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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

Methods and Results Patients with total coronary artery occlusions who had an optimal PTCA result were randomized either to no further treatment or additional stent implantation. The AVE microstent was used and all patients were scheduled for a 1-, 3-, and 6-month clinical follow-up. Repeat coronary angiography to assess the rate and pattern of restenosis was performed at 6 months or earlier if clinically indicated. Ninety-six patients were enrolled in this study. The mean age was 59·310·3 years and 15 were females. Forty-eight patients were randomized to the stent arm, receiving 52 stents (lengths 18–39 mm). Stent implantation was successful in all and there were no major procedure-related complications. Sixty-nine patients (72%) were restudied after 6 months. The binary restenosis rates (50%), in the PTCA arm were 70·9% with a minimal lumen diameter of 1·010·79 mm compared to 42·1% in the stent arm with a minimal lumen diameter of 1·631·02 mm (P=0·034). Reocclusion occurred in 7·9% in the stent group compared to 16·1% in the PTCA group. Restenosis in the PTCA group was focal in 88% of patients and occurred at the point of total obstruction (within 5 mm), compared to diffuse instent restenosis, which occurred in 54% of the patients in the stent group.

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.

The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents.New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet.Fifty-seven consecutive patients in whom 67 long stents (/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization.Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent.Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.

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.

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) disease is characterized by cutaneous, mucosal, and visceral vascular anomalies. Two patients were previously described with coronary artery aneurysms (ectasia) associated with this disease. This report describes a patient with Osler-Weber-Rendu disease in whom multiple coronary arteriovenous malformations were identified during coronary angiography. The patient presented with anginal chest pain resulting from severe anemia. Upper gastrointestinal endoscopy revealed multiple angiodysplastic lesions throughout the esophagus and stomach.

Coronary angiography is not sensitive enough to define the results of stent implantation. Intravascular ultrasound defines accurately the anatomy of the vessel and the stent within the vessel and is thus considered the gold standard for defining the results of stent implantation. However intravascular ultrasound is an additional invasive procedure that is time consuming and expensive. This study describes a new simple quantitative videodensitometric technique, developed specifically to assess the results of stent implantation and compares the findings to intravascular ultrasound. In the proposed algorithm for the videodensitometric analysis, density profiles were constructed perpendicular to the long axis of the stented segment and each one was compared (after background subtraction) with a theoretic profile of a normal artery at that location. Density deficit index was determined at each point from the actual and theoretic profiles and a global volumetric density deficit index was calculated for each stent by integrating the deficit indices at all points along the stent. Similarly an area stenosis was determined at each point along the stent (using the stent and normal vessel cross sectional areas as defined by intravascular ultrasound) and the global volumetric stent stenosis was calculated by integrating the values of area stenosis along the stent. Twenty-five patients were evaluated immediately before and after coronary stent implantation. Global density deficit index improved from 66.1±16.4% before (after last balloon inflation) to 44.4±11.1% after stenting ( P R =0.74) between the global volumetric density deficit index and the global volumetric stent stenosis is statistically significant ( P

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.

Early thrombolysis can be given at home, by a medical intensive care unit ambulance team, in the emergency room, or in the coronary care unit. Thrombolysis should be given very early (

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.

The aim of this study was to assess whether the performance of RF catheter ablations continues to improve by further staff training once an initial success rate of > 90% has been achieved. Two hundred and ninety-five procedures of SVT catheter ablation using RF energy were studied. Atrial tachycardia and atrial flutter substrate ablations were not included. The procedures were performed during a 4-year period by the same physician and nurse, who had previous training in these procedures. The 4-year period was subdivided into four consecutive 1-year periods in which 69, 72, 68, and 86 procedures were performed. The outcome, recurrence rate, and duration of the curative procedure were compared among the four periods. There was no significant difference in the initial success rate among the four periods. The recurrence rate decreased from 21.74% to 13.95% (P < 0.05). The duration of the curative procedure decreased from 93.7 +/- 78.4 minutes to 39.1 +/- 32.2 minutes (P < 0.001), and the fluoroscopic time decreased from 25.5 +/- 22.3 minutes to 11.3 +/- 8.2 minutes (P < 0.001). These results were similar when accessory pathway and selective AV nodal pathways ablations were separately evaluated. Following the initial staff training, during which the expected 80%-90% success rate is achieved, additional training will reduce the recurrence rate and the duration of the procedures at a similar level of success.

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.

Breast artifact occurrence during 201T1 myocardial image interpretation is a significant problem. We serially evaluated 3 female patients utilizing exercise treadmill perfusion studies in o

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 Percutaneous interventions for aorto-ostial narrowing of native coronary arteries are challenging because of early elastic recoil after the procedure and the high restenosis rate. Cutting balloon angioplasty may reduce this complication. Hypothesis The purpose of the study was to evaluate the clinical outcomes of cutting balloon angioplasty and stent implantation for aorto-ostial lesions with a 1-year clinical follow-up. Methods All patients with aorto-ostial lesions in our laboratory underwent cutting balloon angioplasty and were followed for approximately 1 year. Results Forty-eight patients underwent balloon angioplasty; 36 of whom had lesions in the ostial right coronary artery, and 12 of whom had lesions in the left main coronary artery (LMCA). Thirty-five patients (73%) had a stent implanted. Procedural success was achieved in all patients. The in-hospital rate of major adverse cardiac events (MACEs) was 2.1% because of the death of 1 patient following urgent bypass surgery. Mean clinical follow-up was 11.6 ± 7 month. Twelve patients (27%) required repeat coronary angiography, and restenosis was found in 7 patients (16%). Six patients (13.6%) had MACEs. Conclusions Cutting balloon angioplasty in combination with bare metal stent (BMS) implantation has a good clinical outcome. This technique should be compared with implantation of drug-eluting stents (DESs) in a controlled study. Copyright © 2009 Wiley Periodicals, Inc.

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.

Twenty-eight consecutive male patients were examined a few days before, and again twelve months after, coronary artery bypass surgery. The evaluation included the patients' psychological distress, psychosocial adjustment, cardiac state, personality and family relations. Before surgery the patients were relatively well adjusted, despite being severely disabled physically. On the follow-up evaluation the cardiac state improved significantly on every index examined. On the other hand no change occurred in the psychological distress, personality and family relations. Significant post-operative improvement was found in some of the domains of the psychosocial adjustment, but not in others.

Seven patients with totally occluded coronary artery bypass vein grafts underwent percutaneous transluminal angioplasty. All patients had either acute or recent occlusion of the graft itself. In 2 patients the proximal and in 3 the distal anastomosis were also narrowed. The vein graft was successfully dilated in all the patients. Six patients also received direct intragraft thrombolytic therapy during the procedure. Five uncomplicated patients improved clinically. One patient was studied routinely as part of a myocardial infarction-streptokinase protocol and had no symptoms. This patient had a no-reflow phenomenon. One patient did not receive intragraft thrombolytic therapy and the procedure was complicated by embolization with myocardial infarction and a cerebral embolus. In 2 patients, a routine angiogram was performed two to six months after graft dilatation and in both the grafts were patent. Another patient, initially successfully dilated, had recurrent angina and restenosis of the proximal anastomosis ten months after angioplasty; this was successfully redilated. Angioplasty of acutely or recently totally occluded coronary vein grafts is feasible and improves angina when present. Additional thrombolytic therapy prevents embolization.

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. >

Patients with multivessel coronary artery disease are candidates for either angioplasty and stenting or coronary artery bypass grafting. A prospective randomized study designed to compare the both methods included only a minority of the eligible patients.To compare coronary artery bypass grafting to angioplasty plus stenting in patients with multivessel disease who declined randomization to a multicenter study (the ARTS).During 1997-98 we prospectively followed 96 consecutive patients who were eligible according to the ARTS criteria but refused randomization. Of these patients, 50 underwent angioplasty + stenting and 46 underwent coronary bypass surgery. We compared the incidence of major adverse cardiac and cerebral events, chest pain recurrence, quality of life and procedural cost during the first 6 months.All procedures were completed successfully without mortality or cerebral events. The rate of Q-wave myocardial infarction was 2% in the AS group vs. 0% in the CABG group (not significant). Minor complications occurred in 7 patients (14%) in the AS group and in 21 patients (45%) in the CABG group (P0.01). At 6 months follow-up the incidence of major cardiac and cerebral events was similar in both groups (11% and 4% in the AS and CABG groups respectively, P = NS). Seventeen patients (36%) in the AS group required repeat revascularization compared to only 3 (7%) in the CABG group (P = 0.002). Nevertheless, quality of life was better, hospitalization was shorter and the cost was lower during the first 6 months after angioplasty.Angioplasty with stenting compared to coronary bypass surgery in patients with multivessel disease resulted in similar short-term major complications. However, 36% of patients undergoing angioplasty may need further revascularization procedures during the first 6 months.

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.