin binding domains.

Adult↗

PubMed1992

[Patency of the artery responsible for myocardial infarction: role on ventricular function and long-term outcome].

Out of 3,171 consecutive patients referred for coronary angiography, 240 were selected on the following criteria: recent primary myocardial infarction, single vessel coronary disease, no angioplasty or coronary surgery after the angiography which was performed 20 to 90 days after the onset of myocardial infarction. The patients were divided into 2 groups according to whether the artery responsible for infarction was patent (Group I: 115 patients) or not (Group II: 125 patients). The left ventricular ejection fraction was significantly higher in Group I (58 +/- 10.8%) than in Group II (53.7 +/- 11.3%) and end systolic and end diastolic left ventricular volumes were greater in Group II (51.8 +/- 22 ml/m2 and 88 +/- 22 ml/m2 respectively). Long-term follow-up (56 +/- 25 months in Group I and 61 +/- 26 months in Group II) was possible in 112 patients in Group I and 123 patients in Group II. Of the 7 patients who died in group II, 4 deaths were of cardiac origin; in addition, 2 cases of sustained ventricular tachycardia were observed in this group. None of the 6 deaths observed in Group I was of cardiac origin and there were no cases of ventricular tachycardia (p = 0.05). The functional status was identical in the two groups at the end of the study. These results suggest that the patency of the coronary artery responsible for myocardial infarction at a distance from the acute event is associated with better left ventricular function and a better long term prognosis.

Adult↗

PubMed1987

Application of a combination of sublingually administered vasodilating drugs for rapid action on pulmonary hypertension in patients with cardiac asthma and with pulmonary oedema.

Eight patients with pulmonary oedema and 6 patients with cardiac asthma (primary disease: in 7 patients acute myocardial infarction, in 6--hypertension, in 1--mitral defect) were given sublingually a combination of 0.5 mg nitroglycerin, 10 mg Isodinit (isosorbid dinitrate) and 4 mg Sidnofarm (molsidomine) in powder form. This resulted in a rapid, pronounced and protracted reduction of dyspnoea, pulmonary congestion, respiration rate, and heart rate in the course of a four-hour observation rate, in more than 80% of cases. In patients with high blood pressure it dropped by 27% vs. the initial level; in patients with hypotension the change was only minimal. Pulmonary diastolic pressure began to drop from the 3rd minute after administration of the agents and the maximal decrease was attained after 30 min (34% of the initial value); even 4 hours after administration the values were below the initial level. The mentioned drug combination appears to be valuable especially in the first stage of treatment of cardiac asthma and pulmonary oedema.

Administration, Oral↗

PubMed1987

[Silent myocardial ischemia. Contribution of coronarography].

Coronary angiography enables to determine the true frequency of silent myocardial ischemia (SMI) and specify its prognostic value. Three types of populations are studied. First, patients who are completely asymptomatic and without any past history. The prevalence of coronary disease in this group depends on the age and varies between 2 and 12 p. cent. Then patients with a known coronary insufficiency (past history of myocardial necrosis, for instance). After infarction, in 100 patients evaluated, 50 are asymptomatic and, however, half of them present a SMI. Among those, coronary angiography discloses pluritruncular lesions in half of the cases. And finally, patients with diffuse myocardial disease. 14 p. cent of primary myocardiopathies are of ischemic origin, with diffuse coronary lesions and a severe prognosis.

Coronary Angiography↗

PubMedDate not supplied

Left atrial myxoma: a case presentation and review of the literature.

Cardiac myxomas account for 24% of all primary cardiac tumors. The majority occur in the left atrium and are attached via a pedunculated stalk. The presentation may mimic primary myocardial dysfunction or obstructive valvular disease. Frequently, the diagnosis is delayed secondary to only vague constitutional symptoms. In this article, we present a case of a left atrial myxoma discovered after thoracic surgery in a patient with elevated pulmonary pressures thought to be secondary to mitral stenosis, and demonstrate how transesophageal echocardiography is useful in the evaluation of critically ill patients with cardiac tumors.

Aged↗

PubMed1995

A comparative study of myocardial troponin T levels in patients undergoing hemodialysis.

This study included 25 patients receiving hemodialysis (HD) but in whom diabetes mellitus was not the primary disease (HD-non DM group), 25 patients receiving hemodialysis with diabetes mellitus as the primary disease (HD-DM group), and 50 patients with diabetes mellitus who had not yet been treated with hemodialysis (DM group). The following markers of myocardial injury were measured in these patients: troponin T (TnT), creatine kinase (CK), myoglobin (Mb), and myosin light chain-1 (MLC-1). No significant correlation was found between myocardial TnT and Cr in any study group. The Mb and MLC-1 values in patients receiving HD were markedly higher than normal regardless of the primary disease involvement, while myocardial TnT was found to be only slightly abnormal. These results suggest that myocardial TnT may be a more useful marker of myocardial injury in HD patients than the markers in current use. In the present investigation, myocardial TnT was the only marker that was higher in the HD-DM group than in the HD-non DM group. This suggests the possibility that the HD-DM group included more patients with arteriosclerotic lesions, such as myocardial injury.

Aged↗

PubMed1978

Myocardial abscesses.

A review of postmortem materials from two teaching hospitals, accumulated in a 14-year period (1962--1975), disclosed 63 patients with myocardial abscesses among 12,359 autopsies, an incidence of 0.5%. All 63 patients had multi-focal myocardial abscesses; the lesions were grossly discernible in six patients. Coexisting infective endocarditis was present in approximately 20% (12) of the 63 patients with myocardial abscesses. Candida and Staphylococcus aureus were most common organisms responsible for the abscesses. Candida was identified in 23 patients (37%) by histologic examination of the heart sections, and 11 of these also had antemortem blood cultures positive for Candida. Staphylococcus aureus was cultured from the antemortem blood of 22 patients, two of whom also showed candidal organisms in the heart at necropsy. Eighty-one per cent (51) of 63 patients had abscesses in one or more extracardiac organs. It appeared that most of the myocardial abscesses had resulted from disseminated sepsis. Surgical conditions, malignancy and alcoholic hepatic disease were the most frequent primary conditions in patients with myocardial abscesses.

Abscess↗

PubMed1990

Causes of death in aged burn patients: analysis of 36 cases.

Over a 10-year period 110 patients over the age of 65 years were admitted to the Burn Center, Rui Jin Hospital and 36 (32.7 per cent) died. Significant differences between the survivors and non-survivors were related to the total burn surface area and full skin thickness burn size. Among the causes of death, pre-existing cardiopulmonary diseases and associated inhalation injury were particularly important since pneumonia was considered as a primary cause of death in 13 patients, myocardial disease in two, cor-pulmonale and heart failure in two. Care of the early fluid resuscitation, early excision of deep burn wounds and grafting, prevention or treatment of a variety of life-threatening complications, and nutritional supplementation appeared to decrease the mortality of aged burn patients.

Age Factors↗

PubMed1999

Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT).

BACKGROUND: Mivazerol is a drug with alpha2-agonist properties that reduces post-ganglionic noradrenaline availability and spinal efferent sympathetic output. METHODS: A double-blind randomized placebo-controlled trial was conducted in 61 European centers during a 2.5-yr period on 2,854 patients: 1,897 with coronary heart disease and 957 patients without overt coronary heart disease but classified as at high risk for it. The present analysis was restricted to those patients with previous known coronary heart disease of whom 48% had vascular surgery, 32% non-vascular thoracic or abdominal surgery, and 20% orthopedic surgery. Mivazerol or placebo were given intravenously from the induction of anesthesia for up to 72 h. RESULTS: In the 1,897 patients with established coronary heart disease, mivazerol did not reduce the primary endpoint--the combination of myocardial infarction or death--or all-cause deaths significantly. A preplanned subgroup analysis of 904 patients with known coronary heart disease undergoing vascular surgery showed that there were fewer primary endpoints in those receiving mivazerol (risk ratio [RR], 0.67; 95% CL, 0.45-0.98; P = 0.037) and fewer cardiac deaths (6 of 454 vs. 18 of 450: RR, 0.33; 95% confidence limits, 0.13-0.82; P = 0.017). The all-cause death rate was also decreased (RR, 0.41; 95% CL, 0.18-0.91; P = 0.024), although there was no significant reduction in myocardial infarction. CONCLUSION: The alpha2-adrenergic agonist, mivazerol, did not alter the rates of myocardial infarction or cardiac death in patients with known coronary heart disease undergoing noncardiac surgery. However, it may have protected patients undergoing vascular surgery from further coronary events, and a specific study of such patients is now indicated.

Adrenergic alpha-Agonists↗