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Background: Stress gated myocardial perfusion single photon emission computed tomography (gSPECT) is increasingly used before and after intercurrent therapeutic intervention and is the basis for ongoing evaluation in the Department of Veterans Affairs clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial.Methods and Results: The COURAGE trial is a North American multicenter randomized clinical trial that enrolled 2287 patients to aggressive medical therapy vs percutaneous coronary intervention plus aggressive medical therapy. Three COURAGE nuclear substudies have been designed. The goals of substudy 0 are to examine the diagnostic accuracy of the extent and severity of inducible ischemia at baseline in COURAGE patients compared with patient symptoms and quantitative coronary angiography and to explore the relationship between inducible ischemia and the benefit from revascularization when added to medical therapy. Substudy 1 will correlate the extent and severity of provocative ischemia with the frequency, quality, and instability of recurrent symptoms in postcatheterization patients. Substudy 2 (n = 300) will examine the usefulness of sequential gSPECT monitoring 6 to 18 months after therapeutic intervention. Together, these nuclear substudies will evaluate the role of gSPECT to determine the effectiveness of aggressive risk-factor modifications, lifestyle interventions, and anti-ischemic medical therapies with or without revascularization in reducing patients' ischemic burdens.Conclusions: The unfolding of evidence on the application of gSPECT in trials such as COURAGE defines a new era for nuclear cardiology. We hope the evidence that emerges from the COURAGE trial will further establish the role of nuclear imaging in the evidence-based management of patients with stable coronary disease. [ABSTRACT FROM AUTHOR]

The article provides information on a study which examined angiographic progression of lesions underlying symptom progression during contemporary optimal medical therapy (OMT). It highlights the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial undergone by patients, who were treated with OMT. A single index lesion was identified for each patient and was considered to be the lesion most likely to be responsible for the change in symptom status.

The article discusses a research study on the cost-effectiveness of percutaneous coronary intervention (PCI) as a function of angina severity in patients with stable angina. The researchers assessed angina severity using the Seattle Angina Questionnaire (SAQ). They determined that incremental cost of PCI to provide meaningful clinical benefit was lower for patients with severe angina than those with mild or no angina.

Introduction: Limitations of endoscopic therapies for Barrett's esophagus and superficial cancer include a compromised histological assessment, the need for surveillance, subsequent procedures, and stricture formation. Circumferential en bloc resection of the mucosa-submucosa complex followed by deployment of a biologic scaffold onto the remaining muscularis propria may address these concerns. The objective of this study was to determine technical feasibility of transoral resection of the esophageal lining.Materials and Methods: Transoral endoscopic inner layer esophagectomy was performed in ten swine. Endpoints included procedure duration, hemorrhage, number of perforations, and adequacy of resection length and depth.Results: Procedures were successfully completed in all animals without perioperative mortality. Procedure times averaged 179 min (range 125-320). No perforations were found, and a mean of 1.7 (0-4) interventions for hemorrhage was required. Complete longitudinal resection was achieved in nine of ten animals. Resection depth included all mucosal layers in 100% of tissue sections, the submucosal layers, SM1 in 100%, and SM2 in 96%. A portion of SM3 was adherent to the muscularis propria in 70%.Conclusion: Transoral endoscopic resection of the inner esophageal layers was feasible and reproducible. This technique may facilitate a single-step definitive treatment and staging tool for early neoplastic lesions, obviating the need for esophagectomy. [ABSTRACT FROM AUTHOR]

Multiple clinical trials have demonstrated β-blockers improving survival after myocardial infarction (MI). Patients with “bradycardia-related” contraindications to β-blockers, such as those with asymptomatic bradycardia or AV conduction abnormalities, have been excluded from clinical trials of β-blockers and continue to be excluded from post-MI β-blocker therapy in routine clinical practice. These patients tend to be elderly and have a high 1-year mortality. If β-blockers provide benefit to the post-MI patient independent of their heart rate–lowering effect, then these patients could benefit substantially from initiation of β-blocker therapy. However, in this particular group of patients, β-blockers can be safely initiated only if more severe or significant bradycardia can be prevented by pacemaker implantation. It is unclear whether adverse effects related to pacemaker implantation could also negate some or all of the hypothesized benefit of β-blocker therapy. Although β-blockers are particularly effective in the elderly, the benefit of β-blocker therapy in patients with bradycardia-related contraindications to β-blockers has not been established. The PACE-MI trial is a randomized controlled trial that will address whether β-blocker therapy enabled by pacemaker implantation is superior to no β-blocker and no pacemaker therapy after MI in patients with rhythm contraindications to β-blockers or in those who have developed symptomatic bradycardia due to β-blockers. The trial will randomize 1124 patients to standard therapy (not to include β-blockers as patients must have a contraindication to be enrolled) or standard therapy plus pacemaker implantation and β-blocker. The primary end point is the composite end point of total mortality plus nonfatal reinfarction. [Copyright &y& Elsevier]

Background: In patients with stable coronary artery disease, it remains unclear whether an initial management strategy of percutaneous coronary intervention (PCI) with intensive pharmacologic therapy and lifestyle intervention (optimal medical therapy) is superior to optimal medical therapy alone in reducing the risk of cardiovascular events. Methods: We conducted a randomized trial involving 2287 patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centers. Between 1999 and 2004, we assigned 1149 patients to undergo PCI with optimal medical therapy (PCI group) and 1138 to receive optimal medical therapy alone (medical-therapy group). The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median, 4.6). Results: There were 211 primary events in the PCI group and 202 events in the medical-therapy group. The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (hazard ratio for the PCI group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P=0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P=0.62); hospitalization for acute coronary syndrome (12.4% vs. 11.8%; hazard ratio, 1.07; 95% CI, 0.84 to 1.37; P=0.56); or myocardial infarction (13.2% vs. 12.3%; hazard ratio, 1.13; 95% CI, 0.89 to 1.43; P=0.33). Conclusions: As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number, NCT00007657.) [ABSTRACT FROM AUTHOR]

Cardiovascular disease is a major clinical problem in the elderly, with coronary heart disease the most frequent cause of death and with hypertension present in as many as 50% of these patients. The cardiovascular manifestations of aging must be differentiated from those due to disease. There are clinical manifestations and responses to therapy in the elderly that differ from those in younger patients. The extent of diagnostic and therapeutic procedures undertaken should be based on the patient's physiologic age, the presence and severity of concomitant diseases, mental status and cognitive ability, and the patient's expectations from medical care. Preventive approaches are also warranted. [ABSTRACT FROM AUTHOR]

Assesses the effects of oral propranolol and digoxin alone and in combination on angina frequency, heart size, systolic time intervals and treadmill exercise tolerance in 20 patients with coronary heart disease. Treatment for patients with angina pectoris; Statistical data on heart rate recorded during the treatment periods.

A case is presented in which an implantable cardioverter defibrillator (ICD) became infected in the abdominal wall pocket 5 weeks following implantation. There was no evidence clinically or by computed tomographic scan suggesting mediastinal extension of the infection. The infection was treated successfully by debriding the abdominal wall pocket followed by a combination of pocket irrigation with antibiotic solution, parenteral antibiotics, and long-term oral antibiotics. This conservative therapy was successful and avoided removal of the device. [ABSTRACT FROM AUTHOR]

The authors of the meta-analysis of a percutaneous coronary intervention (PCI)-based invasive strategy for improving prognosis for the treatment of angina conclude that a pooling of data from various studies can be sufficiently powered to evaluate the impact of PCI on long-term mortality. However, most randomized coronary artery patient trials have insufficient power to detect significant differences in hard end points. Randomized trials in patients with chronic stable angina enroll few patients who are over age 65 years, have depressed ventricular function, have clinical instability, or who have undergone previous coronary artery bypass grafting (CABG) or PCI. “Medical therapy” today no longer means the absence of PCI, but rather the presence of intensive, evidence-based pharmacologic intervention. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial randomized 2,287 patients to optimal medical therapy alone or optimal medical therapy plus PCI. Optimal medical therapy consisted of antiplatelet therapy, anti-ischemic therapy, and aggressive lipid and blood pressure control. Based on the strength of the evidence, the author of this commentary recommends more-aggressive medical therapy for patients with moderate-to-severe angina, and PCI or CABG for many patients in whom symptoms persist. Optimal medical therapy is a proven option for chronic stable angina. [Copyright &y& Elsevier]

BACKGROUND Controversy surrounds optimum treatment during the subacute phase after myocardial infarction (MI) in stable patients presenting with occlusion of the infarct-related artery. Percutaneous coronary intervention (PCI) is a favored procedure in these circumstances, but its efficacy has not been established. OBJECTIVE To determine whether PCI 3-28 days after MI, plus optimum medical therapy, improves long-term arterial patency and left ventricular (LV) size and function at 1 year when compared with medical therapy alone. DESIGN The Total Occlusion Study of Canada (TOSCA)-2 trial was an ancillary study of the international, randomized Occluded Artery Trial (OAT), and included patients already enrolled in OAT from 33 of 217 participating centers. Enrollment into the ancillary study took place between May 2000 and July 2005. All patients underwent cardiac catheterization 3-28 days after a documented MI, and had either proximal coronary occlusion of the artery supplying at least 25% of the left ventricle, or LV ejection fraction (LVEF) of less than 50%. Exclusion criteria included clinical instability, severe inducible ischemia, or left-main or three-vessel disease. INTERVENTION Patients were randomly assigned to receive PCI with optimum medical therapy (PCI+M; including aspirin, angiotensin-converting-enzyme inhibitors, β-blockers, lipid-lowering therapy, and anticoagulants), or medical therapy alone. PCI using one or more coronary stents was performed within 24 h of randomization. All patients undergoing PCI also received thienopyridine therapy before and 2-4 weeks after the procedure, with a recommendation for medication to be continued up to 1 year. Follow-up angiography took place 12±3 months after randomization. OUTCOME MEASURES There were two primary end points: IRA patency and change in LVEF. Changes in LV end-systolic and end-diastolic volume index were also assessed as secondary end points. RESULTS The TOSCA-2 trial enrolled 381 patients (PCI+M n=195; medical therapy n=186), representing 67% of the OAT study population. Crossover from the medical therapy group to the PCI+M group was 17.5%. Late arterial patency was observed in significantly more patients who underwent PCI+M than in those who received medical therapy alone (83% versus 25%, respectively; P<0.0001). Although both treatments resulted in an improvement in LVEF at 1-year follow-up, there was no significant difference between the groups (mean change in LVEF 4.2±8.9% versus 3.5±8.2%, respectively; P=0.47). Neither was there a significant difference between PCI+M and medical therapy in the two secondary end points of LV endsystolic volume index (P=0.10) and LV end-diastolic volume index (P = 0.07). CONCLUSION PCI and stenting of an occluded IRA 3-28 days following MI, plus optimum medical therapy, significantly improves long-term arterial patency, but not LVEF, when compared with medical therapy alone. [ABSTRACT FROM AUTHOR]