BIBLIOGRAFIA

ABSTRACT SELECCIONADOS (Medline 1999-2000)

Cost-effectiveness of minimally invasive coronary artery bypass surgery.
Arom-KV; Emery-RW; Flavin-TF; Petersen-RJ
Ann-Thorac-Surg. 1999 Oct; 68(4): 1562-6
BACKGROUND: Coronary artery bypass grafting without cardiopulmonary bypass is gaining popularity as an alternative to conventional on-pump technique for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off-pump (OPCAB) methods. These two approaches should be evaluated for financial and clinical appropriateness. METHODS: Records of patients who had single or double bypass (internal mammary artery and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed. These included 44 MIDCAB, 62 OPCAB, and 243 conventional coronary artery bypass (CCAB) patients. Univariate analysis was applied to pre, intra, and postoperative variables, comparing MIDCAB and OPCAB to the CCAB group. Procedural cost information was obtained from participating institutions. RESULTS: MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4+/-11 versus 2.3+/-2.8, p = 0.012) and OPCAB patients had a predicted risk of 5.3+/-7.8. MIDCAB and OPCAB procedures required less operating room time and blood utilization. Observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6%, and CCAB 2.8% (not significant). Mean hospital costs were CCAB at $19,000, OPCAB at $15,000, and $17,000 for MIDCAB. CONCLUSION : Off pump procedures currently reflect acute episode-of-care cost savings over CCAB.

Prevalence of coronary artery disease, ischemic stroke, peripheral arterial disease, and coronary revascularization in older African-Americans, Asians, Hispanics, whites, men, and women.
Ness-J; Aronow-WS
Am-J-Cardiol. 1999 Oct 15; 84(8): 932-3, A7
The prevalence of coronary artery disease and of peripheral arterial disease was similar in older African-Americans, Asians, Hispanics, and whites, and the prevalence of ischemic stroke was lower in older whites than in older African-Americans and Hispanics. The prevalence of coronary revascularization in older persons with coronary artery disease was lower in African-Americans than in whites and Hispanics and was lower in women than in men.

Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction.
Alter-DA; Naylor-CD; Austin-P; Tu-JV
N-Engl-J-Med. 1999 Oct 28; 341(18): 1359-67
BACKGROUND: Universal health care systems seek to ensure access to care on the basis of need rather than income and to improve the health status of all citizens. We examined the performance of the Canadian health system with respect to these goals in the province of Ontario by assessing the effects of neighborhood income on access to invasive cardiac procedures and on mortality one year after acute myocardial infarction. METHODS: We linked claims for payment for physicians' services, hospital-discharge abstracts, and vital-status data for all patients with acute myocardial infarction who were admitted to hospitals in Ontario between April 1994 and March 1997. Patients' income levels were imputed from the median incomes of their residential neighborhoods as determined in Canada's 1996 census. We determined rates of use and waiting times for coronary angiography and revascularization procedures after the index admission for acute myocardial infarction and determined death rates at one year. In multivariate analyses, we controlled for the patient's age, sex, and severity of disease; the specialty of the attending physician; the volume of cases, teaching status, and on-site facilities for cardiac procedures at the admitting hospital; and the geographic proximity of the admitting hospital to tertiary care centers. RESULTS: The study cohort consisted of 51,591 patients. With respect to coronary angiography, increases in neighborhood income from the lowest to the highest quintile were associated with a 23 percent increase in rates of use and a 45 percent decrease in waiting times. There was a strong inverse relation between income and mortality at one year (P<0.001). Each $10,000 increase in the neighborhood median income was associated with a 10 percent reduction in the risk of death within one year (adjusted hazard ratio, 0.90; 95 percent confidence interval, 0.86 to 0.94). CONCLUSION : In the province of Ontario, despite Canada's universal health care system, socioeconomic status had pronounced effects on access to specialized cardiac services as well as on mortality one year after acute myocardial infarction.

Direct myocardial revascularization and angiogenesis--how many patients might be eligible?
Mukherjee-D; Bhatt-DL; Roe-MT; Patel-V; Ellis-SG
Am-J-Cardiol. 1999 Sep 1; 84(5): 598-600, A8
This study examines the proportion of patients with ischemic heart disease who may be candidates for the newer modalities of revascularization. A significant proportion (approximately 5%) of patients who undergo coronary angiography at tertiary referral centers may be eligible for newer methods of therapy.

Primary coronary infarct artery stenting in acute myocardial infarction.
Antoniucci-D; Valenti-R; Santoro-GM; Bolognese-L; Trapani-M; Moschi-G; Fazzini-PF
Am-J-Cardiol. 1999 Sep 1; 84(5): 505-10
Completed and ongoing randomized trials have provided results that favor primary infarct-related artery (IRA) stenting as opposed to primary percutaneous transluminal coronary angioplasty, but the applicability of the trial results to all patients with acute myocardial infarction (AMI) has not yet been investigated. This study sought to determine the applicability of an unconditional IRA stenting strategy in nonselected patients with AMI. After successful mechanical recanalization of the IRA, all patients with AMI and a reference diameter > or =2.5 mm were considered eligible for primary IRA stenting without any restriction regarding age or clinical status on presentation. The primary end point of the study was a composite end point defined as death, reinfarction, or repeat target lesion revascularization. Primary IRA stenting was successfully performed in 161 of 190 consecutive patients with AMI (85%), and of 162 (99%) considered suitable for stenting. Patients with nonstented IRA had a reference IRA diameter smaller than patients with a stent (2.71+/-0.48 vs 3.20+/-0.41 mm, p <0.001). Overall, the 6-month mortality was 5%. Mortality was 2% for patients without, and 32% for patients with cardiogenic shock. The incidences of reinfarction and of repeat target lesion revascularization were 1% and 12%, respectively. The 6-month angiographic follow-up showed an IRA patency rate of 94% and a restenosis rate of 26%. The results of this study strengthen the hypothesis that unconditional primary IRA stenting is highly feasible, and may actually improve the outcome of patients with AMI.

Less invasive, continuous hemodynamic monitoring during minimally invasive coronary surgery.
Godje-O; Thiel-C; Lamm-P; Reichenspurner-H; Schmitz-C; Schutz-A; Reichart-B
Ann-Thorac-Surg. 1999 Oct; 68(4): 1532-6
BACKGROUND: Minimally invasive coronary surgery has gained more and more clinical acceptance. A clear contrast to the minimally invasive idea is the highly invasive pulmonary artery catheter used for hemodynamic monitoring during the operation. We evaluated a less invasive device which calculates cardiac output (CO) and hemodynamics based on arterial pulse-contour analysis. METHODS: In 20 patients revascularized by the off-pump technique with the octopus system, agreement of CO by pulse-contour was compared to pulmonary arterial and femoral arterial thermodilution and hemodynamic alterations during the operation were recorded. Pulse-contour CO is computed by measuring the area under the arterial pressure waveform and dividing it by aortic impedance. Aortic impedance is determined by an arterial thermodilution at the onset of the system. RESULTS: Correlation of pulmonary arterial and arterial thermodilution CO to pulse-contour CO was 0.91 and 0.90 respectively (both p<0.01). Coefficients of variations were 6.2% and 6.7%. The bias was 0.1 L per minute and standard deviations were 0.42 L per minute and 0.55 L per minute. Hemodynamic changes during the operations were seen mainly during the distal anastomosis of the first diagonal branch; only slight changes occurred during the anastomosis of the left anterior descending coronary artery. CONCLUSION : Arterial pulse-contour analysis is easy to use and minimally invasive, thus qualifies as a reliable routine monitoring tool during minimally invasive coronary surgery with tissue stabilizers.

Reappraisal of coronary endarterectomy for the treatment of diffuse coronary artery disease.
Sundt-TM-3rd; Camillo-CJ; Mendeloff-EN; Barner-HB; Gay-WA Jr
Ann-Thorac-Surg. 1999 Oct; 68(4): 1272-7
BACKGROUND: The development of new technologies such as transmyocardial laser revascularization and, more recently, local delivery of angiogenic growth factors has refocused attention on the surgical management of diffuse coronary artery disease. In some cases, coronary endarterectomy is also technically feasible. To facilitate decision-making among these options, we reviewed our experience with coronary endarterectomy to determine the results to be expected with this more traditional approach. METHODS: A search of our computerized database identified 7,096 patients undergoing myocardial revascularization between January 1, 1986 and March 30, 1997, of whom 177 (2.3%) underwent endarterectomy of at least one coronary artery. Perioperative events were derived from the database. Follow-up information was obtained from patients at 3 months to 11.5 years (mean = 55.7 +/- 38.8 months) after surgery. RESULTS: Endarterectomy was performed on the right coronary artery (RCA) system in 100 patients, the left anterior descending (LAD) system in 52, the circumflex system in 18, and in multiple distributions in 7. The 30-day mortality was 7% for RCA, 0% for LAD, 17% for circumflex, and 14% for multi-system endarterectomy (p = 0.20). There were no statistically significant differences in perioperative myocardial infarction or ventricular dysrhythmia between these groups. Actuarial survival at 5 years was 76% for patients undergoing RCA endarterectomy and 75% for left sided (LAD or circumflex) endarterectomy (p = 0.91). At late follow-up, 74% (86/117) of survivors were angina-free, 6% (7/117) had undergone subsequent angioplasty, and 3% (4/117) had undergone subsequent surgery. CONCLUSION : Coronary endarterectomy can be accomplished with acceptable operative risk and good long-term results, even when applied in a highly selective manner. The results of novel therapies for diffuse coronary artery disease should be considered in the context of those achievable with more traditional approaches.

Transmyocardial laser revascularization in the patient with unmanageable unstable angina.
Hattler-BG; Griffith-BP; Zenati-MA; Crew-JR; Mirhoseini-M; Cohn-LH; Aranki-SF; Frazier-OH; Cooley-DA; Lansing-AM; Horvath-KA; Fontana-GP; Landolfo-KP; Lowe-JE; Boyce-SW
Ann-Thorac-Surg. 1999 Oct; 68(4): 1203-9
BACKGROUND: Transmyocardial laser revascularization (TMR) provides relief for patients with chronic angina, nonamenable to direct coronary revascularization. Unmanageable, unstable angina (UUA) defines a subset of patients with refractory angina who are at high risk for myocardial infarction and death. Patients were classified in the UUA group when they had been admitted to the critical care unit with unstable angina for 7 days with three failed attempts at weaning them off intravenous antianginal medications. METHODS: Seventy-six treated patients were analyzed to determine if TMR is a viable option for patients with unmanageable unstable angina. These patients were compared with 91 routine protocol patients (protocol group [PG]) undergoing TMR for chronic angina not amenable to standard revascularization. The procedure was performed through a left thoracotomy without cardiopulmonary bypass. These patients were followed for 12 months after the TMR procedure. Both unmanageable and chronic angina patients had a high incidence of at least one prior surgical revascularization (87% and 91%, respectively). RESULTS: Perioperative mortality (< or = 30 days post-TMR) was higher in the UUAG versus PG (16% vs 3%, p = 0.005). Late mortality, up to 1 year of follow-up, was similar (13% vs 11%, UUAG vs PG; p = 0.83). A majority of the adverse events in the UUAG occurred within the first 3 months post-TMR, and patients surviving this interval did well, with reduced angina of at least two classes occurring in 69%, 82%, and 82% of patients at 3, 6, and 12 months, respectively. The percent improvement in angina class from baseline was statistically significant at 3, 6, and 12 months. A comparable improvement in angina was found in the protocol group of patients. CONCLUSION : TMR carried a significantly higher risk in unmanageable, unstable angina than in patients with chronic angina. In the later follow-up intervals, however, both groups demonstrated similar and persistent improvement in their angina up to 12 months after the procedure. TMR may be considered in the therapy of patients with unmanageable, unstable angina who otherwise have no recourse to effective therapy in the control of their disabling angina.

Multivessel coronary artery bypass surgery without cardiopulmonary bypass.
Ardehali-A; Kessler-D; Foroushani-F; Laks-H
Am-Heart-J. 1999 Nov; 138(5 Pt 1): 983-6
BACKGROUND: There is limited experience with complete myocardial revascularization on a beating heart. Using a mechanical stabilization system, we sought to determine if complete coronary revascularization is feasible without cardiopulmonary bypass and what the short-term clinical outcome would be. METHODS: From February through September 1998, 26 patients underwent complete myocardial revascularization with Medtronics Octopus Tissue Stabilization System. Mean age for the group was 62 +/- 7 years (range 48 to 78 years); 11% had prior interventions. Mean preoperative ejection fraction was 49% +/- 14% (range 20% to 66%); 38% of operations were performed urgently. The mean number of vessels grafted was 3.0 +/- 0.9 (range 1 to 5 grafts/patient). In 96% of patients, at least one arterial graft was used. Fifteen percent of patients had 2 or more arterial grafts. In 58% of patients, a branch of circumflex coronary artery was bypassed. RESULTS: The median time to extubation was 2 hours (range 0 to 37 hours). None of the patients had perioperative myocardial infarction, cerebrovascular accident, or renal failure requiring dialysis. The 30-day survival rate was 100%. Angiographic follow-up was not available. At a mean follow-up period of 3.8 +/- 2.9 months, all patients remained free of angina and none has required cardiac reintervention. CONCLUSION : Complete myocardial revascularization on a beating heart can be achieved with the currently available stabilization systems and is associated with low perioperative complications and satisfactory short-term clinical outcomes. The long-term outcomes and graft patency remain to be determined.

Minimizing bleeding complications of percutaneous coronary intervention and glycoprotein IIb-IIIa antiplatelet therapy.
Juran-NB
Am-Heart-J. 1999 Oct; 138(4 Pt 2): 297-306
Percutaneous coronary intervention in patients with coronary artery disease can lead to thrombotic occlusion of the artery and to subsequent ischemic complications. Patients undergoing these procedures have been treated with aspirin, heparin, or both as a means of preventing thrombosis. The arsenal of antithrombotic agents has recently been augmented by the addition of a new class of drugs the platelet receptor glycoprotein (GP) IIb-IIIa inhibitors, which include abciximab, eptifibatide, and tirofiban. Unlike aspirin or heparin, which inhibit some but not all pathways leading to thrombosis, GP IIb-IIIa inhibitors block the final common pathway of platelet aggregation. When used in conjunction with aspirin and heparin, GP IIb-IIIa inhibitors have yielded favorable clinical outcomes, reducing the incidence of death, myocardial infarction, and urgent intervention. However, GP IIb-IIIa inhibitors also have been associated with an increased risk of bleeding complications, especially at the femoral access site. This presents new challenges for nurses charged with the care of patients treated with these agents. The goal of nursing care for this population is to ensure the optimal benefits of GP IIb-IIIa inhibitor therapy while simultaneously preventing or minimizing groin bleeding in patients undergoing percutaneous coronary procedures.

Prediction of recovery of left ventricular dysfunction after acute myocardial infarction: comparison between 99mTc-sestamibi cardiac tomography and low-dose dobutamine echocardiography.
Spinelli-L; Petretta-M; Cuocolo-A; Nicolai-E; Acampa-W; Vicario-L; Bonaduce-D
J-Nucl-Med. 1999 Oct; 40(10): 1683-92
The aim of this study was to evaluate the role of 99mTc-sestamibi cardiac imaging and dobutamine echocardiography in detecting myocardial viability early after acute myocardial infarction. METHODS: Forty-nine patients (mean age 52 +/- 10 y) underwent coronary angiography, low-dose dobutamine echocardiography, radionuclide angiography and rest 99mTc-sestamibi imaging within 10 d after myocardial infarction. Of these patients, 19 were revascularized and 30 were treated medically. Resting echocardiogram and radionuclide angiography were repeated 8 mo later to evaluate segmental functional recovery and changes in left ventricular (LV) ejection fraction, respectively. RESULTS: In revascularized patients, 61 of 108 akinetic or dyskinetic segments showed functional recovery. In these patients, sensitivity in predicting segmental functional recovery was 87% for sestamibi imaging and 66% for dobutamine echocardiography (P < 0.001), whereas specificity and accuracy were comparable. Sestamibi activity (> or =55% of peak) was the strongest predictor of segmental functional recovery (P < 0.001) and of LV ejection fraction improvement > or =5% (P < 0.01) after revascularization. In medically treated patients, 60 of 149 akinetic or dyskinetic segments showed functional recovery. In these patients, the majority (94%) of segments with contractile reserve on dobutamine were viable on sestamibi imaging and 86% of them improved function at follow-up. Functional recovery was poor in segments without contractile reserve either with (38%) or without (62%) preserved sestamibi uptake. Inotropic response was the best predictor of segmental (P < 0.001) and global (P < 0.01) LV functional improvement in medically treated patients. CONCLUSION: Dobutamine echocardiography predicts spontaneous functional recovery after acute myocardial infarction. However, sestamibi imaging is useful to identify patients with dysfunctional myocardium without contractile reserve who may benefit from coronary revascularization.

Does increased investment in coronary angiography and revascularisation reduce socioeconomic inequalities in utilisation?
Manson-Siddle-CJ; Robinson-MB
J-Epidemiol-Community-Health. 1999 Sep; 53(9): 572-7
OBJECTIVES: To investigate whether additional resources for tertiary cardiology services, aimed at increasing coronary angiography and revascularisation rates, can improve socioeconomic equity of utilisation. DESIGN: Cross sectional ecological study, using the Super Profile classification of enumeration districts and ischaemic heart disease (IHD) standardised mortality ratios (SMR) as a proxy for need. The degree of equity before the provision of extra resources was determined using data for April 1992 to March 1994, and the corresponding picture after, using data for April 1994 to March 1996. SETTING: South Humberside (United Health-Grimsby and Scunthorpe Health Authority, a district of the former Yorkshire Region, before the April 1996 boundary changes). SUBJECTS: Patients with a primary diagnosis of IHD aged > or = 25 years who underwent investigation by angiography, or treatment by coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, as a primary procedure. MAIN RESULTS: In 1992/4, before concerted intervention, both investigation and revascularisation rates, although increasing, were low in Grimsby and Scunthorpe district compared with most other districts in the Yorkshire Region. Also, there was a decreasing trend across Super Profile Lifestyle groups from the Affluent Achievers to the Have-Nots despite a two-fold increase in SMRs indicating the greater need of the more deprived. After appointing a consultant general physician with an interest in cardiology in the Scunthorpe district general hospital in 1994; arranging for both the Grimsby physician and the Scunthorpe physician to undertake angiography at a neighbouring district tertiary cardiology centre in 1995; together with significant additional health authority investment in cardiac procedures in 1995/6, district rates increased considerably, (a 41% increase in investigation and a 47% increase in revascularisation rates). Also, after additional resource input began, the trend for angiographies across socioeconomic groups clearly became more equitable, although increased equity for revascularisations is less apparent. CONCLUSION: Early indications are that additional resources for tertiary cardiology may have reduced socioeconomic inequities in angiography, without being specifically targeted at the needier, more deprived groups. Improvement in socioeconomic equity of utilisation of revascularisation is not yet clear, although data for April 1996 to March 1998 (after a lengthier intervention period) may confirm improved equity. Should this not be so, it might be necessary to specifically target resources to the deprived to increase equity in revascularisation.

Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective.
Spencer-FA; Meyer-TE; Goldberg-RJ; Yarzebski-J; Hatton-M; Lessard-D; Gore-JM
J-Am-Coll-Cardiol. 1999 Nov 1; 34(5): 1378-87
OBJECTIVES: To describe from a population-based perspective, recent and temporal (1975-1995) trends in the incidence, in-hospital and postdischarge case-fatality rates of heart failure (HF) complicating acute myocardial infarction (AMI). BACKGROUND: Extremely limited data are available describing the incidence and case-fatality rates associated with HF complicating AMI from a community-wide perspective. METHODS: The medical records of 6,798 residents of the Worcester, Massachusetts metropolitan area with validated MI and without previous HF hospitalized in 10 annual periods between 1975 and 1995 were reviewed. RESULTS: The proportion of AMI patients developing HF during hospitalization declined between 1975-1978 (38%) and 1993-1995 (33%) (p < 0.001). After controlling for potentially confounding factors, the risk of developing HF declined progressively, albeit modestly, over time. In-hospital case-fatality rates of patients with AMI complicated by HF declined by approximately 46% between 1975-1978 (33%) and 1993-1995 (18%) (p < 0.001). Improving trends in hospital survival were observed after adjusting for potentially confounding prognostic factors. The one-year post-discharge mortality rate for hospital survivors of HF did not change over the 20-year period under study, even after controlling for additional prognostic characteristics. CONCLUSION : The results of this community-wide study suggest encouraging declines in the incidence and hospital death rates associated with HF complicating AMI. Continued efforts need to be directed towards the prevention of HF given the magnitude of this clinical syndrome. Efforts of secondary prevention are needed to identify and improve the treatment of patients with symptomatic left ventricular dysfunction following AMI given the lack of improvement in the long-term prognosis of these patients.

Coronary artery disease in potential lung transplant recipients > 50 years old: the role of coronary intervention.
Snell-GI; Richardson-M; Griffiths-AP; Williams-TJ; Esmore-DS
Chest. 1999 Oct; 116(4): 874-9
STUDY OBJECTIVES: To review the experience of the Alfred Hospital in the systematic assessment of coronary artery disease (CAD) using coronary angiography (CA), and the subsequent management of CAD, in potential lung transplant recipients. DESIGN: Retrospective study. SETTING: The Alfred Hospital Lung and Heart Transplant Service. PATIENTS: CAD risk factors were sought in potential recipients of lung transplantation (LTx) who were > 50 years old, including a history of smoking, male gender, hypertension, diabetes, hypercholesterolemia, angina, and a family history of CAD. When feasible, and in the presence of more than one cardiac risk factor, CA was performed. RESULTS: From 243 referral patients who were > 50 years old, 97 were listed for LTx, and 77 underwent LTx. Four patients were refused LTx on the basis of CAD. Of 101 patients undergoing a detailed cardiac assessment for LTx, 83 had smoked, 56 were male, 48 had hypercholesterolemia, 22 had hypertension, 4 had diabetes, and 3 had a history consistent with angina. Eighty-five patients underwent CA. In 32 cases, CA revealed CAD, and half of these cases were significant stenoses. Eight patients who were assessed required intervention. Five patients of this group have been transplanted; of these, three patients underwent coronary artery grafting at the time of LTx, and two patients underwent preoperative angioplasty or stenting. Only one of these five patients died < 90 days postoperatively. CONCLUSION: Significant CAD is a common finding in older patients who are presenting for LTx. Coronary revascularization for severe large vessel stenoses can allow safe LTx. CAD risk factors may predict who should undergo CA, but further studies of clinical and noninvasive assessments of CAD are needed if CA is to be safely avoided in patients at low risk of CAD.

Incomplete expansion of Palmaz-Schatz stents despite high-pressure implantation technique: impact on target lesion revascularization.
Blessing-E; Hausmann-D; Sturm-M; Wolpers-HG; Amende-I; Mugge-A
Cardiology. 1999; 91(2): 102-8
Improved expansion of stents using high-pressure implantation technique with subsequent antiplatelet therapy has improved patient outcome regarding the incidence of subacute stent thrombosis, bleeding complications and restenosis. Whether high-pressure implantation per se guarantees adequate stent expansion remains unclear. The aim of the study was to determine (1) stent expansion after high-pressure implantation technique and (2) whether stent expansion influences rate of target lesion revascularization within 6 months of follow-up. One hundred Palmaz-Schatz stents were implanted in 98 lesions (91 native vessels, 7 graft vessels) of 94 patients using high-pressure implantation technique (balloon pressure 12-20 atm). Stent expansion was investigated using intravascular ultrasound imaging (IVUS). Clinical follow-up of the patients was performed for 6 months. After implantation, stent/mean reference ratio was 0.81 +/- 0.16. Noncompliant balloons used for implantation were chosen by angiographic criteria. Mean balloon/reference ratio was 1.08 +/- 0.22; therefore balloons were not undersized. Additional balloon dilataion using higher pressures and/or larger balloons based on IVUS criteria and subsequent IVUS measurements was performed in 52 patients (55%); in these patients, stent expansion improved from 79 +/- 16 to 91 +/- 15% (mean +/- SD) of average reference areas (p < 0.002). Within the 6 months' clinical follow-up, target lesion revascularization was performed in 19 patients (20%). The only prognostic factors for the development of in-stent restenosis requiring target lesion revascularization were the vessel size (p < 0.05) and the extent of plaque distal to the stents (p < 0.05). Implantation of Palmaz-Schatz stents using high-pressure technique does not guarantee adequate stent expansion. Additional dilatation with higher pressures and/or larger balloons improves stent expansion. The size of the stented vessel and the extent of plaque at the distal stent end (residual outflow stenosis) but not the degree of stent expansion were predictors for target lesion revascularization within 6 months' follow-up.

Up-regulation of vascular endothelial growth factor mRNA and angiogenesis after transmyocardial laser revascularization.
Horvath-KA; Chiu-E; Maun-DC; Lomasney-JW; Greene-R; Pearce-WH; Fullerton-DA
Ann-Thorac-Surg. 1999 Sep; 68(3): 825-9
BACKGROUND: Angiogenesis has been proposed as a potential mechanism whereby transmyocardial laser revascularization (TMLR) has provided clinical relief of angina. Experimental work has found histologic evidence supporting this, as well as an improved response when angiogenic growth factors have been added to TMLR. The purpose of this study was to demonstrate that the molecular response to TMLR was an increase in the production of endogenous vascular endothelial growth factor to promote angiogenesis. METHODS: Ameroid constrictors were placed on the proximal circumflex artery in 12 domestic pigs. After a chronic ischemic zone was established the animals were randomly divided into two groups. In the TMLR group the ischemic zone was treated with carbon dioxide laser. In the control group the ischemic zone was untreated. Six weeks later the animals were sacrificed, and sections from the ischemic zone and the nonischemic zone were submitted for immunohistochemical, histologic, and molecular analysis. Messenger RNA was obtained from northern blot analysis after being probed with vascular endothelial growth factor. RESULTS: There was a twofold increase in the vascular endothelial growth factor messenger RNA in the ischemic zone of the TMLR group compared with the control group. Additionally, there was a threefold increase in the number of new blood vessels in the ischemic zone of the TMLR group compared with the control group. CONCLUSION : Transmyocardial laser revascularization promotes angiogenesis by upregulation of vascular endothelial growth factor. The resulting angiogenesis could be the principle mechanism for the clinical efficacy of TMLR.

Reperfusion revisited: beyond TIMI 3 flow.
Gassler-JP; Topol-EJ
Clin-Cardiol. 1999 Aug; 22(8 Suppl): IV20-9
Therapy for acute myocardial infarction has advanced dramatically since the early 1980s with the use of early intravenous fibrinolytic therapy. Combining low-dose fibrinolysis and platelet lysis appears to provide an additional increase in infarct-related artery (IRA) patency, but the large-scale mortality reduction trials evaluating this strategy are just getting under way. Recently, considerable attention has shifted away from the epicardial arteries to the microvasculature. Contemporary evidence suggests that epicardial patency does not necessarily translate to actual perfusion at the myocardial level. Techniques to evaluate beyond thrombolysis in myocardial infarction (TIMI) epicardial flow are now available and validated. In addition, there are promising treatments for the prevention or alleviation of certain forms of microvascular obstruction. This review attempts to clarify the confusion surrounding epicardial flow and "myocardial malperfusion" and to provide some insight into the next direction in acute myocardial infarction therapeutics.

Long-term additive prognostic value of thallium-201 myocardial perfusion imaging over clinical and exercise stress test in low to intermediate risk patients : study in 1137 patients with 6-year follow-up.
Vanzetto-G; Ormezzano-O; Fagret-D; Comet-M; Denis-B; Machecourt-J
Circulation. 1999 Oct 5; 100(14): 1521-7
BACKGROUND: The exercise treadmill test (ETT) and Tl201 single proton emission computed tomography (SPECT) are of short- to medium-term prognostic value in coronary heart disease. We assessed the long-term prognostic value of these tests in a large population of patients with low- to intermediate risk of cardiac events. METHODS AND RESULTS: One thousand one hundred thirty-seven patients (857 men, age 55+/-9 years) referred for typical (62.1%) or atypical (22.4%) chest pain, or suspected silent ischemia (15.5%), were followed up for 72+/-18 months. Overall mortality was higher after strongly positive (ST depression >2 mm, or >1 mm for a workload </=75 W) (2. 36%/y) or nondiagnostic ETT (1.63%/y) than after normal (0.85%/y) or positive ETT (1.37%/y) (P=0.002), and after abnormal SPECT than after normal SPECT (1.60%/y versus 0.68%/y, P=0.001). The major cardiac event rate (cardiac death or myocardial infarction [MI]) was 0.88%, 1.59%, 2.10%, and 2.13%/y after negative, positive, strongly positive, and nondiagnostic ETT, respectively (P=0.003), and 0.56%, 1.43%, and 2.05%/y in patients with 0, 1 to 2, and >/=3 abnormal segments on SPECT, respectively (P<0.002). An abnormal SPECT was predictive of MI (P<0.001), whereas ETT was not. In multivariate analysis, SPECT was of incremental prognostic value over clinical and ETT data for predicting overall mortality and major cardiac events. CONCLUSION : The incremental predictive value of SPECT is maintained over 6 years and is particularly relevant after positive, strongly positive, and nondiagnostic ETT.

Circulating levels of secretory type II phospholipase A(2) predict coronary events in patients with coronary artery disease.
Kugiyama-K; Ota-Y; Takazoe-K; Moriyama-Y; Kawano-H; Miyao-Y; Sakamoto-T; Soejima-H; Ogawa-H; Doi-H; Sugiyama-S; Yasue-H
Circulation. 1999 Sep 21; 100(12): 1280-4
Background-The circulating levels of secretory nonpancreatic type II phospholipase A(2) (sPLA(2)) are increased in various chronic inflammatory diseases and the increase in the levels correlates with the disease severity. sPLA(2) may possibly play a role in atherogenesis and is highly expressed in atherosclerotic arterial walls that are known to have inflammatory features. Thus, this study prospectively examined whether circulating levels of sPLA(2) may have a significant risk and prognostic values in patients with coronary artery disease (CAD). Methods and Results-Plasma levels of sPLA(2) were measured in 142 patients with CAD and in 93 control subjects by a radioimmunoassay. The sPLA(2) levels had a significant and positive relations with serum levels of C-reactive protein, a marker of systemic inflammation, and with the number of the traditional coronary risk factors associated with individuals. Multivariate logistic regression analysis showed that higher levels of sPLA(2) (>246 ng/dL; 75th percentile of sPLA(2) distribution in controls) were a significant and independent risk factor for the presence of CAD. In multivariate Cox hazard analysis, the higher levels of sPLA(2) were a significant predictor of developing coronary events (ie, coronary revascularization, myocardial infarction, coronary death) during a 2-year follow-up period in patients with CAD independent of other risk factors, including CRP levels, an established inflammatory predictor. CONCLUSION -The increase in circulating levels of sPLA(2) is a significant risk factor for the presence of CAD and predicts clinical coronary events independent of other risk factors in patients with CAD; these results may reflect possible relation of sPLA(2) levels with inflammatory activity in atherosclerotic arteries.

BMIPP imaging to improve the value of sestamibi scintigraphy for predicting functional outcome in severe chronic ischemic left ventricular dysfunction.
Hambye-AS; Dobbeleir-AA; Vervaet-AM; Van-den-Heuvel-PA; Franken-PR
J-Nucl-Med. 1999 Sep; 40(9): 1468-76
Mismatching between beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) and perfusion accurately predicts functional outcome after acute myocardial infarction. The current investigation was aimed at evaluating the value of this method to predict the evolution of global function according to the applied treatment in patients with chronic ischemic heart disease. METHODS: Twenty patients with infarction and chronic left ventricular dysfunction were studied (median infarction age 12 wk, range 2 wk-15 y). Radionuclide angiography, two-dimensional echocardiography and BMIPP and gated sestamibi scintigraphy were performed with the patient at rest before and >6 mo after treatment (revascularization in 13 patients and conservative therapy in 7 patients). In 7 patients, radionuclide angiography was repeated after 1 y. RESULTS: On a patient basis, mismatching with BMIPP less than sestamibi was noted in 15 patients at baseline. Of these 15 patients, 11 had significant functional improvement at follow-up versus only 1 of the 5 patients with a matched decreased uptake. Hence, the combined sestamibi/BMIPP was 73% positive and 80% negative in predicting functional outcome, with a global accuracy of 75%. On a segmental basis, using an optimal threshold of uptake defined by receiver operating characteristic curve analysis, sestamibi was only 63% accurate in predicting regional outcome. Adding BMIPP improved the accuracy to 80% (P = 0.001). At follow-up, significant mismatching was still noted in 7 patients in the revascularized group and 1 in the medically treated group. The mismatch was associated with a further increase in ejection fraction at 1-y follow-up in only the revascularized group. CONCLUSION: In patients with chronic left ventricular dysfunction after infarction, a mismatching with BMIPP less than sestamibi reliably identifies jeopardized but viable myocardium and predicts functional recovery with an accuracy similar to that reported in the acute and subacute phases of the infarction.

Real time assessment of myocardial revascularization during coronary artery bypass surgery by means of ultrasonic integrated backscatter.
Hirata-N; Maeda-S; Takiuchi-S; Iwata-K; Ohtake-S; Sawa-Y; Matsuda-H
Eur-J-Cardiothorac-Surg. 1999 Aug; 16(2): 156-9
OBJECTIVE: The recovery of cyclic variation (CV) of ultrasonic integrated backscatter (IB) may provide a more sensitive predictor of the success of myocardial revascularization. This study was designed to elucidate the possibility of real time assessment of coronary artery bypass grafting (CABG) using CV of IB. METHODS: We studied 10 patients (61 +/- 4 years old) with the perfused areas by stenosed or occluded LAD without myocardial infarction. There were six ischemic dysfunctional areas, and four ischemic but non-dysfunctional areas. The CV of IB was measured before and just after extracorporeal circulation (ECC). Wall motion was analyzed by segmental wall thickening during systole at the same time of the IB analysis during CABG and at 3 weeks after CABG. Those 10 areas were completely revascularized. RESULTS: In the non-dysfunctional areas, wall thickening did not change and remained at normal values before and after ECC, and 3 weeks after CABG (31 +/- 3% 29 +/- 3% and 29 +/- 5%, respectively). The magnitude of CV of IB did not also change before and after ECC (8.0 +/- 1.6 dB and 7.8 +/- 1.3 dB). However, in the ischemic dysfunctional areas, while wall thickening did not change before and after ECC (21 +/- 5% and 20 +/- 5%), it increased and reached similar values as the non-dysfunctional regions at 3 weeks after CABG (26 +/- 7%, P < 0.01 vs. before and after ECC values). The magnitude of CV of IB increased even after ECC (3.71 +/- 0.4 dB vs. 7.4 +/- 3.5 dB, P < 0.05), and reached the same level as those in the non-dysfunctional areas. There was a significant relationship between wall thickening at 3 weeks after bypass grafting and magnitude of CV of IB after ECC (r = 0.67, P < 0.05). CONCLUSION : Improvement in wall motion was gradually attained after bypass grafting. On the contrary, an increase in the magnitude of CV of IB was obtained immediately after myocardial revascularization. Our data suggest that CV of ultrasonic IB method can provide close real time information regarding the effectiveness of bypass surgery.

Two-year assessment by exercise Thallium scintigraphy of myocardial revascularization using bilateral internal mammary and gastroepiploic arteries.
Jegaden-O; Bontemps-L; de-Gevigney-G; Chatel-C; Itti-R; Mikaeloff-P
Eur-J-Cardiothorac-Surg. 1999 Aug; 16(2): 131-4
OBJECTIVE: To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries. METHODS: Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients. RESULTS: During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy. CONCLUSION : Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.

Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina [see comments]
Allen-KB; Dowling-RD; Fudge-TL; Schoettle-GP; Selinger-SL; Gangahar-DM; Angell-WW; Petracek-MR; Shaar-CJ; O'Neill-WW
N-Engl-J-Med. 1999 Sep 30; 341(14): 1029-36
BACKGROUND: Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society). METHODS: In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients). RESULTS: After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning. CONCLUSION : Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease [see comments]
Frazier-OH; March-RJ; Horvath-KA
N-Engl-J-Med. 1999 Sep 30; 341(14): 1021-8
BACKGROUND: The construction of subendocardial channels to perfuse ischemic areas of the myocardium has been investigated since the 1950s. We assessed the safety and efficacy of transmyocardial revascularization with a carbon dioxide laser in patients with refractory angina and left ventricular free-wall ischemia that was not amenable to direct coronary revascularization. METHODS: In a prospective, controlled, multicenter trial, we randomly assigned 91 patients to undergo transmyocardial revascularization and 101 patients to receive continued medical treatment. The severity of angina (according to the Canadian Cardiovascular Society [CCS] classification), quality of life, and cardiac perfusion (as assessed by thallium-201 scanning) were evaluated at base line and 3, 6, and 12 months after randomization. RESULTS: At 12 months, angina had improved by at least two CCS classes in 72 percent of the patients assigned to transmyocardial revascularization, as compared with 13 percent of the patients assigned to medical treatment who continued medical treatment (P<0.001). Patients in the transmyocardial-revascularization group also had a significantly improved quality of life as compared with the medical-treatment group. Myocardial perfusion improved by 20 percent in the transmyocardial-revascularization group and worsened by 27 percent in the medical-treatment group (P=0.002). In the first year of follow-up, 2 percent of patients assigned to undergo transmyocardial revascularization were hospitalized because of unstable angina, as compared with 69 percent of patients assigned to medical treatment (P<0.001). The perioperative mortality rate associated with transmyocardial revascularization was 3 percent. The rate of survival at 12 months was 85 percent in the transmyocardial-revascularization group and 79 percent in the medical-treatment group (P=0.50). CONCLUSION : In patients with angina refractory to medical treatment and coronary artery disease that precluded coronary-artery bypass surgery or percutaneous transluminal coronary angioplasty, transmyocardial revascularization improved cardiac perfusion and clinical status over a 12-month period.

Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison.
Burkhoff-D; Schmidt-S; Schulman-SP; Myers-J; Resar-J; Becker-LC; Weiss-J; Jones-JW
Lancet. 1999 Sep 11; 354(9182): 885-90
BACKGROUND: Transmyocardial revascularisation (TMR) is an operative treatment for refractory angina pectoris when bypass surgery or percutaneous transluminal angioplasty is not indicated. We did a prospective randomised trial to compare TMR with continued medication. METHODS: We recruited 182 patients from 16 US centres with Canadian Cardiovascular Society Angina (CCSA) score III (38%) or IV (62%), reversible ischaemia, and incomplete response to other therapies. Patients were randomly assigned TMR and continued medication (n=92) or continued medication alone (n=90). Baseline assessments were angina class, exercise tolerance, Seattle angina questionnaire for quality of life, and dipyridamole thallium stress test. We reassessed patients at 3 months, 6 months, and 12 months, with independent masked angina assessment at 12 months. FINDINGS: At 12 months, total exercise tolerance increased by a median of 65 s in the TMR group compared with a 46 s decrease in the medication-only group (p<0.0001, median difference 111 s). Independent CCSA score was II or lower in 47.8% in the TMR group compared with 14.3% in the medication-only group (p<0.001). Each Seattle angina questionnaire index increased in the TMR group significantly more than in the medication-only group (p<0.001). INTERPRETATION: TMR lowered angina scores, increased exercise tolerance time, and improved patients' perceptions of quality of life. This operative treatment provided clinical benefits in patients with no other therapeutic options.

Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators [see comments]
Lancet. 1999 Aug 28; 354(9180): 708-15
BACKGROUND: In unstable coronary-artery disease early invasive procedures are common, despite lack of evidence for the superiority of this approach. We compared an early invasive with a non-invasive treatment strategy in unstable coronary-artery disease. METHODS: In a prospective randomised multicentre study, we randomly assigned 2457 patients in 58 Scandinavian hospitals (median age 66 years, 70% men) an early invasive or non-invasive treatment strategy with placebo-controlled long-term low-molecular-mass heparin (dalteparin) for 3 months. Coronary angiography was done within the first 7 days in 96% and 10%, and revascularisation within the first 10 days in 71% and 9% of patients in the invasive and non-invasive groups, respectively. We followed up patients for 6 months. Analysis was by intention to treat. FINDINGS: After 6 months there was a decrease in the composite endpoint of death or myocardial infarction of 9.4% in the invasive group, compared with 12.1% in the non-invasive group (risk ratio 0.78 [95% CI 0.62-0.98], p=0.031). There was a significant decrease in myocardial infarction alone (7.8 vs 10.1%, 0.77 [0.60-0.99]; p=0.045) and non-significantly lower mortality (1.9 vs 2.9%, 0.65 [0.39-1.09]; p=0.10). Symptoms of angina and re-admission were halved by the invasive strategy. Results were independent of the randomised dalteparin treatment. The greatest advantages were seen in high-risk patients. INTERPRETATION: The early invasive approach should be the preferred strategy in most patients with unstable coronary-artery disease who have signs of ischaemia on electrocardiography or raised biochemical markers of myocardial damage.

Long-term low-molecular-mass heparin in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease. Investigators [see comments]
Lancet. 1999 Aug 28; 354(9180): 701-7
BACKGROUND: Short-term treatment with subcutaneous low-molecular-mass heparin in addition to aspirin is effective in unstable coronary-artery disease. We assessed the efficacy of long-term treatment with dalteparin in patients managed with a non-invasive treatment strategy. METHODS: 2267 patients from three Scandinavian countries (median age 67 years, 68% men) with unstable coronary-artery disease were randomly assigned to continue double-blind subcutaneous dalteparin twice daily or placebo for 3 months, after at least 5 days' treatment with open-label dalteparin. The composite primary endpoint was death or myocardial infarction. Analysis was by intention to treat. FINDINGS: During the 3 months of double-blind treatment, there was a non-significant decrease in the composite endpoint of death or myocardial infarction of 6.7% and 8.0% in the dalteparin and placebo groups, respectively (risk ratio 0.81 [95% CI 0.60-1.10], p=0.17). At 30 days, this decrease was significant (3.1 vs 5.9%, 0.53 [0.35-0.80]; p=0.002). In the total cohort there was at 3 months a decrease in death, myocardial infarction, or revascularisation (29.1 vs 33.4%, 0.87 [0.77-0.99]; p=0.031). The initial benefits were not sustained at 6-month follow-up. INTERPRETATION: Long-term dalteparin lowers the risk of death, myocardial infarction, and revascularisation in unstable coronary-artery disease at least during the first month of therapy. These early protective effects could be used to lower the risk of events in patients waiting for invasive procedures.

Thoracic Surgery Directors Association Award. Angiogenesis in transmyocardial revascularization: comparison of laser versus mechanical punctures.
Chu-VF; Giaid-A; Kuang-JQ; McGinn-AN; Li-CM; Pelletier-MP; Chiu-RC
Ann-Thorac-Surg. 1999 Aug; 68(2): 301-7; discussion 307-8
BACKGROUND: Transmyocardial laser revascularization (TMLR), which has been shown to reduce angina in clinical trials, was originally based on the belief that laser channels are unique and can remain patent. An increasing body of evidence indicates otherwise, and transmyocardial revascularization (TMR) angiogenesis is currently thought to be induced by nonspecific inflammatory response to tissue injuries. We tested the hypothesis that mechanical transmyocardial revascularization (TMMR) may induce angiogenic responses similar to that seen with lasers. METHODS: Ameroid constrictors were implanted around proximal circumflex arteries of porcine hearts. Six weeks later, they were randomly assigned (n = 5 each) to receive 10 transmural channels in the ischemic zone by a carbon dioxide laser (group I) or by a needle (group II). A third group (group III) had 30 needle channels in the same area, while a control group (group IV) received no TMR. The hearts were harvested 1 week later, and, using immunohistochemistry, vascular endothelial growth factor (VEGF) expression was studied and quantified by computerized morphometric analysis. Densities of vascular structures positively stained for VEGF per high-power field (HPF) were also compared. RESULTS: Virtually no TMR channels remained patent histologically. Group III had a significant higher level of total VEGF expression (14.18+/-0.78 mm2) compared with group I (7.07+/-2.06 mm2, p < 0.001) and group II (4.74+/-3.35 mm2, p < 0.001). Vascular density was significantly elevated in all treatment groups compared with the control (group I, 7.7+/-0.8/HPF vs group II, 4.5+/-2.3/HPF vs group III, 8.1+/-0.6/HPF vs group IV, 1.1+/-0.5/HPF). CONCLUSION : In view of the significant cost implications, our findings that needle punctures may also induce angiogenic response comparable with that with laser suggest that it is justifiable and desirable to include a TMMR arm for comparison with TMLR in future clinical trials.

Cardiac observations late after operative transmyocardial laser "revascularization".
Summers-JH; Henry-AC-3rd; Roberts-WC
Am-J-Cardiol. 1999 Aug 15; 84(4): 489-90, A10
This case study suggests that transmyocardial laser revascularization does not produce lasting benefit.
Patient preferences in coronary revascularization [see comments]
Hornberger-J; Bloch-DA; Hlatky-MA; Baumgartner-W
Am-Heart-J. 1999 Jun; 137(6): 1153-62
BACKGROUND: This study was performed to assess patient preferences for consequences of 3 coronary revascularization procedures: angioplasty, conventional coronary bypass surgery, and minimally invasive coronary bypass surgery. METHOD: A nationwide sample of 3 types of respondents was recruited: respondents with no heart disease (n = 89), respondents with heart disease who had not undergone cardiac surgery (n = 97), and respondents with heart disease who had undergone cardiac surgery (n = 118). RESULTS: Sixty-two percent ranked the risk of repeat revascularization as the most important concern, followed by postprocedure pain (22%), time to recovery of physical functioning (8%), time in hospital (4%), and body appearance (4%). Respondents preferred angioplasty to conventional and minimally invasive cardiac surgery if the 3-year risk of repeat revascularization with angioplasty were to decline to less than 28% and 21%, respectively. CONCLUSION: These data suggest that patient preference should influence individual and policy recommendations when choosing among coronary revascularization procedures.

Acute and long-term cost implications of coronary stenting.
Peterson-ED; Cowper-PA; DeLong-ER; Zidar-JP; Stack-RS; Mark-DB
J-Am-Coll-Cardiol. 1999 May; 33(6): 1610-8
OBJECTIVES: We compared the acute and one year medical costs and outcomes of coronary stenting with those for balloon angioplasty (percutaneous transluminal coronary angioplasty) in contemporary clinical practice. BACKGROUND: While coronary stent implantation reduces the need for repeat revascularization, it has been associated with significantly higher acute costs compared with coronary angioplasty. METHODS: We studied patients treated at Duke University between September 1995 and June 1996 who received either coronary stent (n = 384) or coronary angioplasty (n = 159) and met eligibility criteria. Detailed cost data were collected initially and up to one year following the procedure. Our primary analyses compared six and 12 month cumulative costs for coronary angioplasty- and stent-treated cohorts. We also compared treatment costs after excluding nontarget vessel interventions; after limiting analysis to those without prior revascularization; and after risk-adjusting cumulative cost estimates. RESULTS: Baseline clinical characteristics were generally similar between the two treatment groups. The mean in-hospital cost for stent patients was $3,268 higher than for those receiving coronary angioplasty ($14,802 vs. $11,534, p < 0.001). However, stent patients were less likely to be rehospitalized (22% vs. 34%, p = 0.002) or to undergo repeat revascularization (9% vs. 26%, p = 0.001) than coronary angioplasty patients within six months of the procedure. As such, mean cumulative costs at 6 months ($19,598 vs. $19,820, p = 0.18) and one year ($22,140 vs. $22,571, p = 0.26) were similar for the two treatments. Adjusting for baseline predictors of cost and selectively examining target vessel revascularization, or those without prior coronary intervention yielded similar CONCLUSION . CONCLUSION : In contemporary practice, coronary stenting provides equivalent or better one-year patient outcomes without increasing cumulative health care costs.

Management and outcome of acute myocardial infarction in older patients in the thrombolytic era.
Mahon-NG; Codd-MB; O'Rorke-C; Egan-B; McCann-HA; Sugrue-DD
J-Am-Geriatr-Soc. 1999 Mar; 47(3): 291-4
OBJECTIVE: Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group. DESIGN: An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI. SETTING: An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center. RESULTS: Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short- and long-term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta-blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care. CONCLUSION: Patients more than age 75 comprise almost one-third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.

Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project.
O'Connor-GT; Quinton-HB; Traven-ND; Ramunno-LD; Dodds-TA; Marciniak-TA; Wennberg-JE
JAMA. 1999 Feb 17; 281(7): 627-33
CONTEXT: Quality indicators for the treatment of acute myocardial infarction include pharmacologic therapy, reperfusion, and smoking cessation advice, but these therapies may not be administered to all patients who could benefit from them. OBJECTIVE: To assess geographic variation in adherence to quality indicators for treatment of acute myocardial infarction. DESIGN: Inception cohort using data from the Health Care Financing Administration Cooperative Cardiovascular Project. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 186800 Medicare beneficiaries hospitalized for treatment of confirmed acute myocardial infarction from February 1994 through July 1995. MAIN OUTCOME MEASURES: Adherence to quality indicators for pharmacologic therapy, reperfusion, and smoking cessation advice for patients judged to be ideal candidates for these therapies. The mean rates of adherence to these quality indicators for the entire United States were determined, and the 20th and 80th percentiles of the age- and sex-adjusted rates for each of 306 hospital referral regions were contrasted (mean rate [20th-80th percentiles]). RESULTS: Aspirin was used frequently both during hospitalization (86.2% [82.6%-90.1%]) and at discharge (77.8% [72.5% -83.9%]). Calcium channel blockers were withheld from most patients with impaired left ventricular function (81.9% [73.6%-90.8%]). Lower rates were seen in the use of angiotensin-converting enzyme inhibitors at discharge (59.3% [49.2%-69.2%]); reperfusion, using thrombolytic therapy or coronary angioplasty (67.2% [59.8%-75.1%]); prescription of beta-blockers at discharge (49.5% [35.8%-61.5%]); and for smoking cessation advice (41.9% [32.8%-51.3%]). CONCLUSION : Substantial geographic variation exists in the treatment of patients with acute myocardial infarction, and these gaps between knowledge and practice have important consequences. Therapies with proven benefit for AMI are underused despite strong evidence that their use will result in better patient outcomes.