Search

Hypothermia can cause several ECG changes which can be mistaken for other cardiac diseases, most importantly acute transmural ischaemia. These ECG changes correlate strongly with the degree of hypothermia and the prognosis of the patient. This brief report presents a 32-year-old male who was seen after a drowning accident. After resuscitation a 12-lead electrocardiogram showed changes typical for hypothermia: atrial fibrillation and Osborn waves. The ECG of the patient normalised after rewarming.

Aims Thrombolytic therapy restores coronary patency in patients with acute myocardial infarction, although normal perfusion (TIMI 3 flow) is not achieved in all patients. In an attempt to improve TIMI 3 flow, a combination of full-dose streptokinase, aspirin and escalating dosages of a platelet glycoprotein IIb/IIIa receptor blocker, eptifibatide, vs placebo were tested. Methods and Results A bolus of 180μg.kg−1of eptifibatide was administered in each group, followed by a 72h continuous infusion of 0·75 (44 patients), 1·33 (n=45) and 2·00μg.kg−1.min−1(n=30); 62 patients received placebo. Normal perfusion (TIMI 3 flow) at 90min was observed in 31% of placebo patients compared to 46, 42 and 45% in the ascending eptifibatide groups (44% for combined eptifibatide groups, P =0·07). Patency (TIMI 2 and 3 flow combined) increased from 61% (placebo) to 78% for the combined eptifibatide groups ( P =0·02). Reocclusion was infrequent. No differences were observed in TIMI flow grades among eptifibatide groups. Major and minor bleeding was increased and occurred mainly at the arterial puncture site. Conclusion A combination of full dose streptokinase with different eptifibatide regimens enhanced coronary perfusion, but bleeding risk was excessive. Additional trials are needed with different dosage regimens to determine the optimal combination of fibrinolytic agents and platelet glycoprotein IIb/IIIa receptor blockers.

BACKGROUND--Is it safe to discharge patients from hospital on the same day as percutaneous transluminal coronary angioplasty (PTCA)? The hypothesis tested was that careful pre and post angioplasty selection of patients can identify a group that is at very low risk of postprocedural complications and that these patients may be discharged on the day of the procedure. METHODS--63 patients undergoing limited risk coronary angioplasty of 72 lesions were studied. So that patients would be able to walk soon after PTCA miniature equipment (6 French catheters and balloon-on-a-wire devices) was passed percutaneously through the right brachial artery. After coronary angioplasty patients with angiographic evidence of dissection and/or thrombus and with complications were assigned to an inpatient group and those in whom PTCA had achieved a good angiographic result were assigned to an outpatient group. RESULTS--Two patients were excluded because the brachial approach failed, leaving 61 patients (70 lesions). After PTCA 50 patients (82%) with 57 lesions (81%) attempted were assigned to the outpatient group. No cardiac complication occurred in this subset (0%; 95% confidence interval 0 to 7%). Eleven patients (18%), in whom 13 lesions (19%) were attempted, were assigned to the inpatient group. Three of these patients (27%; 95% confidence interval 6 to 61%) had cardiac complications. Two patients needed local surgical repair after catheterisation of the brachial artery; one had a haematoma and one had a false aneurysm. CONCLUSIONS--Coronary angioplasty with miniature equipment passed through the brachial artery was a safe procedure with a high initial success rate. The results of this pilot trial suggest that with careful selection of patients before and after angioplasty PTCA can be performed safely in outpatients.

BACKGROUND Patients with unstable angina despite intensive medical therapy, ie, refractory angina, are at high risk for developing thrombotic complications: myocardial infarction or coronary occlusion during percutaneous transluminal coronary angioplasty (PTCA). Chimeric 7E3 (c7E3) Fab is an antibody fragment that blocks the platelet glycoprotein (GP) IIb/IIIa receptor and potently inhibits platelet aggregation. METHODS AND RESULTS To evaluate whether potent platelet inhibition could reduce these complications, 60 patients with dynamic ST-T changes and recurrent pain despite intensive medical therapy were randomized to c7E3 Fab or placebo. After initial angiography had demonstrated a culprit lesion suitable for PTCA, placebo or c7E3 Fab was administered as 0.25 mg/kg bolus injection followed by 10 micrograms/min for 18 to 24 hours until 1 hour after completion of second angiography and PTCA. During study drug infusion, ischemia occurred in 9 c7E3 Fab and 16 placebo patients (P = .06). During hospital stay, 12 major events occurred in 7 placebo patients (23%), including 1 death, 4 infarcts, and 7 urgent interventions. In the c7E3 Fab group, only 1 event (an infarct) occurred (3%, P = .03). Angiography showed improved TIMI flow in 4 placebo and 6 c7E3 Fab patients and worsening of flow in 3 placebo patients but in none of the c7E3 Fab patients. Quantitative analysis showed significant improvement of the lesion in the patients treated with c7E3 Fab, which was not observed in the placebo group, although the difference between the two treatment groups was not significant. Measurement of platelet function and bleeding time demonstrated > 90% blockade of GPIIb/IIIa receptors, > 90% reduction of ex vivo platelet aggregation to ADP, and a significantly prolonged bleeding time during c7E3 Fab infusion, without excess bleeding. CONCLUSIONS Combined therapy with c7E3 Fab, heparin, and aspirin appears safe. These pilot study results support the concept that effective blockade of the platelet GPIIb/IIIa receptors can reduce myocardial infarction and facilitate PTCA in patients with refractory unstable angina.

The consumption of recreational drugs has reached epidemic proportions. Forty five million European Union citizens have used cannabis at some time, with proportionately higher use among younger people.1 The consumption of harder drugs such as cocaine and heroin is rising, with an estimated 1.5 million problem users in the European Union. Drug use is commonly associated with complications, including an increased risk of premature death. 1 2 In particular, recreational drugs have profound effects on cardiovascular function. Some studies suggest that adverse cardiac events are relatively uncommon, 1 3-5 though recent data from the United States indicate that one in four myocardial infarcts in people aged 18-45 years can be linked to cocaine use, suggesting that variation in definitions may contribute to under-reporting. 1 6 Many physicians will encounter patients with cardiovascular problems related to recreational drug misuse. In addition to the problems posed by self administration, massive overdoses may occur in individuals who attempt to smuggle illegal drugs by ingesting packets which rupture in the gastrointestinal tract; and inadvertent ingestion of recreational drugs by children has been reported. …

Percutaneous transluminal coronary angioplasty (PTCA) for total occlusions frequently fails, because the guidewire fails to pass the occlusion. With the use of the Probe exchange catheter (PEC), however, stiffness of the guidewire is increased and a higher pushability is obtained in order to manipulate the guidewire beyond the lesion. Once the guidewire has passed, the PEC is advanced and a non-over-the-wire dilatation catheter can be introduced through the PEC. This paper describes the technique in a representative case. The results of this technique in 19 consecutive patients with class III-IV/IV(NYHA) angina due to an occluded coronary artery are presented. In 16 patients the PEC reached the lesion (84%) and in all these patients the guidewire could pass the occlusion. A successful PTCA was performed in 14 patients (74%).

OBJECTIVE—Lefradafiban is the orally active prodrug of fradafiban, a glycoprotein IIb/IIIa receptor antagonist. The present phase II study aimed to determine the dose of lefradafiban that provides 80% blockade of the glycoprotein IIb/IIIa receptors by fradafiban, and to study the pharmacodynamics and safety of different doses in patients with stable angina undergoing angioplasty. DESIGN—A double blind, placebo controlled, dose finding study. SETTING—Four academic and community hospitals in the Netherlands. PATIENTS—64 patients with stable coronary artery disease undergoing elective percutaneous transluminal coronary angioplasty. INTERVENTIONS—30 mg, 45 mg, and 60 mg of lefradafiban three times daily or placebo was given for 48 hours. MAIN OUTCOME MEASURES—The primary safety end point was the occurrence of bleeding, classified as major, minor, or insignificant according to the thrombolysis in myocardial infarction (TIMI) criteria. Efficacy indices included per cent fibrinogen receptor occupancy (FRO), ex vivo platelet aggregation, and plasma concentrations of fradafiban. RESULTS—Administration of lefradafiban 30, 45, and 60 mg three times daily resulted in a dose dependent increase in median FRO levels of 71%, 85%, and 88%, respectively. Inhibition of platelet aggregation was closely related to FRO. There were no major bleeding events. The 60 mg lefradafiban group had a high (71%) incidence of minor and insignificant bleeding. The incidence of bleeding was 44% in the 30 mg and 45 mg groups, compared with 9% in placebo patients. Puncture site bleeding was the most common event. The odds of bleeding increased by 3% for every 1% increase in FRO. CONCLUSIONS—Lefradafiban is an effective oral glycoprotein IIb/IIIa receptor blocker. The clinical effectiveness of doses up to 45 mg three times daily should be investigated. Keywords: platelet aggregation inhibitors; glycoprotein IIb/IIIa blockers; lefradafiban; angioplasty

Both the implantation of intracoronary stents and the use of glycoprotein IIb/IIIa receptor blocking agents have been proven to be of value in the invasive management of coronary artery disease. Stenting is shown to decrease restenosis rate considerably, and is of great use in countering complications of balloon angioplasty, e.g. dissection and abrupt closure. The use of glycoprotein IIb/IIIa receptor blocking agents has been demonstrated to be beneficial as an adjunctive to intracoronary interventions; it has a profound effect on the rate of acute intervention related complications, but not on the occurrence of chronic restenosis. The scope of this article is to evaluate the usefulness of the combination of stents and glycoprotein IIb/IIIa blocking agents in various manifestations of coronary artery disease. It is concluded that a glycoprotein IIb/IIIa receptor antagonist as an adjunctive to the application of a stent is especially useful when thrombus can be assumed to be present in a clinically relevant quantity.

Patients with unstable angina, refractory to intensive medical therapy, are at high risk of developing thrombotic complications, such as myocardial infarction and coronary occlusion during coronary angioplasty. As platelet aggregation and thrombus formation play an important role in this ongoing ischaemic process, a monoclonal platelet GPIIb/IIIa receptor antibody (c7E3) has been designed to modify the clinical course and underlying coronary lesion morphology. To evaluate whether c7E3 could influence the incidence of complications, we randomized 60 patients to c7E3 or placebo after initial angiography had demonstrated a culprit lesion amenable for angioplasty. All patients exhibited dynamic ECG changes and recurrent pain attacks, despite intensive medical therapy. After study drug bolus and infusion, angiography was repeated and angioplasty performed. Recurrent ischaemia during study drug infusion occurred in nine and 16 patients from the c7E3 and placebo groups, respectively (P = 0.06). Major events defined as death, myocardial infarction or urgent intervention occurred in one and seven patients, respectively (P = 0.03). One patient from the placebo group died as a result of recurrent infarction. Resolution of clots was only observed in the c7E3 group, combined with improvement in TIMI flow grade in 20% of patients. Quantitative angiography showed an improvement in percentage diameter stenosis in the c7E3 group, which was not observed in the placebo group, although the difference between the two treatment groups was not significant. No excess bleeding was observed in the treatment group. Thus, c7E3 bolus and infusion, combined with heparin and aspirin improved the clinical course, the coronary lesion morphology and rheology in patients with unstable angina, refractory to medical treatment.

Patients with unstable angina, refractory to intensive medical therapy, are at high risk for developing thrombotic complications, such as recurrent ischemia, myocardial infarction and coronary occlusion during coronary angioplasty. As both platelet aggregation and/or thrombus formation play an important role in this ongoing ischemic process, a monoclonal platelet GPIIb/IIIa receptor antibody (c7E3) or thrombolytic therapy (alteplase) might be able to modify the clinical course and underlying coronary lesion morphology. To evaluate whether alteplase or c7E3 could influence the incidence of complications, we randomized 36 and 60 patients, respectively to alteplase or placebo, or c7E3 or placebo. All patients exhibited dynamic ECG changes and recurrent pain attacks, despite maximal tolerated medical therapy. Patients were randomized in both studies after initial angiography had demonstrated a culprit lesion amenable for angioplasty. After study drug infusion quantitative angiography was repeated and angioplasty performed. Recurrent ischemia during study drug infusion occurred in 5, 6, 9 and 16 patients from the alteplase, placebo, c7E3 and placebo group, respectively. Major events defined as death, myocardial infarction or urgent intervention occurred in 7, 3, 1 and 7 patients, respectively. Two patients died: one in the alteplase group and one in the placebo group from the c7E3 study. The first patient due to retroperitoneal hemorrhage, the second as a result of recurrent infarction. Qualitative angiography showed resolution of clots in the c7E3 group only, while the same group of patients showed in 20% an improvement in TIMI flow grade, without deterioration in any patient from this group.(ABSTRACT TRUNCATED AT 250 WORDS)

A 16-weeks' pregnant woman with situs inversus and dextrocardia underwent successful closed commissurotomy for severe mitral stenosis. The electrocardiogram revealed sinus rhythm with right axis deviation and progressive diminishing of QRS amplitude towards the left precordial leads. The chest X-ray showed dextrocardia with situs inversus. Doppler echocardiography depicted severe mitral stenosis; the mitral valve area increased from 0.9 cm2 pre-operatively to 1.8 cm2 post-operatively with mild increase of mitral regurgitation from grade I to II post-valvotomy. She also had associated mild functional tricuspid insufficiency and moderate pulmonary hypertension. No thrombo-embolic complications occurred intra- or post-operatively. There was no evidence of either clinical or Doppler restenosis. The course of pregnancy was uneventful. At 39 weeks a healthy baby was vaginally delivered. The patient is still free of cardiac symptoms.

A 16-weeks'pregnant woman with situs inversus and dextrocardia underwent successful closed commissurotomy for severe mitral stenosis. The electrocardiogram revealed sinus rhythm with right axis deviation and progressive diminishing of QRS amplitude towards the left precordial leads. The chest X-ray showed dextrocardia with situs inversus. Doppler echocardiography depicted severe mitral stenosis; the mitral valve area increased from 0·9 cm2 pre-operatively to 1·8 cm2 post-operatively with mild increase of mitral regurgitation from grade I to II post-valvotomy. She also had associated mild functional tricuspid insufficiency and moderate pulmonary hypertension. No thrombo-embolic complications occurred intra- or post-operatively. There was no evidence of either clinical or Doppler restenosis. The course of pregnancy was uneventful. At 39 weeks a healthy baby was vaginally delivered. The patient is still free of cardiac symptoms.

In a randomized, double-blind, multicenter study, the efficacy of diltiazem controlled-release (CR) 120 mg b.i.d. was compared with metoprolol 100 mg b.i.d. in 56 patients with stable exertional angina pectoris. Fifty-one patients (28 receiving diltiazem CR, 23 receiving metoprolol), completed a follow-up period of 8 weeks. Thirty-nine patients (20 receiving diltiazem CR, 19 receiving metoprolol), completed a follow-up period of 32 weeks. Maximal exercise testing was performed at baseline and after 8, 20, and 32 weeks of treatment. Most exercise parameters were not significantly different between the patients on diltiazem CR and those on metoprolol. However, exercise duration was longer and maximal work load was higher in patients on diltiazem CR than in patients on metoprolol, and significant differences were observed at 20 weeks of treatment (p = 0.006 and p = 0.008, respectively). At all times during treatment, heart rate at maximal exercise and rate-pressure product at maximal exercise were significantly lower in the patients treated with metoprolol. In conclusion, monotherapy with diltiazem CR is at least as effective as monotherapy with metoprolol in patients with stable angina pectoris. As compared to metoprolol, diltiazem CR has a minor depressing effect on rate-pressure product, resulting in a favorable effect on exercise duration.

Development of an acute myocardial infarction is described in two previously healthy men of 25 and 40 years respectively, shortly after taking oral amphetamine derivatives. Coronary angiography disclosed in both men a normal coronary system without stenoses or irregularities. Ventriculography revealed in both a segmental dysfunction of the left ventricle. A relationship is postulated between use of amphetamine and occurrence of acute myocardial infarction in the absence of coronary artery disease.

To determine the value of thallium-201 scintigraphy as a decisive factor in admission policy for patients with acute chest pain and nondiagnostic electrocardio-grams, we undertook a prospective study in 149 such patients. The interval between pain and scan never exceeded 12 hr. Of 57 patients in whom a defect was seen, 34 had an acute infarction, 7 developed infarction within 2 months, and in 11 coronary heart disease was proven by angiography or strongly suggested by stress tests (ECG and thallium-201 scan). In 13 patients with an equivocal scan, coronary heart disease was proven or strongly suggested in 5. Of 79 patients with a normal scan, only 1 had acute infarction, and stress tests were positive in 6 and negative in 72. In these 72 no cardiac event occurred during a 1-year follow-up. Thallium-201 scintigraphy can help to select those patients with acute chest pain and nondiagnostic electrocardiograms who need observation in a CCU.

In this experimental study we measured the magnetocardiograms (MCGs) of 17 normals at 42 measuring sites in a plane near the chest. The recordings were made in an unshielded environment with a single channel second-order SOUID gradiometer. From these recordings spatial maps were constructed of the atrial depolarisation and repolarisation. The two series of maps were found to be dipolar, but opposite in sign for 14 of the 17 subjects. The relatively small change in the amplitude and pattern of the atrial repolarisation maps built up out confidence in the method of subtracting a computed mean repolarisation map from the maps obtained during the last 40 ms before the QRS-onset. This method of separating His-Purkinje activity from atrial repolarisation led to distinct dipolar patterns in 9 out of the 17 cases. The direction and location of the associated electric current dipole was in good agreement with what can be expected electrophysiologically for His-Purkinje activation.