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Background: Akinesis becoming dyskinesis at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, to our knowledge, the relationship between this pattern and myocardial viability has not been assessed., Methods: We studied 42 patients with myocardial infarction who underwent DSE (up to 40 micrograms/kg/min) before coronary artery bypass surgery, and resting echocardiogram 3 months after surgery. Viability in akinetic segments was considered to be present if systolic thickening occurred with low-dose dobutamine (LDD)., Results: During high-dose DSE, dyskinesis occurred in 35 of the 164 akinetic segments (group A). The remaining 129 segments comprised group B. Segments of group B had a higher prevalence of viability pattern with LDD (18% vs 0%; p < 0.01) and a higher prevalence of functional improvement (20% vs 0%; p < 0.005) compared with group A. In absence of viability pattern with LDD, postoperative improvement occurred in 10% of segments in group B and in none of segments in group A, resulting in a higher negative predictive value of LDD in group A vs B (100% vs 90%; p < 0.05)., Conclusion: The phenomenon of akinesis becoming dyskinesis with high-dose DSE is associated with absence of viability pattern with LDD and poor functional outcome after surgical revascularization. Observation of this pattern provides additional data to those obtained only with LDD echocardiography.

Objectives: We sought to determine the role of stent implantation in vein grafts by evaluating the long-term clinical outcome and estimated event-free survival at 5 years in 62 patients and by comparing our data with those of other treatment modalities previously reported., Background: Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty., Methods: Patients undergoing stenting of a vein graft were entered into a dedicated data base. They were screened for death, infarction, bypass surgery and repeat angioplasty. Procedure-related events were included in the follow-up analysis. Survival and event-free survival curves were constructed by the Kaplan Meier method., Results: A total of 93 stents (84 Wallstent and 9 Palmaz-Shatz) were implanted in 62 patients. During the in-hospital period seven patients (11%) sustained a major cardiac event: two deaths (3%), two myocardial infarctions (3%) and three urgent bypass surgeries (5%). The clinical success rate, therefore, was 89%. During the follow-up period (median 2.5 years, range 0 to 5.9), another five patients (8%) died, 14 (23%) sustained a myocardial infarction, 12 (20%) underwent bypass surgery, and 14 (23%) underwent angioplasty. The estimated 5-year survival and event-free survival rates (free from infarction, repeat surgery and repeat angioplasty) were (mean +/- SD) 83 +/- 5% (95% confidence interval [CI] 73% to 93%) and 30 +/- 7% (95% CI 16% to 44%), respectively., Conclusions: The in-hospital outcome of patients who underwent stent implantation in a vein graft is acceptable, but the long-term clinical outcome is poor. It is unlikely that mechanical intervention alone will provide a satisfactory or definite answer for the patient with graft sclerosis over the long term.

Objectives: This study reports the 10-year outcome of 856 consecutive patients who underwent attempted coronary angioplasty at the Thoraxcenter during the years 1980 to 1985., Background: Coronary balloon angioplasty was first performed in 1977, and this procedure was introduced into clinical practice at the Thoraxcenter in 1980. Although advances have been made, extending our knowledge of the long-term outcome in terms of survival and major cardiac events remains of interest and a valuable guide in the treatment of patients with coronary artery disease., Methods: Details of survival, cardiac events, symptoms and medication were retrospectively obtained from the Dutch civil registry, medical records or by letter or telephone or from the patient's physician and entered into a dedicated data base. Patient survival curves were constructed, and factors influencing survival and cardiac events were identified., Results: The procedural clinical success rate was 82%. Follow-up information was obtained in 837 patients (97.8%). Six hundred forty-one patients (77%) were alive, of whom 334 (53%) were symptom free, and 254 (40%) were taking no antianginal medication. The overall 5- and 10-year survival rates were 90% (95% confidence interval [CI] 87.6% to 92.4%) and 78% (95% CI 75.0% to 81.0%), respectively, and the respective freedom from significant cardiac events (death, myocardial infarction, coronary artery bypass surgery and repeat angioplasty) was 57% (95% CI 53.4% to 60.6%) and 36% (95% CI 32.4% to 39.6%). Factors that were found to adversely influence 10-year survival were age > or = 60 years (> or = 60 years [67%], 50 to 59 years [82%], < 50 years [88%]), multivessel disease (multivessel disease [69%], single-vessel disease [82%]), impaired left ventricular function (ejection fraction < 50% [57%], > or = 50% [80%]) and a history of previous myocardial infarction (previous myocardial infarction [72%], no previous infarction [83%]). These factors were also found to be independent predictors of death during the follow-up period by a multivariate stepwise logistic regression analysis. Other factors tested, with no influence on survival, were gender, procedural success and stability of angina at the time of intervention., Conclusions: The long-term prognosis of patients after coronary angioplasty is good, particularly in those <60 years old with single-vessel disease and normal left ventricular function. The majority of patients are likely to experience a further cardiac event in the 10 years after their first angioplasty procedure.

Spontaneous improvement of contraction and perfusion occurs after acute myocardial infarction. The relative merit of low-dose dobutamine stress echocardiography (LDDE) and rest-redistribution thallium scintigraphy (RR TI) in this setting has not been evaluated. We studied 30 patients at 7 +/- 3 days after acute myocardial infarction with LDDE (5 to 10 micrograms/kg/min) and RR TI single photon emission computed tomography. Viability was defined as improvement of wall thickening at LDDE in the presence of redistribution or a defect with uptake > or = 50% of peak activity at RR TI. Baseline echocardiography and RR TI were repeated after 3 months. In 112 dyssynergic segments, viability was detected in 60 (54%) by RR TI and in 39 (35%) by LDDE (p < 0.005). Spontaneous improvement of function was detected in 35 (31 %) segments. In the same regions, thallium uptake increased significantly. The sensitivity, specificity, and accuracy of LDDE for predicting late improvement of wall motion were 77%, 84%, and 82%, respectively. Those of RR TI were 77%, 57%, and 63%, respectively. Specificity and accuracy of LDDE were higher than RR TI (p < 0.005). We conclude that a myocardial viability pattern after acute myocardial infarction is more frequently detected by RR TI than by LDDE. Both techniques are equally sensitive, but LDDE is a more specific predictor of spontaneous recovery of regional left ventricular function.

Dobutamine stress echocardiography is an accurate method for the diagnosis and localization of vascular compromise in patients evaluated after coronary artery bypass graft surgery. The test provides useful data for selection of patients for whom coronary angiography may be indicated.

To evaluate the prognostic value of normal dobutamine-atropine technetium-99m sestamibi single-photon emission computed tomography (SPECT) perfusion imaging in women with chest pain and inability to perform an adequate exercise test, 80 women with a normal scintigram were followed up for 23 +/- 13 months. Mean age of the patients was 61 +/- 12 years. Nine patients (11%) had a low probability (< 10%) of coronary artery disease, 43 (54%) had an intermediate probability (10% to 80%) of disease, and 28 (35%) had a high probability (>80%) of disease (including 19 patients with known coronary artery disease). During follow-up, no major cardiac events (cardiac death or nonfatal myocardial infarction) occurred. One patient with known coronary disease underwent coronary bypass surgery after 3 months, and 1 patient with a 91% pretest likelihood of coronary disease underwent coronary angioplasty after 7 months. Thus, the overall incidence of (soft) cardiac events during the follow-up period was 2 of 80 patients, or 1.3%/year. It is concluded that normal dobutamine-atropine technetium-99m sestamibi SPECT perfusion imaging in women with chest pain implies an excellent prognosis, even in women with high pretest likelihood of coronary disease.

There are no standard criteria for the diagnosis of myocardial ischemia in akinetic segments during dobutamine stress echocardiography (DSE). The aim of the study was to assess the relation between different responses of akinetic segments during DSE and ischemia assessed by thallium-201 single-photon emission computed tomography (SPECT). Dobutamine-atropine stress echocardiography with simultaneous stress-reinjection thallium-201 SPECT was performed in 67 patients with old myocardial infarction significant and coronary artery stenosis. Fourteen myocardial segments were matched for both DSE and SPECT. Ischemia on SPECT was defined as reversible thallium defects. In 257 akinetic segments, 4 patterns during DSE were identified: (1) biphasic response in 41 segments (16%), defined as improvement at low dose (5 to 10 microgram/kg/min) followed by worsening at high dose; (2) persistent akinesia in 155 segments (60%); (3) akinesia becoming dyskinesia in 39 segments (15%); and (4) sustained improvement in 22 segments (9%). Reversible thallium defects were detected in 21 segments (51%) in group 1, in 20 segments (13%) in group 2, none in group 3, and in 2 segments in group 4 (9%). The prevalence of reversible defects in biphasic segments was higher compared with other patterns (p <0.00001 vs groups 2 and 3, p <0.005 vs group 4). The ischemic perfusion defect score was significantly higher in group 1 than group 2. The positive predictive value of biphasic response for reversible thallium defects was similar to that of stress-induced dyssynergia in normal segments at rest (51% vs 58%). It is concluded that of the various responses of akinetic segments to dobutamine infusion, the biphasic response is associated with the highest prevalence and greatest severity of ischemic on thallium SPECT. Observation of contractile response at both low- and high-dose DSE is a valuable approach for the diagnosis of myocardial ischemia in akinetic segments.

Objectives: This study investigates whether repeat coronary interventions, applied over an extended time period, can successfully curtail the progression of ischemic symptoms and angiographic lumen narrowing., Background: Coronary artery disease is a chronic and generally progressive disorder, and potential treatment strategies should be examined and compared with this chronicity in mind. Percutaneous interventional revascularization procedures could theoretically be useful in controlling progression of the disease through repeated use as new coronary lesions arise. However, the outcome of this long-term management concept has not previously been subjected to detailed investigation., Methods: From a consecutive series of 4,357 interventional cardiac procedures, 544 patients were identified who received two or more interventions during the 13-year study period. These patients were categorized into one of three groups: restenosis (repeat interventions limited to the same target segment, n = 261), new stenosis (all repeat interventions directed to stenoses not previously treated, n = 155) or both (repeat interventions directed both to the same and to different target lesions, n = 128)., Results: Two to five procedures were performed per patient; the time period (mean +/- SD) separating each procedure was significantly less (p < 0.0001) for the restenosis group (4.2 +/- 2.3 months) than for the new stenosis (24.2 +/- 23.5 months) or the "both" groups (11.4 +/- 11.0 months). Despite the need for repeat procedures, the severity of angina (mean New York Heart Association functional class 1.6 +/- 0.9) after 6.2 +/- 2.3 years of follow-up was substantially better than before the initial procedure (mean functional class 3.2 +/- 0.8), with a similar magnitude of change found in all three groups. This long-term functional improvement was mirrored by a corresponding anatomic improvement, with the mean number of diseased vessels remaining constant at the time of each procedure (1.5 +/- 0.7, 1.5 +/- 0.7 and 1.6 +/- 0.7, respectively, for the first, second and third procedures, p = NS). The restenosis and the new stenosis groups also demonstrated statistically similar annual rates of mortality (1.9% vs. 1.8%) and coronary surgery (2.3% vs. 2.6%), although the restenosis group had a lower rate of infarction (1.4% vs. 3.2%, p = 0.002)., Conclusions: Repeat interventional treatment of newly acquired stenoses provides a rational approach for the long-term management of chronic coronary artery disease. In addition to yielding a favorable late outcome, the use of this strategy can result in sustained functional improvement and can check the progression of clinically significant stenoses.

Unlabelled: Conflicting results in a heterogenous patient population have been described on the functional significance of stress-induced T wave normalization in the ECG. The aim of this study was to evaluate the relationship between T wave normalization during dobutamine stress testing and stress-induced ischaemia evaluated by echocardiography and myocardial perfusion scintigraphy in patients with previous non-Q wave myocardial infarction. Among 520 patients who underwent dobutamine stress, testing in conjunction with simultaneous echocardiography and 201 thallium or sestamibi SPECT for evaluation of suspected myocardial ischaemia, 36 were selected according to the following criteria: previous non-Q wave myocardial infarction, normal QRS, negative T waves in two or more ECG leads and no significant ST segment depression or elevation at rest or during stress. Diagnosis of ischaemia relied upon the occurrence of reversible perfusion defects by scintigraphy and stress-induced wall motion abnormalities by echocardiography. During the test, T wave normalization (defined as a resting negative T wave becoming upright in one or more ECG leads during stress) occurred in 20 patients (group 1), while in 16 patients the T waves remained negative (group 2). The prevalence of ischaemia was higher in group 1 than in group 2 both by scintigraphy (85% vs 38%, P = 0.004) and by echocardiography (70% vs 32%, P = 0.02). The sensitivity, specificity and accuracy of T wave normalization in the detection of ischaemia were 74%, 77% and 75% by SPECT and 74%, 65% and 69% by echocardiography respectively., Conclusion: In patients with non-Q wave myocardial infarction and suspected myocardial ischaemia, T wave normalization without concomitant ECG changes during dobutamine stress testing is associated with a higher prevalence of ischaemia compared to patients with persistent T wave inversion. This ECG finding should not be disregarded as a marker of ischaemia in that particular patient population.

Objectives: This study sought to compare the clinical characteristics, hemodynamic response and severity of ischemia in patients with coronary artery disease and reversible perfusion defects on dobutamine 2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) with or without transient wall motion abnormalities., Background: The occurrence of reversible perfusion defects without concomitant wall motion abnormalities in patients with coronary artery disease was attributed to less severe ischemia. However, little data are available to support this observation., Methods: Fifty-four consecutive patients with significant coronary artery disease and reversible perfusion defects on dobutamine (up to 40 micrograms/kg body weight per min) MIBI SPECT were studied (mean [+/- SD] age 59 +/- 11 years; 38 men, 16 women). All patients underwent simultaneous echocardiography. The myocardium was divided into six matched segments, and ischemic perfusion score was quantitatively derived in myocardial segments with reversible defects., Results: New or worsening wall motion abnormalities occurred in 40 patients (74%) (group A) and were absent in 14 (26%) (group B). There was no significant difference between the two groups with respect to age, previous myocardial infarction, number of abnormal coronary arteries (1.8 +/- 0.8 vs. 1.6 +/- 0.9), number of reversible perfusion defects (1.6 +/- 0.9 vs. 1.8 +/- 0.7) or ischemic perfusion score (412 +/- 750 vs. 526 +/- 553). Patients in group A had a higher prevalence of male gender (80% vs. 43%, p < 0.01), higher peak systolic blood pressure (147 +/- 30 vs. 127 +/- 31 mm Hg, p < 0.05), higher peak rate-pressure product (19,632 +/- 4,081 vs. 16,939 +/- 4,344, p < 0.01) and a higher prevalence of angina (53% vs. 14%) and ST segment depression (55% vs. 14%) than group B (p < 0.05 for both)., Conclusions: In patients with coronary artery disease and ischemia on dobutamine MIBI SPECT, the absence of transient wall motion abnormalities is associated with a similar extent and severity of reversible perfusion defects, a lower stress rate-pressure product and a higher prevalence of female gender than patients with transient wall motion abnormalities. Mechanically silent ischemia should not be regarded as a marker of less severe ischemia on myocardial perfusion scintigraphy.

Unlabelled: To study the in-hospital outcome of all coronary angioplasty procedures performed in a single centre over a 1 year period, with regard to angiographic success and the clinical complications of death, myocardial infarction, emergency coronary bypass surgery and abrupt coronary occlusion necessitating reintervention., Methods: One thousand one hundred and thirty-three lesions were treated in 970 procedures in 799 patients between October 1993 and October 1994. Clinical, procedural, angiographic and outcome data were entered into a dedicated computer data-base and variables tested with respect to outcome using the chi-square test and univariate and multivariate analysis techniques., Results: Angioplasty was performed for stable angina in 473 (49%) patients, unstable angina in 410 (42%) and 80 procedures were emergency--primary myocardial infarction in 44 (4.5%), shock in two, abrupt closure in 34 (3.5%) and other indications in seven patients. There were 10 (1.0%) deaths and 71 (7.3%) patient were documented to have suffered a myocardial infarction as a result of angioplasty. Nineteen (2.0%) patients underwent emergency coronary artery bypass surgery. Age >60 and a type C lesion were found to be associated with angiographic failure. The chance of a complication was increased if the patient was aged >60 years, suffered unstable angina, had an ejection fraction <50%, was treated with a new device or suffered a significant dissection., Conclusion: Despite refinement in techniques and increased experience, coronary angioplasty retains a significant associated chance of angiographic failure. The complication rate remains significant and there has been little reduction in mortality, infarction and abrupt closure rates over the last 15 years. The requirement for emergency coronary artery bypass surgery appears to be diminishing with the introduction of improved bail-out techniques, in particular intracoronary stenting.

ST-segment elevation during exercise testing has been attributed to myocardial ischemia and wall motion abnormalities (WMA). However, the functional significance of ST-segment elevation during dobutamine stress testing (DST) has not been evaluated in patients referred for diagnostic evaluation of myocardial ischemia. DST (up to 40 micrograms/kg/min) with simultaneous echocardiography and technetium-99m sestamibi single-photon emission computed tomography (SPECT) was performed in 229 consecutive patients with suspected myocardial ischemia who were unable to perform an adequate exercise test; 127 (55%) had a previous acute myocardial infarction (AMI). ST elevation was defined as > or = 1 mm new or additional J point elevations with a horizontal or upsloping ST segment lasting 80 ms. Reversible perfusion defects on SPECT and new or worsening WMA during stress on echocardiography were considered diagnostic of ischemia. ST elevation occurred in 40 patients (17%) during the test; 34 of them (85%) had previous AMI. All patients with ST-segment elevation had abnormal scintigrams (fixed or reversible defects, or both) and abnormal wall motion (fixed or transient defect, or both) at peak stress. In patients who had ST elevation and no previous AMI (n = 6), ischemia was detected in all by echocardiography and in 5 (83%) by SPECT. In patients with previous AMI, the prevalence of ischemia was not different with or without ST elevation (53% vs 43% by echocardiography and 53% vs 48% by SPECT, respectively). Baseline regional wall motion score in the infarct zone was higher in patients with ST elevation.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To investigate the efficacy of long term oral anticoagulant treatment in subgroups of patients after myocardial infarction., Design: Analysis of the effect of anticoagulant treatment in subgroups of hospital survivors of myocardial infarction based upon age, gender, history of hypertension, previous myocardial infarction, smoking habits, diabetes mellitus, Killip class, anterior location of infarction, thrombolytic therapy, and use of beta blockers., Subjects: Participants of a multicentre, randomised, double blind, placebo controlled trial that assessed the effect of oral anticoagulant treatment on mortality as well as cerebrovascular and cardiovascular morbidity in 3404 hospital survivors of acute myocardial infarction., Main Outcome Measures: The effect of anticoagulant treatment on recurrent myocardial infarction, cerebrovascular events, and vascular events (the composite endpoint of reinfarction, cerebrovascular event, and vascular death)., Results: Long term anticoagulant treatment was associated with a reduction in mortality of 10% (95% confidence interval -11% to 27%), recurrent myocardial infarction of 53% (41% to 62%), cerebrovascular events of 40% (10% to 60%) and vascular events of 35% (24% to 45%). Treatment effect with respect to recurrent myocardial infarction was comparable among all subgroups of patients. Although treatment effect appeared to be somewhat smaller in females than in males (-11% v -45%), and in patients with diabetes compared to those without (-14% v -42%) with respect to vascular events, none of these differences reached statistical significance. In multivariate analysis, more advanced age, previous myocardial infarction, diabetes mellitus, and heart failure during admission were independently associated with increased incidence of cardiovascular complications., Conclusions: The relative benefit of long term anticoagulant therapy in survivors of myocardial infarction is not modified by known prognostic factors for cardiovascular disease.

The extent and severity of dobutamine-induced left ventricular (LV) dysfunction with and without angina were evaluated in 105 consecutive patients with significant coronary artery disease and a positive dobutamine stress echocardiographic test, defined as new or worsening wall motion abnormalities during high-dose dobutamine stress (up to 40 micrograms/kg/min). Wall motion score (WMS) was derived using a 16-segment, 4-grade scoring method. The difference between stress and rest WMS (delta WMS) was derived as a global measure of stress-induced LV dysfunction. Typical angina occurred in 61 patients (58%) during the test. There was no significant difference between patients with or without angina with respect to age, gender, prevalence of previous myocardial infarction, multivessel disease, or number of diseased coronary arteries. Patients with angina had a higher prevalence of a history of angina before the test. Rest, stress, and delta WMS, number and distribution of ischemic segments, and number of segments with an increase in regional WMS of > or = 2 were not significantly different in patients with or without angina. ST-segment depression was more frequent in patients with angina (56% vs 29%, p < 0.05). Patients with (vs those without) ST-segment depression had a significantly higher number of ischemic segments with normal baseline contraction, an equal total number of ischemic segments, and a similar delta WMS. It is concluded that in patients with anatomically and functionally significant coronary artery disease, the amount of stress-induced LV dysfunction evaluated by dobutamine stress echocardiography is similar in patients with or without angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Participants of a randomised trial may differ from eligible non-participants as a result of selection. We studied the distribution of prognostic factors and survival in eligible patients of a multi-centre trial of long-term oral anticoagulant treatment after myocardial infarction. All hospital survivors of myocardial infarction in one participating clinical centre of a multi-centre, randomised, double-blind, placebo-controlled trial of long-term anticoagulant treatment after myocardial infarction were screened for entry criteria. Subsequently, prognostic factors and survival of participants were compared with eligible but not randomised patients. The 350 participants were younger and were more often of male gender and more often smokers compared with 587 non-participants. Non-participants had more frequently suffered a previous myocardial infarction and were treated more often with diuretics and ACE-inhibitors, suggesting a higher proportion of patients with chronic heart failure in this group. Age, previous myocardial infarction and the use of diuretics at discharge were independent predictors of mortality, consent showed no association. Our findings indicate that participants of a clinical trial have a better prognosis during the first years following myocardial infarction compared to eligible non-participants as a result of a higher prevalence of cardiovascular risk factors associated with mortality in the non-participants.

Objective: To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial infarction., Design: Cost-effectiveness analysis, based on a randomized, double-blind, placebo-controlled trial., Setting: Sixty Dutch hospitals., Patients: A total of 3404 hospital survivors of acute myocardial infarction randomized within a median period of 4 days after discharge to either oral anticoagulant treatment or placebo. The mean follow-up was 37 months., Intervention: Oral anticoagulant treatment aimed at a target international normalized ratio of 2.8 to 4.8., Main Outcome Measurements: Costs of hospital stay during readmissions, costs related to major cardiologic interventions, and costs of oral anticoagulant treatment., Results: The costs of oral anticoagulant treatment were estimated at 394 Dutch guilders (Dfl) per patient-year (Dfl 1 = US $0.58). Placebo patients stayed 18,830 days in the hospital compared with 15,083 days for anticoagulation patients. Average costs per patient of medical care during follow-up were estimated at Dfl 10,784 for placebo patients and Dfl 9878 for anticoagulation patients., Conclusions: Costs of long-term anticoagulant treatment are outweighed by the costs of prevented clinical events.

Objective: To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less., Design: Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians., Setting: A tertiary referral cardiac centre., Patients: 57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient., Results: The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival., Conclusions: In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.

Unlabelled: Left atrial spontaneous echo contrast, detected by transoesophageal echocardiography in patients with non-valvular atrial fibrillation reflects slow blood flow and is associated with an increased risk of cardio-embolism. The purpose of this study was to find echo/Doppler predictors of left atrial spontaneous echo contrast by transthoracic examination. In a retrospective case control study, 17 patients with chronic non-valvular atrial fibrillation who had suffered a recent cerebral ischaemic event (group A) and 17 patients with chronic non-valvular atrial fibrillation who had not suffered such an event (group B) were studied. Both groups were matched for age and sex. All patients underwent standard transthoracic echocardiography with transmitral Doppler as well as transoesophageal echocardiography. Left atrial spontaneous echo contrast was demonstrated by transoesophageal echocardiography in nine group A patients and in two group B patients (P = 0.028); left atrial spontaneous echo contrast was not detected by transthoracic echocardiography in these patients. All patients with left atrial spontaneous echo contrast (11 patients) had a left atrial size, corrected for base index, exceeding 24 mm and a transmitral time velocity integral < 10 cm (sensitivity 100%). Left atrial spontaneous echo contrast was absent in six patients with both characteristics (specificity 74%)., Conclusion: transthoracic echo/Doppler aids in the prediction of the presence of left atrial spontaneous echo contrast and the identification of patients with non-valvular atrial fibrillation with increased cardioembolic risk, thus avoiding transoesophageal echocardiography.

Thrombolytic therapy improves outcome in patients with myocardial infarction but is associated with an increased risk of intracranial haemorrhage. For some patients, this risk may outweigh the potential benefits of thrombolytic treatment. Using data from other studies, we developed a model for the assessment of an individual's risk of intracranial haemorrhage during thrombolysis. Data were available from 150 patients with documented intracranial haemorrhage and 294 matched controls. 49 patients with intracranial haemorrhage and 122 controls had been treated with streptokinase, whereas 88 cases and 148 controls had received alteplase. By multivariate analysis, four factors were identified as independent predictors of intracranial haemorrhage; age over 65 years (odds ratio 2.2 [95% Cl 1.4-3.5]), body weight below 70 kg (2.1 [1.3-3.2]), hypertension on hospital admission (2.0 [1.2-3.2]), and administration of alteplase (1.6 [1.0-2.5]). If the overall incidence of intracranial haemorrhage is assumed to be 0.75%, patients without risk factors who receive streptokinase have a 0.26% probability of intracranial haemorrhage. The risk is 0.96%, 1.32%, and 2.17% in patients with one, two, or three risk factors, respectively. We present a model for individual risk assessment that can be used easily in clinical practice.

The authors investigated 40 heart transplant recipients and their partners to determine both the partner's quality of life upon transplantation and the experiences of both patient and partner with compliance with the medical regimen. Data on sleep disturbances, social isolation, emotional reactions, depression, anxiety, partner's apprehension, social support and compliance (regarding behaviour and emotional experience) were obtained approximately 21 months after transplantation. Compared to related study groups, partners did not experience more problems in sleep, social isolation, emotional reactions, depression and anxiety. Patients overestimated the apprehension of their partners significantly (p < 0.0001). Generally speaking, with the exception of three items relating to eating fish, canned food and forgetfulness in medicine intake, patients and partners agreed with respect to actual compliance behaviour. Lowest compliance concerned regular physical exercise: 28%. Both patient and partner insisted that they had scarcely any emotional problem with the regimen. Further systematic research is needed to bring to light factors that affect compliance as well as adequate methods to bring about an improvement therein.

The most feared complication of thrombolytic therapy is intracranial hemorrhage. Nevertheless, the benefits of thrombolysis far outweight the potential hazards of a cerebral bleed. In individual patients the expected benefit of thrombolytic therapy can be estimated by subtraction of the risk for intracranial hemorrhage from the predicted gain in survival. Accordingly, the net effect of thrombolysis will be beneficial in most patients who can be treated within the first 12 hours after symptom onset, even if one or two risk factors for intracranial hemorrhage can be identified. On the other hand, thrombolytic therapy is not warranted in elderly patients with a relatively small predicted infarct size and multiple risk factors for intracranial hemorrhage.

Objective: To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old., Design: Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician., Setting: A tertiary referral cardiac centre., Patients: 166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients)., Results: The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease., Conclusions: Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.

To evaluate longterm survival after a first aortocoronary bypass operation we followed up all such patients with operations between July 1971 and June 1980. Included were 1041 patients, mean follow-up time was 11 years (8.5-17.4). Data were complete in 98%. The perioperative mortality equalled 1.2%, survival probability at 5 and 10 years was 92% and 77%, respectively. The yearly mortality rate increased from the fifth year onward up to 5% in the tenth. Of the deceased patients 72% had a cardiac cause of death. Extent of vascular involvement, quality of left ventricular function and age at operation had an important influence on survival probability. The aortocoronary bypass operation is a safe procedure, with a good prognosis for survival, but does not prevent cardiac death in the future.

Background: Acute coronary artery occlusion after percutaneous transluminal coronary angioplasty (PTCA) continues to remain a serious complication despite significant improvement in operator performance and technological advancements. This retrospective study was performed to ascertain the frequency, predictive variables, management, and outcome of acute coronary artery occlusion., Methods and Results: The study was based on data from 1,423 consecutive patients who underwent an elective coronary angioplasty between January 1986 and December 1988. Acute coronary artery occlusion occurred in 104 patients (7.3%). Acute occlusion developed during the dilatation procedure in 80 patients (5.6%) and within 24 hours after the procedure in 24 patients (1.7%). Four clinical and 14 angiographic variables predictive for acute coronary artery occlusion were analyzed in these 104 patients with a complicated procedure and were compared with those in 104 representative patients with successful attempts. Multivariate analysis found three independent predictive variables: unstable angina, multivessel disease, and complex lesions. The overall clinical outcome after management of acute coronary artery occlusion including immediate repeat dilatation (95 patients), use of intracoronary streptokinase (34 patients), or autoperfusion catheter (12 patients) was successful (reduction of lumen diameter to less than 50%, no death, no myocardial infarction [MI], and no emergency surgery) in 42 patients (40%), was a failure without major complication in four patients (4%), and was a failure with major complication (death, MI, and emergency surgery) in 58 patients (56%). The overall mortality rate was 6% (six patients), the overall MI rate was 36% (37 patients), and emergency bypass surgery was required in 30% of patients (31 patients). At 6 months' follow-up of 42 patients with successful management, recurrent angina pectoris due to restenosis occurred in 10 patients (24%), and a late MI occurred in one patient (3%). At 6 months' follow-up of 56 survivors with unsuccessful management (development of MI or need for emergency bypass surgery), recurrent angina occurred in nine patients (16%), and cardiac death in two patients (4%). However, the majority of patients in both groups were either symptom free or had mild angina pectoris., Conclusion: Acute coronary artery occlusion during PTCA is often unpredictable, but its frequency is higher in patients with unstable angina, multivessel disease, and complex lesions. Despite immediate redilatation, use of intracoronary streptokinase, and emergency bypass surgery, PTCA is associated with a high mortality and morbidity.

To evaluate longterm survival, 1041 consecutive patients with aorto-coronary bypass operations were followed for a mean of 7.5 years (range 5 to 14.5). The peri-operative mortality was 12 (1.2%). Of the 131 late deaths, 97 (74%) were cardiac in origin. The survival probability at 5 years was 92 +/- 2% and at 10 years 79 +/- 4%. Figures for a matched general Dutch population are 94% and 87%, respectively. Stepwise multivariate analysis revealed an association between death rate and impaired left ventricular function (rate ratio impaired function versus normal: 1.82, P = 0.0007) and extent of vascular disease (rate ratio 3 vessel-versus 1 vessel disease: 1.80, P = 0.01) while no relation was found with sex or age at operation. Surgery seems to provide a good probability of survival, although in patients with extensive vascular involvement and/or a decreased left ventricular function at the time of operation, the longterm outlook is less favourable than for those without these characteristics.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

Reintervention was required in 123 (12%) individuals during a follow up (mean 7.5 years, range 5-14.5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5.6%) than at the primary operation (1.2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1.82) and with extent of vascular disease (rate ratio 1.80) but not with reintervention (rate ratio 1.45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention. Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.

Two hundred patients (mean age 56 years, range 36 to 74) with unstable angina (chest pain at rest, associated with ST-T changes) underwent coronary angioplasty. In 65 patients with multivessel disease, only the "culprit" lesion was dilated. The initial success rate was 89.5% (179 of 200 patients). At least one major procedure-related complication occurred in 21 patients (10.5%): (death in 1, myocardial infarction in 16 and urgent surgery in 18). All patients were followed up for 2 years. Five patients died late; 8 had a late nonfatal myocardial infarction and 52 had recurrence of angina pectoris. The restenosis rate was 32% (51 of 158) in the patients with initial successful angioplasty who had repeat angiography. At the 2 year follow-up, after attempted coronary angioplasty in all 200 patients, the total incidence rate of death was 3% (one procedure related; five late deaths), of nonfatal myocardial infarction 12% (16 procedure related and 8 late after angioplasty), and 13% (26 patients) were still symptomatic although they had improved in functional class. Multivariate analysis showed that variables indicating an increased risk 1) for major procedure-related complications were: ST segment elevation, persistent negative T wave and stenosis greater than or equal to 65% (odds ratio 3.7, 3.7 and 3.3, respectively); 2) for angiographic restenosis were: presence of collateral vessels, ST segment depression, multivessel disease, left anterior descending coronary artery stenosis and history of recent onset of symptoms (odds ratio: 2.2, 2.0, 1.9, 1.9 and 0.54, respectively); and 3) for late coronary events (recurrence of angina, late myocardial infarction or late death) were: multivessel disease, total occluded vessel and ST segment elevation (odds ratio 3.7, 2.8 and 0.44, respectively). Thus, coronary angioplasty for unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. The prognosis is favorable after initial successful coronary angioplasty.

The effect of myocardial reperfusion on regional left ventricular function has been quantitated by analysis of segmental wall motion in 185 patients enrolled in a randomized trial comparing thrombolysis with conventional treatment in patients with acute myocardial infarction. When analyzing the hemodynamic data on an "intention to treat" basis we found a significant preservation of left ventricular function after thrombolytic therapy when compared to conventional treatment. In addition, the wall motion analysis showed that a significant improvement of regional function in the "infarct zone" was observed in inferior infarction as well as in anterior infarction, although significant changes in regional function of the remote "non infarct zone" were observed at the acute as well as at the chronic stage. However, our follow-up data indicate that as yet it has not been resolved whether this method of treatment does indeed improve prognosis in patients with acute myocardial infarction. Accordingly, we maintain the view that such invasive treatment should not be generally applied until more follow-up data become available from larger randomized trials.

Between September 1981 and May 1986, coronary angioplasty immediately after intracoronary thrombolysis was attempted in 115 patients with acute myocardial infarction. The present study describes our experience with this combined procedure. Primary success was achieved in 102 patients (89%). Before discharge, 79 of these patients agreed to be restudied angiographically. The infarct-related vessel was still patent in 71 patients (patency rate of 90%). Sequential left ventricular angiograms of quality sufficient to allow automated analysis were obtained in 58 patients. Global ejection fraction improved significantly from 52 +/- 10% to 55 +/- 9% (p = 0.01) from the acute to the chronic stage. In patients with anterior infarction, the increase in global ejection fraction was primarily the result of significant improvement of the regional myocardial function of the infarct zone. No significant changes in global and regional myocardial function could be seen in patients with inferior infarction. However, when patients in whom the infarct-related vessel was reoccluded at follow-up angiography are excluded from analysis, the global and regional myocardial function did improve significantly irrespective of the location of the infarct. Median clinical follow-up of 20 months (range 4 to 50) resulted in an overall mortality rate of 4%. Preservation of global and regional left ventricular function with a low mortality rate suggests that immediate coronary angioplasty after thrombolysis can be safely used to provide reperfusion in the setting of acute myocardial infarction and that this combined procedure may be the optimal mode of therapy. Further randomized studies are warranted to precisely define the role of coronary angioplasty in acute myocardial infarction.

In order to evaluate the independent prognostic information provided by exercise testing in populations with a high prevalence of coronary artery disease, survival rates were calculated with the life table method in 372 men, mean age 48 years, referred for coronary arteriography. The prevalence of angiographic coronary artery disease was 82%. During a mean follow-up of 29 months (1 to 8 years), 32 patients died and 27 patients had a nonfatal event (acute infarction or hospitalization for disabling angina). Both the history (presence or absence of typical angina pectoris or of a previous myocardial infarction) and the exercise test results (abnormal if angina and/or ST segment changes greater or equal to 0.1 mV occurred) had a significant prognostic value for the 5 year survival rate (P less than 0.001). In patients with a positive history, the 5 year cumulative survival rate was 76% if the exercise test was abnormal versus 94% if it was normal (P less than 0.001). The following 8 noninvasive and 2 invasive variables were submitted to a Cox regression analysis: age, typical angina pectoris, previous myocardial infarction, maximal heart rate and workload, maximal ST segment depression and elevation, angina pectoris during exercise testing, number of diseased vessels, and wall motion score on contrast ventriculography. By univariate analysis, the age and the maximal workload reached during exercise were the only noninvasive predictive variables for survival or cardiac events (P less than 0.05). By multivariate analysis, and combining all noninvasive and invasive variables, survival was predicted by the wall motion score, the presence or absence of 3 vessel disease, and age.(ABSTRACT TRUNCATED AT 250 WORDS)

To examine whether coronary angioplasty has a different effect on work resumption than has coronary artery bypass surgery, we studied the work status of patients before and at least 1 year after either intervention. The population consisted of men aged less than 60 years, submitted to these procedures from September 1983 to July 1984. Of the 261 eligible patients, 219 (84%) participated, 94 after an angioplasty and 125 after a bypass procedure. 6 months preceding the intervention, 52% of the men were working. This had decreased to 47% at follow-up. Multiple logistic regression analysis showed that failure to resume work was correlated with bypass surgery vs balloon dilatation (rate ratio 1.8; 95% CI, 1.0-3.4), not working beforehand (rate ratio 6.5; 1.2-4.3), age greater than 55 years vs less than or equal to 50 years (rate ratio 2.6; 1.3-5.4) and with angina at follow-up (rate ratio 1.8; 1.0-3.3). Taking these additional risk factors into account permits a prediction of the probability of a return to work.

The effect of thrombolysis in acute myocardial infarction on enzymatic infarct size, left ventricular function, and early mortality was studied in subsets of patients in a randomized trial. Early thrombolytic therapy with intracoronary streptokinase (152 patients) or with intracoronary streptokinase preceded by intravenous streptokinase (117 patients) was compared with conventional treatment (264 patients). All 533 patients were admitted to the coronary care unit within 4 hr after onset of symptoms indicative of acute myocardial infarction. Four hundred eighty-eight patients were eligible for this detailed analysis, and 245 of these were allocated to thrombolytic therapy and 243 to conventional treatment. Early angiographic examinations were performed in 212 patients allocated to thrombolytic therapy. Patency of the infarct-related artery was achieved in 181 patients (85%). Enzymatic infarct size, as measured from cumulative alpha-hydroxybutyrate dehydrogenase release, was smaller in patients allocated to thrombolytic therapy (median 760 vs 1170 U/liter in control patients, p = .0001). Left ventricular ejection fraction measured by radionuclide angiography before discharge from the hospital was higher after thrombolytic therapy (median 50% vs 43% in control patients, p = .0001). Three month mortality was lower in patients allocated to thrombolytic therapy (6% vs 14% in the control group, p = .006). With the use of multivariate regression analysis, infarct size limitation, improvement in left ventricular ejection fraction, and three month mortality were predicted by sum of the ST segment elevation, time from onset of symptoms to admission, and Killip class at admission. Thrombolysis was most effective in patients admitted within 2 hr after onset of symptoms and in patients with a sum of ST segment elevation of 1.2 mV or more. On the other hand, no beneficial effects of streptokinase on enzymatic infarct size, left ventricular function, or mortality were observed in the subset of patients with a sum of ST segment elevation of less than 1.2 mV who were admitted between 2 and 4 hr after onset of symptoms.