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At least 649 records · Page 36Linked to original sources
PubMed2003

The antioxidant acetylcysteine reduces cardiovascular events in patients with end-stage renal failure: a randomized, controlled trial.

BACKGROUND: Patients with end-stage renal failure have increased oxidative stress and show elevated cardiovascular mortality. Whether increased cardiovascular events can be prevented by the administration of antioxidants is unknown. METHODS AND RESULTS: We evaluated the effects of acetylcysteine, a thiol-containing antioxidant, on cardiovascular events in patients undergoing hemodialysis. A prospective, randomized, placebo-controlled trial was conducted between October 1, 1999, and September 30, 2001, in 134 patients (76 male and 58 female) with a mean age of 62+/-16 years (mean+/-SD) who had been undergoing maintenance hemodialysis for a minimum of 3 months 3 times weekly in an ambulatory center. Median (range) follow-up was 14.5 (1 to 24) months. Patients were randomly assigned either to receive acetylcysteine (600 mg BID) or placebo. The primary end point was a composite variable consisting of cardiac events including fatal and nonfatal myocardial infarction, cardiovascular disease death, need for coronary angioplasty or coronary bypass surgery, ischemic stroke, peripheral vascular disease with amputation, or need for angioplasty. Secondary end points included each of the component outcomes, total mortality, and cardiovascular mortality. A total of 18 (28%) of the 64 hemodialysis patients assigned to acetylcysteine group and 33 (47%) of the 70 hemodialysis patients assigned to control group had a primary end point (relative risk, 0.60 [95% CI, 0.38 to 0.95], P=0.03). No significant differences in secondary end points or total mortality were detected. CONCLUSIONS: In hemodialysis patients, treatment with acetylcysteine (600 mg BID) reduces composite cardiovascular end points.

Acetylcysteine↗
PubMed2004

A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).

Over the past several decades, significant advances have been made in the primary and secondary prevention of coronary artery disease. However, effects of changing lifestyle and treatment practices on demographic and clinical profiles and on hospital outcomes of patients who present with acute myocardial infarction (AMI) have not been well characterized. We carried out a prospective population-based investigation of >25-year trends (1975 to 2001) in demographic and clinical characteristics, treatment practices, and hospital outcomes of patients who had been hospitalized with AMI. Residents of a metropolitan area (Worcester, Massachusetts) who had been hospitalized with validated AMI (n = 10,440) in all greater Worcester hospitals during thirteen 1-year periods between 1975 and 2001 comprised the sample of interest. Patients who had been hospitalized during the most recent study years were significantly older, were more likely to be women, and had a greater prevalence of co-morbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventions over the period under investigation. Multivariable-adjusted hospital survival rates improved considerably over time, whereas different trends were observed in the occurrence of several important clinical complications. The present results provide insights into the changing characteristics of patients who are hospitalized with AMI, treatment practices, and their short-term outcomes. Given the magnitude of AMI and evolving approaches to manage it, continued monitoring of these trends remains of considerable clinical and public health importance.

Adult↗
PubMed1999

[Physiopathology of acute coronary syndromes].

Coronary atherosclerosis and its thrombotic complications represent one of the leading causes of lesions usually consists of successive acute episodes, either silent or in the form of an acute coronary syndrome such as unstable angina, non-Q-wave myocardial infarctions, transmural myocardial infarctions or sudden death. This mode of progression does not exclude phases of regression, or more frequently stabilization of plaques, which, depending on their haemodynamic repercussions, are then responsible for chronic myocardial ischaemia. Acute coronary syndrome (ACS) correspond to the same pathophysiological process: rupture of an atheromatous plaque initiating harmful thrombotic, inflammatory and vasomotor phenomena. This is not a new concept, but progress over recent years suggests that the composition and biology of the plaque are factors involved more in the initiation of ACS than the size of the plaque. "Soft" lesions, rich in lipids, are clearly not only the most unstable lesions, but also the most thrombogenic because of their large tissue factor content. After describing the structure of vulnerable plaques, the authors discuss the causes of their rupture and the resulting cascade or events, responsible for life-threatening clinical situations.

Acute Disease↗
PubMed2003

[Treating hypertension is more important than the choice of agent; results from the largest clinical trial until now].

During the past few years, several randomised trials have compared the effects of older blood-pressure lowering drugs (diuretics, beta-blockers) with those of newer ones (angiotensin converting enzyme (ACE) inhibitors, calcium entry blockers) on the long-term prognosis. In general, no significant differences were found between these regimes. Recently, the ALLHAT trial, which was the largest hypertension trial ever and in which over 40,000 patients with hypertension participated, was completed. The initial treatment consisted of either the diuretic chlorthalidone, the calcium entry blocker amlodipine, the ACE inhibitor lisinopril, or the alpha-blocker doxazosin. The latter arm was prematurely discontinued because of a higher incidence of the secondary endpoint heart failure and stroke. Based on an intention-to-treat analysis, the other types of treatment proved to be equivalent in terms of the primary endpoint, a composite of fatal coronary heart disease and non-fatal myocardial infarction. Although the investigators conclude that ALLHAT suggests that thiazide diuretics should be first choice in the treatment of hypertension, there are several caveats that tend to lessen the strength of this conclusion.

Adrenergic beta-Antagonists↗
PubMed1997

[Surgical alternatives to direct repeat revascularization of coronary arteries--common mechanisms for reducing ventricular volume, laser transmyocardial revascularization and cardiomyoplasty].

There are a number of surgical alternatives to repeat artery bypass grafting, which is the primary treatment for recurrent severe myocardial ischemia. In patients with endstage coronary artery disease unsuitable for repeat bypass procedures, orthotopic heart transplantation is now well established. However, the increasing donor shortage limits this option to relatively few patients, a fact well documented by longer waiting lists despite less stringent donor criteria. Hence, other surgical therapies, which may at this time be underused, should be explored. In addition to mechanical circulatory support by means of implantable blood pumps which are now available with wearable drivers and rechargeable batteries, mention should be made of surgical left ventricular volume reduction and reverse remodeling, transmyocardial laser revascularization (TMR), and dynamic cardiomyoplasty. The mechanisms that explain the beneficial effects of the three latter procedures are not fully understood. But it may be speculated for these procedures that Laplace and Starling laws play a major role in the sometimes spectacular recovery. It is probably due to the complexity of the procedures mentioned, the severe condition of the patients, the high risk of a proactive attitude under such circumstances, and the significant cost, that the number of these alternative procedures performed is still rather low despite the fact that the results are similar to those of transplantation. However, careful individual evaluation is of prime importance for better results. The presence or absence of symptoms is certainly a major issue for the decision-making process. If the left ventricular ejection fraction is preserved, transmyocardial laser revascularisation may relieve angina. Dynamic cardiomyoplasty may be appropriate if the left ventricular ejection fraction is low, provided the heart is not too big and that there is neither too much mitral regurgitation nor major arrhythmia. If the left ventricle is very big and major mitral regurgitation is present, volume reduction giving transventricular access to the mitral valve can be evaluated. A decision-making tree is proposed.

Cardiomyoplasty↗
PubMed2003

[Arrhythmias of primary hypertrophic cardiomyopathy].

Primary hypertrophic cardiomyopathy is a genetic disease causing sarcomere dysfunction. The structural and functional myocardial changes combine to produce cardiac arrhythmias related to reentry phenomena and to triggered automatic activity. The commonest arrhythmias are atrial fibrillation and ventricular arrhythmias; junctional tachycardias via the bundle of Kent are rare. Atrial fibrillation and the Wolff-Parkinson-White syndrome are more commonly associated with certain genetic mutations. Their treatment is mainly based on medication with amiodarone or on radiofrequency ablation in cases of junctional tachycardia. Ventricular arrhythmias are mainly isolated ventricular extrasystoles and non-sustained ventricular tachycardia. The prognostic significance of the latter has been subject of debate for many years but recent studies report a poor prognosis with non-sustained ventricular tachycardia especially in the young patients. Sustained ventricular tachycardia and ventricular fibrillation, though life-threatening complications of hypertrophic cardiomyopathy, are rarely documented and justify implantation of an automatic defibrillator as the risk of recurrence is high. The main objective of the cardiologist in cases of primary hypertrophic cardiomyopathy is to identify the patient at high risk of sudden death. This requires analysis of several parameters: clinical, anatomical, haemodynamic, rhythmic, functional and genetic. The presence of at least two risk factors for sudden death justifies preventive measures. The implantation of an automatic defibrillator is the most reliable form of treatment.

Arrhythmias, Cardiac↗
PubMedDate not supplied

[Primary angioplasty in acute myocardial infarct. A report on 304 consecutive patients].

The purpose of this study is to describe a single-center experience in primary coronary angioplasty in 304 consecutive patients with acute myocardial infarction. Sixty-seven percent were men and 33% women, the mean age was 69 years. The time from onset to treatment was 3.5 hours, 14% had previous bypass surgery and 23% prior myocardial infarction, 11% arrived in cardiogenic shock. Coronary angiography showed multivessel disease in 56% of patients, 73% had TIMI 0-1 flow. Successful PTCA occurred in 95% and in hospital mortality was 6.5%. Primary coronary angioplasty is a successful reperfusion method in acute myocardial infarction and it is associated with low mortality even in high risk groups. The rates of success and major complications in this series are similar to other publications.

Adult↗
PubMed1996

Two-dimensional stress echocardiography in coronary artery disease.

Stress echocardiography done using various methods has become a primary way to assess and quantify the extent of myocardial ischemia. Although it is highly versatile, its use remains patchy, and in many centers it is simply considered a research technique. This review discusses some of the advantages of stress echocardiography in relation to recent publications, and it points to some areas for future research.

Coronary Disease↗
PubMed1998

Rationale and design of the International Verapamil SR/Trandolapril Study (INVEST): an Internet-based randomized trial in coronary artery disease patients with hypertension.

OBJECTIVES: The primary objective of the International Verapamil SR/Trandolapril Study (INVEST) is to compare the risk for adverse outcomes (all-cause mortality, nonfatal myocardial infarction [MI] or nonfatal stroke) in hypertensive patients with coronary artery disease (CAD) treated with either a calcium antagonist-based or a noncalcium antagonist-based strategy. BACKGROUND: Treatment recommendations for hypertension include initial therapy with a diuretic or beta-adrenergic blocking agent, for which reductions in morbidity and mortality are documented from randomized trials but are less than expected from epidemiologic data. For this reason, recent attention has focused on calcium antagonists or angiotensin-converting enzyme inhibitors. While these agents reduce blood pressure, outcome data from large randomized trials are lacking, but some case-control data, dominated by short-acting dihydropyridines, suggest an increased risk of cardiovascular events. These studies had methodologic limitations and did not differentiate among calcium antagonist types and formulations. Several studies differentiating among calcium antagonist types and an overview of published randomized trials show no increased risk with verapamil and suggestion for benefit in CAD patients. METHODS: A total of 27,000 CAD patients with hypertension will be randomized at 1,500 primary care sites to receive either a calcium antagonist-based (verapamil) or beta-blocker/diuretic-based (atenolol/hydrochlorothiazide) antihypertensive care strategy. The study uses a novel, electronic "paper-less" system for direct on-screen data entry, randomization and drug distribution from a mail pharmacy linked to the coordination center via the Internet. RESULTS: Contract negotiations with the United States and international sites are ongoing. Patients being enrolled are predominantly elderly (72% aged 60 years or older) men (54%), with either an abnormal coronary angiogram or prior MI (71%). In addition to hypertension, CAD and elderly age, most patients (89%) have one or more associated conditions (diabetes, dyslipidemia, smoking, cerebral or peripheral vascular disease, etc.) contributing to increased risk for adverse outcome. While 26% have diabetes, most of these are noninsulin dependent. Using the protocol strategies, target blood pressures (according to JNC VI) have been reached in 58% at the fourth visit, and as expected most (89%) are requiring multiple antihypertensive drugs. CONCLUSION: The design and baseline characteristics of the initial patients recruited for a prospective, randomized, international, multicenter study comparing two therapeutic strategies to control hypertension in CAD patients are described.

Aged↗
PubMed1999

Update on aspirin in the treatment and prevention of cardiovascular disease.

The effects of low-dose aspirin on cardiovascular disease have been tested in randomized trials in 3 types of populations: (1) patients with a history of cardiovascular disease; (2) patients with evolving acute myocardial infarction (MI), and (3) apparently healthy subjects. In a very wide range of patients with prior occlusive cardiovascular disease, aspirin reduces the risks of nonfatal MI, nonfatal stroke, and vascular death. Initiating aspirin therapy within 24 hours after the onset of symptoms of an acute MI also confers conclusive reductions in the risk of nonfatal reinfarction, nonfatal stroke, and total cardiovascular death. In primary prevention trials, aspirin has been shown to reduce the risk of a first MI in men, but the data on stroke and total cardiovascular death are not sufficient to allow firm conclusions to be drawn; randomized data from studies in women are not yet available. The Women's Health Study, an ongoing large-scale trial in female health care professionals, will provide the data necessary to assess the balance of benefits and risks of aspirin in primary prevention. Until then, the decision to use aspirin in primary prevention should be based on the clinical judgment of the physician and considered as an adjunct in the management of other cardiovascular disease risk factors.

Aspirin↗
PubMed1992

Effects of combined renovascular hypertension and diabetes mellitus on myocardial cells, non-vascular interstitium and capillaries: a stereological study on rat hearts.

The effects of combined renovascular hypertension and diabetes mellitus on the rat heart were investigated in order to detect possible synergistic effects of the two conditions. Hypertensive diabetic and hypertensive non-diabetic animals were compared to diabetic and non-diabetic controls. Hypertension was established for 12 weeks by a surgical stenosis of the left renal artery; diabetes mellitus was maintained for 8 weeks by a single intraperitoneal injection of 60 mg/kg streptozotocin. Light microscopic stereology did not reveal significant divergences between diabetic hypertensives and non-diabetic hypertensives. Hypertension induced a focal perivascular and interstitial fibrosis with increased volume densities of non-vascular interstitium and fibrosis (P less than 0.001). Capillary density (QA) was decreased in transverse sections (P less than 0.01) and increased in longitudinal sections (P less than 0.01). This indicates a three-dimensional remodelling of the capillary bed with an increased number of obliquely running capillaries. At least the length density (LV) of capillaries (mm/mm3) tends to be normalized in long-term renovascular hypertension. At the ultrastructural level, a synergism of hypertension and diabetes mellitus was observed: the volume ratio of mitochondria to myofibrils was significantly decreased in hypertensive diabetics, but not in non-diabetic hypertensives or in diabetics. This may enhance the risk of cardiac deterioration. We conclude that the primary target of the synergistic damage in hypertensive diabetic heart muscle disease is the myocardial cell and not the cardiac interstitium.

Animals↗
PubMed1997

Antithrombotic treatment in stable coronary syndromes: long-term intermittent urokinase therapy in end-stage coronary artery disease and refractory angina pectoris.

Interventions that modify lipid metabolism and blood coagulation have been shown to favourably influence the natural course of coronary artery disease in terms of the primary prevention and treatment of acute cardiovascular events. Various findings suggest that such interventions may also preserve and enhance myocardial perfusion in the chronic stage of the disease. Long-term intermittent urokinase therapy was developed for patients with end-stage coronary artery disease and refractory angina pectoris. A dose of 500,000 IU of urokinase given intravenously as a bolus three times a week for of 12 weeks reduced symptoms by 70% and was accompanied by objective improvements in myocardial perfusion and an increase of ergometric exercise capacity. The possible therapeutic mechanisms of long-term intermittent urokinase therapy-improvement of rheological blood properties mediated by fibrinogen reduction, thrombolysis of non-occlusive subclinical thrombi, and regression of atherosclerotic plaques-are discussed in the context of other antithrombotic approaches.

Angina Pectoris↗
PubMed2002

Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial.

BACKGROUND: Although statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged individuals, their efficacy and safety in elderly people is not fully established. Our aim was to test the benefits of pravastatin treatment in an elderly cohort of men and women with, or at high risk of developing, cardiovascular disease and stroke. METHODS: We did a randomised controlled trial in which we assigned 5804 men (n=2804) and women (n=3000) aged 70-82 years with a history of, or risk factors for, vascular disease to pravastatin (40 mg per day; n=2891) or placebo (n=2913). Baseline cholesterol concentrations ranged from 4.0 mmol/L to 9.0 mmol/L. Follow-up was 3.2 years on average and our primary endpoint was a composite of coronary death, non-fatal myocardial infarction, and fatal or non-fatal stroke. Analysis was by intention-to-treat. FINDINGS: Pravastatin lowered LDL cholesterol concentrations by 34% and reduced the incidence of the primary endpoint to 408 events compared with 473 on placebo (hazard ratio 0.85, 95% CI 0.74-0.97, p=0.014). Coronary heart disease death and non-fatal myocardial infarction risk was also reduced (0.81, 0.69-0.94, p=0.006). Stroke risk was unaffected (1.03, 0.81-1.31, p=0.8), but the hazard ratio for transient ischaemic attack was 0.75 (0.55-1.00, p=0.051). New cancer diagnoses were more frequent on pravastatin than on placebo (1.25, 1.04-1.51, p=0.020). However, incorporation of this finding in a meta-analysis of all pravastatin and all statin trials showed no overall increase in risk. Mortality from coronary disease fell by 24% (p=0.043) in the pravastatin group. Pravastatin had no significant effect on cognitive function or disability. INTERPRETATION: Pravastatin given for 3 years reduced the risk of coronary disease in elderly individuals. PROSPER therefore extends to elderly individuals the treatment strategy currently used in middle aged people.

Aged↗
PubMed2005

Myocardial perfusion defects and the left ventricular ejection fraction disclosed by scintigraphy in patients with primary hyperparathyroidism.

Patients with primary hyperparathyroidism (PHPT) have increased risk of cardiovascular disease. For patients undergoing preoperative parathyroid imaging with 99mTc-sestamibi single photon emission computed tomography (SPECT), we combined cervical SPECT and gated cardiac SPECT to achieve information about the localization of parathyroid adenomas, myocardial perfusion, and the left ventricular ejection fraction (LVEF) at rest. A series of 22 patients with PHPT and no history of myocardial infarction or angina pectoris were recruited consecutively. At 60 minutes after injection of 700 MBq 99mTc-sestamibi, SPECT of the neck and gated myocardial perfusion SPECT were performed at the same time. All of the patients who underwent parathyroidectomy had the parathyroid adenoma localized as predicted from the SPECT. Five patients (23%) had myocardial perfusion defects extending more than 15% (range 15-25%), and they had higher plasma parathyroid hormone levels (p = 0.03), and lower LVEF (p = 0.007) than patients without perfusion defects. We suggest that patients with hyperparathyroidism and suspected cardiovascular disease can undergo 99mTc-sestamibi parathyroid SPECT simultaneously with gated myocardial perfusion SPECT to obtain information about the resting perfusion status and cardiac systolic function. The results from myocardial perfusion SPECT can lead to initiation of cardiovascular treatment and eventually perioperative precautions.

Adenoma↗