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We read with great interest the editorial by Dr Bates on the implications of the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial,1 but we suggest taking another small step forward and returning to the strategy we introduced 30 years ago2 (that has somehow been forgotten): prehospital thrombolysis for a subset of patients with ST-segment–elevation myocardial infarction (STEMI) with short ischemic time. Reimer and Jennings3 …

We studied 40 patients with preoperative ejection fraction (EF) of 0.35 or less who underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were 7 late deaths (3 cardiac and 4 non-cardiac). The 5-year cardiac actuarial survival rate was 74 +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.

Aims: Reevaluation of clinical and angiographic predictors for percutaneous recanalization of coronary chronic total occlusion (CTO) using current techniques with conventional PTCA wires and balloons. Methods and Results: We studied 253 consecutive patients with 283 lesions who underwent attempted PTCA of CTO (mean time since occlusion 33 months, range 3–150 month). Immediate procedural success rate was 84.8% (95% CI = 80.3%–88.6%). Multiple clinical and angiographic characteristics were evaluated as possible predictors of success/failure. Multiple logistic regression analysis revealed that a tapered morphology (P < 0.001, OR = 6.1; 95% CI = 2.1–18.2), ≤45 degree of angulations of the target artery (P < 0.03, OR = 4.5; 95% CI = 1.2–17.2), length of occlusion

In their study of optical coherence tomography (OCT)-defined morphological characteristics of coronary artery spasm sites in vasospastic angina, Shin et al. [(1)][1] found thrombi at only 23 (29%) of 80 sites of spasm in patients with vasospastic angina and in only one-half of patients with a

Background In patients with acute myocardial infarction (MI), early fibrinolytic therapy results in improved survival and preservation of ventricular function. The purpose of the study was to determine whether very early treatment also reduces the development of congestive heart failure. Methods and Results During the years 1984 to 1989, 358 consecutive patients with acute MI were treated with streptokinase, 161 within the first 1.5 hours from the onset of chest pain (group A) and 197 within 1.5 to 4.0 hours (group B). In 68, fibrinolysis was initiated in the prehospital setting pioneered by our group. Symptoms related to heart failure including dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturia, and peripheral edema, in addition to pulmonary edema events, were assessed during 5 years of follow-up. The evaluation was based on medical records and a detailed questionnaire, which was filled in by the investigators. A favorable significant effect of very early thrombolysis on the development of most of these limiting symptoms appeared 3 months after hospital discharge and persisted thereafter (P

By graphically identifying patterns of ventricular ectopic beat (VEB) interval characteristics, we sought to enhance arrhythmia analysis, especially in long-term ECG monitoring. Coupling intervals as a function of preceding sinus RR intervals (CI/RR diagrams) with the aid of coupling interval and interectopic interval histograms were analyzed in 172 patients with frequent VEBs. Four distinct types of CI/RR diagrams were observed: horizontal-elongated (25 patients), linear (4 patients), triangular (37 patients), and clusters separated by dot-sparse areas (17 patients). In 89 patients, no definite pattern was discerned. The patients with elongated diagrams were significantly younger, had fixed coupling, uniform QRS complexes, and lacked periodicities in their interectopic interval histograms. The linear pattern was detected in a small group with rate-related VEBs. In the group with a triangular pattern, 30% of the patients exhibited interectopic periodicities suggesting parasystole. The patients with dot-sparse areas in the CI/RR diagrams had more variable coupling and predominantly more multiform QRS complexes. We conclude that CI/RR diagrams in conjunction with coupling interval and interectopic interval histograms enhance arrhythmia analysis by identifying patterns, such as those consistent with either fixed coupling, rate dependence, parasystole, or multiform VEBs.

OBJECTIVES The purpose of the study was to examine the potential renal protective effect of low-dose dopamine in high-risk patients undergoing coronary angiography. BACKGROUND Contrast nephropathy is prevalent in patients with chronic renal failure (CRF) and/or diabetes mellitus (DM). Decreased renal blood flow due to vasoconstriction was suggested as a contributory mechanism. Low-dose dopamine has a dilatory effect on the renal vasculature. METHODS Sixty-six patients with mild or moderate CRF and/or DM undergoing coronary angiography were prospectively double-blindedly randomized, to either 120 ml/day of 0.9% saline plus dopamine 2 μg/kg/min (Dopamine group) or saline alone (Control group) for 48 h. RESULTS Thirty-three Dopamine-treated (30 diabetics and 6 with CRF) and 33 Control (28 diabetics and 5 with CRF) patients were compared. Plasma creatinine (Cr) level increased in the Control group from 100.6 ± 5.2 before to 112.3 ± 8.0 μmol/liter within five days after angiography (p = 0.003), and in the Dopamine group from 100.3 ± 5.4 before to 117.5 ± 8.8 μmol/liter after angiography (p = 0.0001), respectively. There was no significant difference in the changeof Cr level (ΔCr) between the two groups. However, in a subgroup of patients with peripheral vascular disease (PVD), ΔCr was −2.4 ± 2.3 in the Control group and 30.0 ± 12.0 μmol/liter in the Dopamine group (p = 0.01). No significant difference occurred in ΔCr between Control and Dopamine in subgroups of patients with preangiographic CRF or DM. CONCLUSIONS Contrast material caused a small but significant increase in Cr blood level in high-risk patients. There is no advantage of dopamine over adequate hydration in patients with mild to moderate renal failure or DM undergoing coronary angiography. Dopamine should be avoided in patients with PVD exposed to contrast medium.

Changes in heart rate preceding ventricular ectopic beats may be used to identify clinical subsets of patients. We evaluated RR interval patterns preceding ventricular ectopic beats with a rate enhancement method which estimates ventricular ectopic beat dependence on the sinus RR interval preceding the ventricular ectopic beat and the dynamic heart rate trend, which is based on the slope of the five RR intervals preceding the ventricular ectopic beat. Using these two methodologies in 176 patients with frequent ventricular ectopic beats we identified several unique subsets of patients: (1) bradycardia-enhanced patients were younger with a high proportion of males and longer, more variable coupling intervals; (2) tachycardia-enhanced patients exhibited sleep suppression of ventricular ectopic beats and had shorter, less variable coupling intervals; (3) patients with predominantly no change in RR preceding the ventricular ectopic beat were significantly older, with greater prevalence of cardiovascular disease and reduced sinus RR variability, indicating decreased autonomic nervous system activity. These two methods may serve as a basis for further investigations regarding the treatment and prognosis of ventricular ectopic beats.

The long term impact of pre-hospital thrombolysis in acute myocardial infarction on the subsequent development of heart failure symptoms was investigated in 362 consecutive patients. The pre hospital strategy, used in 61 patients, allowed for very early administration of streptokinase, within 1.2±0.6 (mean±S.D.) hours from pain onset. In contrast, 294 patients treated in hospital received lytic treatment within 2.0±0.9 hours. The pre hospital group showed faster reperfusion, as measured by the time to peak creatine kinase and to ST segment recovery, but only a slightly better ventricular function, as compared to hospital treated patients. Heart failure symptoms were significantly reduced in the pre hospital group during hospitalization and at long term follow up: there were less dyspnea, fatigue, orthopnea, nocturnal dyspnea, nocturia, peripheral edema and episodes of pulmonary edema. Angina was reduced as well. We conclude that the initial benefit of prehospital thrombolysis translates into long term reduction of heart failure symptoms, thus improving quality of life.

Coronary arteries in diabetic patients appear to be narrower than in normal subjects, but this has not been examined systematically. To investigate this hypothesis we reviewed the data of 711 consecutive patients with angiographically ‘normal coronary arteries’. Excluded were patients with valvular, myocardial or pericardial disease, and patients with hypertension or hyperlipidemia. Thirteen diabetic patients (10 men) and 22 nondiabetic persons (8 men) constituted the study and control groups, respectively. The diameters of the coronary arteries and their branches were measured and adjusted for body surface area. The sum of the proximal left anterior descending (LAD), circumflex and right coronary arteries (RCA) was calculated and defined as total coronary diameter (TCD). The sum of the distal LAD, first diagonal, first marginal and distal RCA was calculated and defined as total distal coronary diameter (dTCD). The clinical data of both groups were comparable. Adjusted TCD for body surface area was 5.4 ± 1.1 and 6.5 ± 1.1 mm/m2 (p < 0.05) in diabetics and nondiabetics, respectively, and adjusted dTCD was 4.9 ± 1.2 and 6.1 ± 1.2 mm/m2 (p = 0.01) in diabetics and normal subjects, respectively. Specific arteries and branches that were significantly smaller in diabetics included: left main coronary artery, distal LAD, first diagonal, proximal RCA, distal RCA, right ventricular branch, and posterolateral and posterior descending artery of RCA origin. Gender was not a confounding factor since the control group had a larger proportion of women and still larger arteries than the diabetic group. In conclusion, coronary arteries and their branches in diabetic patients have smaller diameters than normal subjects. This may be due to increased coronary tone, diffuse mild atherosclerosis or both.

Objectives. We sought to compare the angiographic outcome of diabetic patients (treated with insulin or oral hypoglycemic agents) after successful coronary angioplasty with that in nondiabetic patients. The analysis included the outcome of the dilated (restenosis) and nondilated narrowings (disease progression). Background. Recent data have confirmed that diabetes mellitus is an important risk factor for long-term adverse events. These adverse events are more common after balloon angioplasty than after bypass surgery (Bypass Angioplasty Revascularization Investigation [BARI]). Methods. We examined retrospectively 353 coronary angiograms of 248 patients (55 diabetic, 193 nondiabetic) who were referred for diagnostic angiography >1 month after successful angioplasty (1.4 ± 0.6 [mean ± SD] repeat angiograms/patient). Restenosis and disease progression/regression were compared between groups by means of quantitative angiography. Results. Baseline clinical and angiographic characteristics were similar in both groups. There was a nonsignificant trend for a higher restenosis rate of dilated narrowings in diabetic patients. There were no significant changes between diabetic and nondiabetic patients in the rates of progression and regression of narrowings that were not dilated during the initial angioplasty. The main difference was in the rate of appearance of new narrowings: There was a 22% increase in the number of narrowings on the follow-up angiogram in diabetic patients (38 new, 174 preexisting narrowings) compared with 12% (86 new, 734 preexisting narrowings) in nondiabetic patients (p Conclusions. The combination of diabetes mellitus and an artery that was instrumented during balloon angioplasty is additive and increases the risk of formation of new narrowing in that artery. This finding may explain the high adverse event rates observed in diabetic patients in the angioplasty arm of the BARI study, most of whom had angioplasty performed in at least two arteries.

We investigated the diameter of epicardial coronary arteries in 12 patients (ten men) with dilated cardiomyopathy, and compared to 21 normal persons (14 men). Dilated cardiomyopathy patients were younger than controls with no difference in height, weight and body surface area. Ejection fraction was lower in dilated cardiomyopathy compared to normals (31+/-10% and 73+/-7%, respectively, P0.001). Left ventricular mass was significantly larger (P=0.04). The sum of diameters of the proximal left anterior descending, circumflex and right coronary arteries (Total Coronary Diameter) in the dilated cardiomyopathy and controls was 13.4+/-2.7 and 10.5+/-1.5 mm (P0.001). Absolute diameters of the left main, left anterior descending, circumflex, proximal right coronary artery and the right ventricular branch in dilated cardiomyopathy were also significantly larger as was Total Coronary Diameter adjusted for body surface area. Total Coronary Diameter adjusted for left ventricular mass, was significantly smaller (103.42+/-30.38, 146.00+/-41.59 mm/mg, respectively, P0.03). Specific arteries in the dilated cardiomyopathy adjusted for left ventricular mass were significantly smaller, or had a tendency for smaller diameter compared to normals. There was no correlation between age and coronary diameter in each group. After adjusting for left ventricular mass there was no difference in coronary artery diameter between men and women. Thus, coronary arteries of patients with dilated cardiomyopathy have increased absolute diameter compared to normals, but decreased diameter when adjusted for left ventricular mass. This may contribute to patients' complaints and to the natural history of the disease.

A group of algorithms has been developed to investigate the characteristics of beat-to-beat intervals preceding and following the onset and termination of repeated pattern ventricular arrhythmias (RPVA) such as bigeminy and trigeminy. Eighty-five patients, each with more than 3000 ventricular ectopic beats in a 24-hour Holter recording and with more than 10 episodes of RPVA, were evaluated. A statistically significant prolongation of sinus intervals preceding the onset of bigeminy and trigeminy and shortening of postectopic intervals after the onset were observed. In addition, shortening of postectopic intervals before the termination of bigeminy and trigeminy and lengthening of sinus intervals following their termination were also seen. A significant presence of these characteristics was not observed in arrhythmias with a greater number of sinus beats between ectopic beats. These dynamics provide information which may be utilized in the assessment of mechanisms involved in the onset and termination of RPVA.

Background The cause of severe cardiac conduction disturbances is often uncertain. The aim of this study was to examine a group of patients with permanent pacemakers who underwent coronary arteriography to determine the extent of coronary atherosclerotic disease that might be responsible for the conduction disturbances. Methods and Results Forty-three consecutive patients with a permanent pacemaker and 36 matched control patients were investigated. The coronary angiographic study included measurement of diameter and stenosis severity, qualitative assessment of flow, and classification of pathological anatomy, particularly the blood supply to territories supplying the different segments of the conduction system. Among 43 patients with a permanent pacemaker, 27 had ischemic heart disease (17 after coronary artery bypass graft surgery). The conduction disturbance was infranodal in 28 patients, sinus nodal in 6, AV nodal in 4, and complete AV block of unspecified origin in 5. Patients with permanent pacemakers had a coronary artery pathology compromising blood flow to the septal branches and the right coronary artery (type IV anatomy). This pattern was significantly different from the matched control patients, in whom the most prevalent coronary anatomy was the combination of right coronary artery with distal left anterior descending artery (not involving the septal branches) lesions ( P =.007). Conclusions Patients with coronary artery disease and severe conduction disturbances that require implantation of permanent pacemakers are more likely to have a specific pathological coronary anatomy that combines a compromised blood flow to the septal branches of the left anterior descending artery with right coronary artery lesions. The location of lesions in the coronary tree rather than severe diffuse atherosclerosis appears to be responsible for the conduction disturbances.

Acute myocardial infarction occurs when a ruptured coronary artery plaque causes sudden thrombotic occlusion of a coronary artery and cessation of coronary artery blood flow. This paper reviews the underlying coronary pathology in progressive coronary atherosclerosis, mechanisms of plaque rupture and arterial occlusion and the time relationship between coronary occlusion and myocardial necrosis. Reperfusion can be achieved by chemical thrombolysis with different thrombolytic agents. Early lysis is achieved best by prehospital administration, a transtelephonic monitor, a mobile intensive care unit, active general practitioner treatment or by warning the emergency room of impending arrival of a patient. Thrombolytic therapy may be unsuccessful and not achieve Grade III TIMI flow in less than 4 h (or even 2 h) due to inadequate or intermittent perfusion or reocclusion. Adjuvant therapy includes aspirin and platelet receptor antagonists. Bleeding is a constant danger. Direct percutaneous transluminal coronary angioplasty (PTCA) may be as effective or better than chemical thrombolysis. Reperfusion protects the myocardium and salvages viable tissue. It also improves mechanical remodelling of the ventricle. Long-term follow-up has shown that quantum leaps of fresh coronary occlusion causes step-wise progression in patient disability and that further early, prompt reperfusion can salvage myocardium and prevent this inexorable progress of the disease.

Thrombolytic therapy reduces mortality and improves ventricular function in acute myocardial infarction. We review the short- and long-term effects of reperfusion after acute myocardial infarction on left ventricular function and heart failure. The beneficial effects of reperfusion may be achieved by immediate limitation of infarct size or through delayed improvement in ventricular remodeling. Infarct size is dependent on the area at risk, the time delay to reperfusion, the completeness and persistence of reperfusion, and collateral blood flow. The main prognostic parameters after myocardial infarction are vessel patency, infarct size, and ventricular volume and function. Initial infarct size and patency of the infarct-related artery are independent predictors of ventricular volume and function, as well as of survival in the long-term following acute myocardial infarction. The beneficial effects of a patent infarct-related artery are only evident if normal flow is achieved and maintained, and are dependent on the degrees of the residual stenosis. Thrombolytic therapy reduces the incidence of in-hospital congestive heart failure, and this improvement is sustained for at least 5 years. As only a fraction of patients with acute myocardial infarction currently receive thrombolytic therapy, heart failure after myocardial infarction can be reduced by administering thrombolytic therapy earlier to more patients with evolving acute myocardial infarction.

Angioplasty in patients with unstable coronary artery disease is associated with higher complication rates compared with patients with stable disease. In this report we describe our results from a group of patients with unstable disease (unstable angina pectoris and postmyocardial infarction) where a strategy of delaying angioplasty for5 days after admission was undertaken. Included are 2069 consecutive patients: 1197 treated for stable angina pectoris and 872 treated during admission for unstable angina or myocardial infarction. There was no difference between the two groups in angioplasty success (92.1% stable, 92.3% unstable), failure to dilate without complication (6.4% stable, 6.1% unstable), or in the rate of major complications: death (0.5% stable, 1.1% unstable), Q-wave myocardial infarction (0.9% stable, 1.1% unstable), and emergency coronary artery bypass (0.6% stable, 0.3% unstable). The duration of hospitalization following angioplasty was longer in the unstable group (5.6 +/- 8.1 days vs. 4.2 +/- 4.1 days; p0.001) because of longer duration of heparin infusion. There was no difference between groups in minor complications such as groin hematoma and pseudoaneurysm, renal failure, or infections. It was concluded that delaying angioplasty in unstable patients for5 days after admission is a safe and effective therapeutic strategy for this group of patients. The need for prolonged heparin infusion after angioplasty is increased in unstable patients and thus the duration of hospitalization after the procedure is longer.

This report describes the effect of age and gender on the results of balloon angioplasty using current technique and indications. A consecutive group of 2,067 patients who underwent angioplasty at a single institution after 1990 is described. Angioplastic success was 92.2% and similar among men and women and the various age groups. Sixteen patients (0.8%) died, and mortality among women was significantly higher (1.4 vs. 0.6%, p0.001). There were no age or gender differences in the rate of Q-wave myocardial infarction and the need for coronary artery bypass. Minor complications such as groin complications (10.5% women, 5.0% men; p0.001) and infections (6.4% women, 3.7% men; p0.05) were more common in women, and as a result the duration of hospitalization after angioplasty was longer. The length of hospitalization after angioplasty was longer with advanced age, mainly as a result of higher groin complications (p0.001), infections (p0.01) and renal failure (p0.05). We conclude that using current indications and technique, angioplasty can be performed safely with a high success rate. Mortality is higher among women. The length of hospitalization after angioplasty is longer in women and, at advanced age, due to higher rate of minor complications.

This study examines the effect of coronary angioplasty on the progression and appearance of new disease in sites of the coronary tree that were not dilated by the balloon. We examined 355 pairs of coronary angiograms from 252 patients. The study consisted of consecutive patients who were referred for catheterization1 month after successful angioplasty. Progression/regression and the appearance of new narrowings at sites not dilated by angioplasty were determined. The life-table method was used to determine outcome, and any event (progression, regression, and new narrowing) was analyzed according to the time of occurrence. The angioplasty artery was compared with the non-angioplasty artery and the effect of restenosis was determined by comparing arteries with and without restenosis. Progression/regression rates were not significantly different in angioplasty and non-angioplasty arteries. More new narrowings were identified in the angioplasty artery (p0.01). With regard to narrowings located in the angioplasty artery, progression was more common, regression less common, and the appearance of new narrowings more common in arteries with restenosis than in non-angioplasty arteries or arteries without restenosis. We believe that mechanical trauma to the artery during angioplasty could accelerate disease progression and the appearance of new narrowings in angioplasty arteries, whereas normalization of flow rate and pattern, especially in arteries without restenosis, attenuates the rate of progression and the appearance of new narrowings in these arteries. The final outcome depends on the balance between these factors.

The angiographic appearance of the coronary arteries were examined in 302 patients with stable angina pectoris and compared to 308 patients with acute myocardial infarction, who received high-dose intravenous thrombolytic therapy, in order to elucidate the underlying angiopathological picture in the two diseases. In each group coronary lesions were present in proximal segments of the arteries and were closely related to bifurcations. Lesions were more extensively distributed in the coronary tree in patients with stable angina and they had an average of 5.4 lesions per patient, compared to the acute myocardial infarction group who had only 2.4 lesions. Also, in the acute myocardial infarction patients, four-fifths of the culprit arteries were patent, 104 (34%) had a ruptured plaque, 22 (7%) had an ulcerated plaque and in 190 (62%) the lesions were eccentric. The study shows that patients with myocardial infarction who are suitable for thrombolysis have a unique coronary angiographic picture and the acute episode is caused by sudden rupture of a localized atheromatous plaque which initiates an obstructive thrombotic cascade.

To compare the long-term prognosis of a group of patients treated by an early invasive approach after a non-Q-wave anterior wall acute myocardial infarction (AMI) with a similar group treated conservatively, data from 110 consecutive patients with non-Q-wave AMI were retrospectively obtained from 3 different hospitals: (1) a hospital with coronary angioplasty and coronary bypass facilities favoring on early invasive approach, (2) a hospital with a catheterization laboratory and no coronary angioplasty or coronary bypass facilities, and (3) a community hospital without a catheterization laboratory. Patients were divided according to the presence or absence of an early invasive approach: those who had undergone in-hospital catheterization and revascularization (n = 55) and those with a conservative approach (n = 55). The early invasive approach resulted in a significant decrease in major events. The rate of recurrent myocardial infarction was 29% in the conservative group versus 7.2% in the invasive group (p = 0.025). Survival rate curves at 3-year follow-up showed significant differences in mortality (p = 0.001), recurrent myocardial infarction (p = 0.002), recurrent angina pectoris (p = 0.001), and development of congestive heart failure (p = 0.05). Multivariate analysis disclosed the early invasive approach to be an independent predictor for decreasing the likelihood of recurrent infarction by 86% (odds ratio 0.14, confidence intervals 0.04 to 0.48, p = 0.0006), and for decreasing the likelihood of recurrent angina by 66% (odds ratio 0.34, confidence intervals 0.18 to 0.63, p0.005). The early invasive strategy may result in an improved outcome in the treatment of patients with non-Q-wave anterior wall AMI compared with patients treated conservatively.

Thrombolytic therapy in acute myocardial infarction is of established value in recanalizing the occluded coronary artery, reducing infarct size, and decreasing mortality. Here, we review the extensive information provided by large clinical trials on agent and patient selection, timing of treatment, adjuvant therapies, and complications. Early treatment is of prime importance. Tissue plasminogen activator is slightly superior to streptokinase, especially in young patients treated early. Intravenous heparin should be used in conjunction with tissue plasminogen activator, although its role when streptokinase is used is less clear. Aspirin, beta-blockers, and converting enzyme inhibitors are of proven value as adjunctive therapies; nitrates and magnesium are not. Newer antithrombotic and antiplatelet agents (eg, hirudin and glycoprotein IIb/IIIa receptor antagonists) may further improve results.

The combination of diagnostic angiography and angioplasty as a single procedure is becoming common practice in many institutions, but the feasibility and safety of this strategy have not been reported. This report describes 2,069 patients who underwent coronary angioplasty over a 3-year period at an institution where combined angiography and angioplasty is the norm. All patients were prepared before angiography for potential immediate angioplasty. In 1,719 patients, angioplasty was performed immediately after the diagnostic angiogram, while separate procedures were performed in 350 patients. Of those 350 patients, 254 were referred for angioplasty after diagnostic angiography at other hospitals. One thousand one hundred ninety-seven patients were admitted electively for treatment of stable angina pectoris, and 872 underwent procedures during hospitalization for unstable angina or acute myocardial infarction. One thousand nine hundred seven patients (92.2%) had successful angioplasties; in 130 patients (6.3%) the lesion could not be dilated, but no complication occurred, and in 32 patients (1.5%) angioplasty ended with a major complication (0.8% death, 1.0% Q-wave myocardial infarction, 0.5% emergency coronary artery bypass surgery). There was no difference between the combined and staged groups with regard to success, major and minor complication rates or in length of hospitalization after angioplasty. We conclude that routine combined strategy for angiography and angioplasty is feasible, safe, easier for the patient, and more cost-effective than 2 separate procedures.

The effect of immediate recoil on the results of balloon angioplasty was examined in a group of 416 patients (596 lesions) who underwent successful coronary angioplasty. Immediate recoil was responsible for loss of 0.42 +/- 0.64 mm from the potentially achievable lesion diameter, and represented 23% of the actual gain in diameter. The immediate recoil was determined mainly by the degree of arterial stretch, which is best represented by the balloon to normal artery size ratio (correlation coefficient 0.49, p0.0001). Classic risk factors for coronary artery disease did not affect immediate recoil, except for a trend toward lower values in patients with history of hypercholesterolemia. There was a tendency for lower recoil in patients with residual coronary thrombus and in those who underwent angioplasty within 1 week of acute myocardial infarction. Recoil was larger in the left anterior descending artery than in the circumflex or the right coronary artery. Patients with more immediate recoil developed more restenosis (50% stenosis at follow-up). However the late loss of luminal diameter due to the restenotic process was smaller in those who had larger initial recoil. It is concluded that immediate recoil after balloon angioplasty is an elastic phenomenon that is related mainly to the degree of arterial stretch. The relative importance of immediate recoil in determining the late outcome of coronary angioplasty is at least as important as the late restenotic process.

The impact of intra-aortic balloon counterpulsation (IABC) on survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has been evaluated in this study of 85 patients. IABC was available for the 24 group A patients (and used in 20 patients). IABC was not available for the 21 group B patients who presented simultaneously with similar clinical characteristics and received identical pharmacological treatment. In-hospital and one year survival was significantly higher in group A (46% and 38% vs 19% and 10%, P < 0.001). Sixteen out of the 20 (group A1) IABC patients received early coronary revascularization. During 1980-1984, 35 patients with AMI and CS received IABC (group C) but none underwent early revascularization. There was no difference in in-hospital or one-year survival between group A1 (50% and 40%) and group C (45% and 40%). We conclude that early IABC improves survival of patients with AMI complicated by CS.

Background: Myocardial infarction (MI) as the first indication of postangioplasty restenosis is extremely rare, and it has been speculated that the fibroproliferative restenotic lesion is less likely to undergo plaque rupture than the lipid -laden native atherosclerotic lesion. Hypothesis: The present study was designed to examine whether intracoronary stent implantation affects this course. Methods: In all, 994 consecutive patients who underwent angioplasty and intracoronary stent implantation in our hospital were reviewed retrospectively for the occurrence of MI. Results: Eight patients (0.8%), all male and hypertensive, aged 33–83 years, presented with an MI due to stent occlusion more than 30 days following stenting (range: 35–398 days). In two patients, MI occurred 3 and 5 h, respectively, following completion of a maximal high-level exercise test that was negative for ischemia. Angiography revealed complete occlusion or significant stenosis of the stent in all eight patients, with an obvious intimal dissection in either edge of the stent in six patients. Except for gender and hypertension, no correlation was found with other risk factors, vessel involved, initial angiographic results, or with stent design, diameter, or length. Conclusions: Myocardial infarction as a late complication of successful stent implantation occurred in 0.8% of our patients. This is only the lower bound of the estimated frequency for such an event. We hypothesize that the transition point between the relatively fixed stent and the normal artery is exposed to high deformation stress which makes it vulnerable to rupture and dissection. Strenuous exercise and hypertension may increase the deformation stress and the risk of intimal rupture.

Background: Patients with diabetes mellitus (D) (both insulin-requiring D [IRD] and non-IRD) who undergo angioplasty have worse long-term outcome than do non-D patients. Few data are available in the literature that explain these findings. Hypothesis: The study was undertaken to compare restenosis and progression of coronary disease after angioplasty in IRD patients, in non-IRD patients, and in non-D patients. Methods: Diabetic patients who underwent coronary angioplasty were separated into two subgroups: IRD and non-IRD patients. Their angiographic outcome was compared with non-D patients. We examined retrospectively 353 coronary angiograms of patients who were referred for diagnostic angiography > 1 month after successful angioplasty. Quantitative angiography was used to determine the outcome in dilated narrowings (restenosis) and in nondilated narrowings (disease progression). Results: Baseline clinical and angiographic characteristics were similar in all groups. Restenosis rate was higher in IRD (61 %) than in non-IRD (36%) and non-D (35%) patients (p = 0.04). Late luminal loss after angioplasty was two times greater in IRD patients than in the other two groups (p=0.01). Disease progression of nondilated narrowings was significantly more prominent in non-IRD than in non-D patients: Diameter stenoses were similar in the initial angiogram, but narrowings were significantly more severe (p=0.02) in the final angiogram (70 ± 27% and 60 ± 33%, respectively). New narrowings were more common in non-IRD than in non-D patients: there was a 23% increase in the number of narrowings in the follow-up angiogram in non-IRD patients compared with only 12% in non-D patients (p < 0.003). These new narrowings were more common (p=0.01) in angioplasty arteries (57 narrowings on 420 arteries—13.6%) than in nonangioplasty arteries (54 narrowings on 639 arteries—8.5%). Conclusion: Restenosis is more common in IRD patients and explains the high rate of adverse cardiac events within the first year after coronary intervention in these patients (mainly target lesion revascularization). Disease progression (including new narrowings) is the main determinant of patient outcome > 1 year after coronary intervention and is accelerated in non-IRD compared with non-D patients.

BACKGROUND The coronary microvasculature may be abnormal even in the presence of angiographically normal epicardial arteries. Abnormalities of small coronary vessels have been invoked as a cause of angina. METHODS AND RESULTS To quantitatively evaluate the morphology of capillaries in patients with idiopathic dilated cardiomyopathy (DCM) or the syndrome of angina and small vessel disease (SVD), we performed electron microscopic morphometry of capillaries in right ventricular biopsy samples taken from 32 patients. Ten had angina, normal epicardial coronary arteries, and evidence for SVD; 12 had DCM; and 10 had normal hearts. In patients with DCM, the ratio of microvessels to myocytes was not different than that of controls (0.49 +/- 0.06 versus 0.51 +/- 0.05). Mean cross-sectional areas of the capillaries (lumen plus wall) and lumen were significantly greater than those of controls (45.3 +/- 15.1 versus 22.7 +/- 8.3 micron 2, p less than 0.001; 17.6 +/- 6.9 versus 11.6 +/- 6.2 micron 2, p less than 0.05, respectively). Fibrous content of the myocardium, as assessed by quantitative light microscopy, was significantly increased (16.3 +/- 3.3% versus 5.0 +/- 2.4%, p less than 0.001). In contrast, in patients with SVD, the capillary-to-myocyte ratio was reduced (0.33 +/- 0.08, p less than 0.001). Although mean cross-sectional areas of the entire capillary (32.4 +/- 19.7 micron 2) and the lumen (8.9 +/- 7.8 micron 2) were not statistically different than those of controls, there was an absence of capillaries less than 15 micron 2 in cross-sectional area, and the frequency distribution of the lumen area was skewed to the left. Swollen endothelial cells frequently encroached upon the lumen. There was a mild increase in fibrous content (9.5 +/- 3.7%, p less than 0.05). CONCLUSIONS Enlarged capillaries and a normal ratio of capillaries to myocytes appear to be features of DCM. Of the patients with SVD, there was both a relative lack of capillaries and capillary lumen narrowing from swollen endothelium. These changes may induce ischemia and angina and may result in mild fibrosis.

Conduction disturbances after coronary artery bypass grafting may result from compromised septal blood flow. To examine this hypothesis we reviewed the preoperative coronary angiography of 55 consecutive patients undergoing coronary artery bypass grafting. Thirty-five patients had either no lesion or a discrete lesion in the left anterior descending coronary artery that did not include the septal perforator (type I anatomy). Twenty patients had a lesion of the left anterior descending coronary artery at the origin of the first septal branch, a lesion of the first septal artery, or a pair of lesions in the left anterior descending coronary artery that straddled the origin of the first septal artery; all lesions were proximal to the graft site (type II anatomy). None of the patients with type I anatomy had a major conduction disturbance after coronary artery bypass grafting. Eleven of the patients with type II anatomy had major conduction disturbances after coronary artery bypass grafting; right bundle-branch block in 1, right bundle-branch block and left anterior hemiblock in 2, left bundle-branch block in 5, and complete atrioventricular block that required pacemaker implantation in 3 (p less than 0.001). In the 20 patients with type II anatomy, the appearance of conduction disturbances correlated well with the absence of retrograde flow to the septal branches from the right coronary artery (p less than 0.01). Pathological lesions in the left anterior descending coronary artery that compromise flow in the first perforator and that do not provide an adequate circulation produce localized damage and conduction disturbances after coronary artery bypass grafting. This can be predicted from the preoperative angiographic anatomy.

Myocardial bridge is a not uncommon finding in routine diagnostic coronary angiog raphy or pathological examination of the heart. It is almost always confined to the left ventricle and the left anterior descending coronary artery. This report describes a patient with chronic lung disease, severe left ventricular dysfunction, and pulmonary hyperten sion in whom coronary angiography revealed bridging of the right ventricular branch of the right coronary artery.

Analysis of heart rate variability with Holter monitoring during the acute phase of myocardial infarction is often difficult due to excessive artifacts and arrhythmias. Detection of noisy epochs of data or arrhythmias and their substitution by interpolation has enabled further analysis on epochs which otherwise would have been discarded. The present paper discusses various strategies for artifact and arrhythmia detection. Although none of the methods solved all varieties of artifacts, a method based on differences from both moving mean and from the last normal value performs well in the majority of cases.

A method for trend subtraction and its effect on long-term monitoring of the low-frequency range of the heart rate variation is described. Slow trend removal is used prior to applying an autoregressive power spectral analysis to Holter heart rate data. Careful application of this trend removal algorithm reveals important changes in slow periodic heart rate fluctuations that are related to the activity of the automatic nervous system. These changes are otherwise masked by nonperiodic alterations. >

The present study employs a computer simulation of the timing of normal and abnormal ventricular activation according to a re-entry model. A wide variety of arrhythmia patterns similar to those obtained in clinical settings may be simulated by using an algorithm which is based on parameters such as the sinus RR interval (RR), the refractory period, the coupling interval between normal activation and re-entry and the coupling interval between one re-entry and a subsequent re-entry (CV). By varying RR and CV the results of the simulation may show transition between different types of arrhythmia such as ventricular tachycardia, bigeminy, trigeminy and more widely separated ventricular ectopic beats such as in concealed bigeminy. The algorithm provides a basis for the study of re-entry, a major mechanism in the genesis of ventricular arrhythmias.

This paper will review the hypothesis that early complete thrombolytic therapy in acute myocardial infarction reduces mortality and improves prognosis. ACE inhibitors improve remodelling and anti-platelet drugs or interventional procedures prevent reocclusion of the infarct related coronary artery. Most patients are left with significant myocardial damage and this effect is cumulative with subsequent infarction. The average age of death has increased by 10 years in the last three decades, so that many older patients survive. They have survived acute myocardial infarction and we now have a significant population with important heart failure despite good thrombolytic therapy.

VDD pacing follow-up is similar in pediatric and adult patients. Atrial and ventricular pacing parameters are stable during 2-year follow-up in children, and single-pass lead VDD pacing is recommended when the sinus node function is normal.

We evaluated the long-term angiographic outcome of balloon angioplasty by comparing original and follow-up target coronary narrowing. Rather than using restenosis to determine outcome, as in most angioplasty studies, we took an unusual approach and analyzed outcome in terms that are commonly used in progression and regression studies after medical interventions. Quantitative angiographic measurements were undertaken in 315 narrowings with an initial diameter stenosis90% before and after angioplasty and at follow-up. Angiographic deterioration (10% increase in follow-up diameter stenosis) was identified in 44 (14%) narrowings. Angiographic deterioration was not influenced by age, sex, risk factors, lipid profile, or the indication for angioplasty. Deterioration was also not predicted by the severity, length, or the location of the narrowing. The deteriorating narrowings had a higher recoil after dilatation compared with narrowings with angiographic improvement (21% +/- 31% vs 12% +/- 17%, p = 0.006); the residual stenosis after angioplasty was therefore higher. The late loss was also significantly increased compared with narrowings with angiographic improvement (65% +/- 26% vs 8% +/- 24%, p0.001). We conclude that the incidence of angiographic deterioration of coronary disease as a result of restenosis is uncommon but not negligible. Interventional cardiologists should resist the temptation to dilate mild, silent coronary narrowings because the procedure might have an unfavorable angiographic (and probably clinical) effect.

Intravascular ultrasound (IVUS) is a new technique of tomographic visualization of the coronary arteries: its lumen, wall and pathology. Three dimensional (3D) reconstruction shows the tubular structure of the arterial wall and its pathology. IVUS has many advantages over coronary angiography: it has better resolution and shows many hidden lesions. IVUS has helped uncover the underlying mechanisms of percutaneous transluminal coronary angioplasty (PTCA), restenosis, the use and value of other interventional techniques such as directional coronary atherectomy (DCA), rotational atherectomy and stent implantation, and has great value in planning complex interventional procedures. The new American Heart Association (AHA) classification of coronary atherosclerosis pathology can be demonstrated by IVUS. IVUS is sensitive for studies of atheroma regression and progression and shows the coronary artery lesions after cardiac transplantation.

We report a patient with ischemic chest pain due to obstructive coronary artery disease. The patient underwent a second cardiac catheterization 2 years later that revealed progression of the coronary disease and the appearance of a new arteriovenous malformation. Unless a prior angiogram was available, this malformation would have been classified as congenital. This case report raises the question of whether all congenital arteriovenous malformations are truly congenital.

Totally occluded venous grafts are usually less amenable to mechanical reperfusion alone (for example percutaneous transluminal coronary angioplasty, PTCA) because of the large mass of thrombotic material within the graft. A combined approach using mechanical and thrombolytic treatment might therefore be more successful. Twenty one patients (20 males, one female) with a mean age of 64.5 (SD 5.6) years underwent angiography because of crescendo or unstable angina (n = 19) or myocardial infarction (n = 2) at a mean of 21.7 (18.6) days after onset of symptoms (range 1-60). All patients had had coronary artery bypass grafting (CABG) at a mean of 8.02 (4.02) years (range 0.3-13 years) before the current admission. At catheterisation, totally occluded venous bypass grafts to the left anterior descending coronary artery or diagonal (n = 10), marginal (n = 6), or right coronary artery (n = 5) were found. A combination of PTCA and thrombolytic treatment (in eight patients extended thrombolysis for 24 hours) was successful in reopening the venous graft in 16/21 patients (76.2%). Immediate complications included femoral haematoma (4), distal embolisation (3), and infection in one patient. Out of 13 patients catheterised within three months, two had reoccluded, seven had restenosis, while four had patent grafts. Recurrent PTCA (at least once more) was done in eight patients. At long term follow up of a mean of 26.7 (21.6) months (range 4-75 months), four patients were asymptomatic, eight still suffered from mild stable angina, while three had recurrent hospital admissions and needed a second coronary artery bypass. A combination of thrombolytic treatment and PTCA is a feasible and practised approach to recanalise recently occluded venous bypass grafts.

A female infant was born by normal vaginal delivery to unrelated Jewish parents of North African origin. There was no family history of congenital heart disease. The pregnancy was unremarkable. Apgar scores were 9 at one minute and 10 at five minutes. Birth weight was 3780 g. On examination aged 24 h she was pink and in no apparent distress. Peripheral pulses were normal. Auscultation of the heart revealed normal heart sounds with a short 2/6 mid-systolic murmur heard maximally at the left lower left sternal border. The heart was not hyperkinetic. The rest of the physical examination was unremarkable. The electrocardiogram (ECG) and chest roentgenogram were normal. Two dimensional echocardiography revealed a slightly dilated right atrium with occa

The transradial approach has currently been advocated as an alternative catheferization method for coronary angiography and angioplasty, due to the recent miniaturization of angioplasty equipment. The purpose of this study was to assess the practical clinical applicability of this method. From June to November 1994, 100 patients underwent coronary angiography and angioplasty with the transradial approach. Their mean age was 66.6 ± 11.2 years, and 79 were men. In 4, radial puncture was not successful, and in 3, femoral access was necessary to complete the procedure. Coronary angioplasty was performed in 63 patients (76 lesions) with angiographic success (per lesion) of 96%. In 5 patients, a stent was successfully implanted. All patients were ambulatory on the day after the angioplasty procedure. In 98% of the patients, the introducer was taken out 1 to 4 hours after the procedure by local compression using a special custom-made device. No patient required blood transfusion. Major complications occurred in 2 patients; both had a cerebrovascular accident (1 probably not procedure-related), and both recovered. A radial pulse was palpated in 91 of the patients before discharge, and in 6 others, adequate flow could be heard with Doppler. In 2 patients, radial flow was restored within several weeks. None of the patients suffered from ischemia of the hand. Two patients had a small pseudoaneurysm successfully treated by local compression. Thus, coronary angioplasty can be performed safely using the transradial approach with relatively few vascular complications and with better patient comfort. However, the procedure is more time-consuming initially compared with the transfemoral approach due to a learning curve regarding equipment selection and catheter manipulation.

Misplacement of pacemaker electrodes has been reported in different locations within the heart with divers clinical consequences. We present a patient in whom transesophageal echocardiography was of significant importance in imaging and understanding the electrode's course within the heart chambers. (J AM Soc ECHOCARDIOGR 1995;8:103-4.)

The prognostic significance of silent myocardial ischemia detected during graded exercise testing (GXT) is uncertain. The angiographic characteristics and long-term follow-up of 83 patients with silent ischemia (group 1), mean age 58 +/- 9 years, were compared with 83 age- and sex-matched patients with typical angina pectoris (group 2). Basic characteristics and mean follow-up (42 +/- 22 months) were similar in both groups. Patients with silent ischemia were characterized by longer duration of exercise test (6.5 vs. 4.8 min, p0.01), larger extent of maximum ST depression during peak exercise (2.4 vs. 2.0 mm, p0.01) and higher maximal double product at peak exercise (24,650 vs. 20,825, p0.01) compared to group 2. Long-term follow-up revealed similar rates of mortality (3.6 vs. 4.8%, p = NS) and major cardiac events (19.3 vs. 21.7%, p = NS). However, patients with typical angina tended to have more revascularization procedures (81 vs. 61%, p0.1). Thus, patients with silent ischemia have a better GXT capacity compared to patients with typical angina pectoris. Despite a similar severity of coronary involvement, patients with typical angina pectoris tend to have more revascularization procedures, yet the long-term prognosis appears similar.

Acute myocardial infarction results from the cessation of myocardial blood flow caused by thrombotic occlusion of a coronary artery. Rapid restoration of blood flow to the ischemic myocardium minimizes cardiac damage and improves early and long-term morbidity and mortality. Chest pain is the first symptom of myocardial infarction, but in some patients with silent ischemia, the disease can be diagnosed only in retrospect. In symptomatic patients, myocardial infarction should be accurately and promptly diagnosed so that reperfusion therapy can begin immediately. Electrocardiography is the simplest diagnostic modality. Although regional ST-segment elevation is specific, it is not sensitive. In contrast, new computerized algorithms for electrocardiographic analysis and serial monitoring increase sensitivity without decreasing specificity. In the emergency room, echocardiography is used to diagnose patients with no prior history of coronary artery disease whose electrocardiograms proved nondiagnostic. Time-consuming perfusion nuclear studies are inferior to echocardiography but may nevertheless enable physicians to diagnose myocardial infarction in the emergency room. Although the presence of excess creatine kinase is a sign of myocardial necrosis, its increase is delayed for a few hours after coronary occlusion. Doctors can diagnose myocardial infarction as early as two hours after coronary occlusion with the help of simpler automatic assays of MB-creatine kinase mass that use monoclonal antibodies. Other investigational markers of myocardial necrosis include myoglobin and troponin. Elevation of a circulating protein marker also signifies established necrosis, but physicians hope to achieve reperfusion through therapy before irreversible damage occurs.

Coronary restenosis after balloon angioplasty is a slow process that develops over a few months. In some patients, with an initially successful angioplasty, an artery that originally had only moderate stenosis becomes totally occluded as a result of restenosis. This report describes 16 such patients out of 415 dilated lesions with late angiographic follow-up. Ten patients presented with stable angina pectoris, 5 had unstable angina and only one was admitted with a small myocardial infarction. Visible collaterals were present in 15 patients. Except for the patient who sustained myocardial infarction, none of the late angiograms showed the typical morphological features of acute lesion. We conclude that total coronary occlusion late after successful angioplasty of an artery that was moderately narrowed is rare. The 'restenotic' occlusion is a slow process that stimulates collateral formation and thus the risk of myocardial infarction is small.

The role of plasma lipoproteins in the pathogenesis of coronary atherosclerosis has been well defined. 1 Restenosis after coronary angioplasty is often described as a form of accelerated atherosclerosis due to phenotypic modification and proliferation of medial muscle myocytes. 2 A few recent studies investigated the role of lipoproteins in restenosis, but the results were conflicting. 3–5 Modification of lipoprotein profile can halt the progression and even induce regression of coronary atherosclerosis 6,7 ; whether it can also decrease the rate of restenosis is not clear. In this investigation, we examined the effect of the different lipoprotein fractions on the development of restenosis, using the absolute and relative amounts of late loss of luminal diameter as a continuous measure of restenosis.

Atheromatous coronary artery disease progresses by atheroma accretion, plaque rupture and thrombus formation, with or without spontaneous fibrinolysis [1–3]. The natural history may be altered by modifying risk factors in an attempt to induce regression [4], or treated by mechanical means such as balloon angioplasty, directional coronary atherectomy or drills, or flow modulated by the insertion of an aorto coronary bypass graft with or without endarterectomy [5, 6].

The efficacy and safety of autodecremental pacing (ADP) to interrupt ventricular tachycardia (VT) and atrial flutter was examined. Once tachycardia was recognized, ADP was initiated using a short train of stimuli with gradual shortening (3%) of the interstimulus interval. ADP was applied to 13 consecutive patients during 75 episodes of VT (mostly following induction by ventricular stimulation). Successful interruption of VT occurred in 88% of the episodes. In 6 episodes (8%), ADP resulted in ventricular fibrillation and in 3 episodes VT was unaffected by ADP. The only significant discriminator between the failure or success of ADP was the rate of VT. ADP was also applied to 17 consecutive patients with an atrial flutter that was resistant to conventional antiarrhythmic agents. Successful conversion of atrial flutter to sinus was seen in only 8 patients (47%). A temporary acceleration to atrial fibrillation appeared in 3 patients (18%), and in 6 patients atrial flutter was unaffected by ADP. ADP was successful in 70% (7/10) of patients with type 1 (< 300 beats/min) atrial flutter. The authors conclude that ADP is beneficial in the interruption of VT and atrial flutter in a selected group of patients, especially with a slower rate of tachyarrhythmia (atrial rate during atrial flutter < 300 beats/min and ventricular tachycardia < 180 beats/min).

Analysis of heart rate variability (HRV) with Holter monitoring is often difficult due to excessive artifacts and arrhythmias. While short sudden surges are treated successfully by most methods, slow heart rate (HR) variations, nocturnal trapezoidally-shaped HR increases and special types of arrhythmias which are similar to normal HRV fluctuations may distort further time domain and spectral analysis. This paper examines the advantages and disadvantages of different methods for preprocessing of HR data. We have developed the following approach to the analysis of HRV. (1) A combination method based on the absolute difference between HR values and both the last normal HR value and an updated mean is used for removal of artifacts and arrhythmias. This method can detect both sudden surges in HR values as well as longer periods of noise combined with slow normal variations. An additional stage of wild point removal is then optionally applied. (2) Certain special problems such as large T-waves, bigeminal rhythm, slow HR variations and nocturnal trapezoidally-shaped HR increases are also identified. Although none of the algorithms can be applied successfully to all cases, the final computer analysis for preprocessing described in the present study has proved to be superior to the simplified methods which are usually used and provides more suitable data for HRV analysis.