Coronary Disease Patients Research Articles

Large artery stiffness: implications for exercise capacity and cardiovascular risk.

1. Large artery stiffness, or its inverse, compliance, determines pulse pressure, which, in turn, influences myocardial work capacity and coronary perfusion, both of which impact on exercise capacity and cardiovascular risk. 2. In support of a role for arterial properties in exercise performance, aerobically trained athletes (aged 30-59 years) have lower arterial stiffness than their sedentary counterparts. Furthermore, in healthy older subjects (aged 57-80 years), time to exhaustion on treadmill testing correlated positively with arterial compliance. 3. Arterial stiffness is more closely linked to exercise capacity and myocardial risk in patients with coronary disease where, independently of degree of coronary disease, those with stiffer proximal arteries have a lower exercise-induced ischaemic threshold. 4. Moderate aerobic training elevates resting arterial compliance by approximately 30%, independently of mean pressure reduction, in young healthy individuals but not in isolated systolic hypertensive patients. Rat training studies support a role for exercise training in structural remodelling of the large arteries. 5. High-resistance strength training is associated with stiffer large arteries and higher pulse pressure than matched controls. 6. Large artery stiffness is an important modulator of the myocardial blood supply and demand equation, with significant ramifications for athletic performance and ischaemic threshold in coronary disease patients. Moderate aerobic training, but not high-resistance strength training, reduces large artery stiffness in young individuals whereas older subjects with established isolated systolic hypertension are resistant to such adaptation.

Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the arterial revascularization therapy study (ARTS) trial

Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the arterial revascularization therapy study (ARTS) trial

Psychiatric morbidity and the presence and absence of angiographic coronary disease in patients with chest pain.

To assess psychiatric morbidity in coronary angiogram patients. A psychiatric assessment of 200 consecutive chest-pain patients was performed the day before coronary angiography in a double-blind study design. The sample included 132 men (mean age 57.2 years, SD 9.5) and 68 women (mean age 59.8 years, SD 8.9). A Structured Clinical Interview for DSM-III-R was used to obtain psychiatric diagnosis. The 21-item Beck Depression Inventory, the 20-item Toronto Alexithymia Scale and a four-item Life Satisfaction Scale were used to assess mental symptoms. A coronary angiography with obstruction of a coronary artery by more than 50% was considered to indicate angiographic coronary disease. Mental disorders were found in 28% (95% CI 14-41) of the patients with normal angiographic findings (n=47) and in 24% (95% CI 17 - 30) of the patients with angiographic coronary disease (n=153). Furthermore, no difference was found between these two groups in other rating scales assessing mental symptoms even when adjusted for the New York Heart Association class, duration of chest-pain symptoms or exercise capacity. Psychiatric morbidity may not be associated with angiographic findings in patients with chest pain.

Psychiatric morbidity and the presence and absence of angiographic coronary disease in patients with chest pain

Objective: To assess psychiatric morbidity in coronary angiogram patients. Method: A psychiatric assessment of 200 consecutive chest‐pain patients was performed the day before coronary angiography in a double‐blind study design. The sample included 132 men (mean age 57.2 years, SD 9.5) and 68 women (mean age 59.8 years, SD 8.9). A Structured Clinical Interview for DSM‐III‐R was used to obtain psychiatric diagnosis. The 21‐item Beck Depression Inventory, the 20‐item Toronto Alexithymia Scale and a four‐item Life Satisfaction Scale were used to assess mental symptoms. A coronary angiography with obstruction of a coronary artery by more than 50% was considered to indicate angiographic coronary disease. Results: Mental disorders were found in 28% (95% CI 14–41) of the patients with normal angiographic findings (n=47) and in 24% (95% CI 17 – 30) of the patients with angiographic coronary disease (n=153). Furthermore, no difference was found between these two groups in other rating scales assessing mental symptoms even when adjusted for the New York Heart Association class, duration of chest‐pain symptoms or exercise capacity. Conclusion: Psychiatric morbidity may not be associated with angiographic findings in patients with chest pain.

Exploration of Syndrome Differentiation patterns in coronary heart disease patients during Peri-Operative stage of coronary artery bypass graft

Objective: To explore the patterns of Syndrome Differentiation (SD) of coronary heart disease (CHD) patients in peri-operative stage of coronary artery bypass graft (CABG).Methods: One week after operation, thirty-seven CHD patients, who received CABG of internal mammary artery or great saphena vein under conventional general anesthesia with low or middle temperature extracorporeal circulation were differentiated as various syndromes, with the pre- or post-operational EKG, color Doppler echocardiography were done during and after operation. The hemodynamic parameters were monitored.Results: In the CHD patients, 64.9% were differentiated as Qi-Yin deficiency, 67.6% were complicated with phlegm syndrome and 62.2% with blood stasis, suggesting that Qi-deficiency, phlegm and stasis are the basic pathogenetic factors in patients with CABG. Moreover, the peri-operative syndrome was correlated with the condition of coronary artery lesion, heart and lung functions before operation, and the extracorporeal circulation time during the operation.Conclusion: TCM SD conducting in peri-operative stage might be useful in exploring the patterns of syndrome alteration which provided a basis for preventing peri-operative complications and elevating success rate of operation.

Differences in presentation and 1 year outcomes in coronary artery disease (CAD) patients of South Asian vs European ethnicity treated in an outpatient cardiology practice Narendra Singh, Milan K. Gupta, Arsh K. Jain, Frank Halperin, David Borts. Rouge Valley Health System, Toronto, ON, Canada, William Osler Health Centre, Brampton, ON, Canada

Differences in presentation and 1 year outcomes in coronary artery disease (CAD) patients of South Asian vs European ethnicity treated in an outpatient cardiology practice Narendra Singh, Milan K. Gupta, Arsh K. Jain, Frank Halperin, David Borts. Rouge Valley Health System, Toronto, ON, Canada, William Osler Health Centre, Brampton, ON, Canada

Variación genética y enfermedad aterosclerótica periférica: estudio preliminar

Summary Objective . To define the association between specific genetic variations and peripheral atherosclerotic disease in young patients. Patients and methods . Prospective observational study. Three groups: 50 patients younger than 50 years with peripheral atherosclerotic disease in physical exploration, ankle/arm index and duplex scanning; 240 healthy volunteer control group; 181 coronary disease patients control group (both of them younger than 50 years). Genetic analysis of the gene polymorphisms in the next enzymes: angiotensin-converting, angiotensin type I and II receptor, an-giotensinogen, oxide nitric synthase and methylenetetrahydrofolate reductase enzymes, comparing their frequencies in peripheral atherosclerotic disease patients overall and by areas (lower extremities area; lower extremities + abdominal aorta area; lower extremities + abdominal aorta + carotid arteries area) with regard to control groups. Results . No statistically significant difference between healthy control group and peripheral atherosclerotic disease patients overall was observed. By areas a difference in angiotensinogen gene polymorphisms was found: in lower extremity + abdominal aorta + carotid arteries area TT genotype frequency is 66.6% vs 33.3% in healthy control group; p= 0.06). Statistically significant difference between peripheral atherosclerotic disease group vs coronary disease group with regard to angiotensin-converting enzyme gene polymorphism was found: overall (50% DD genotype in coronary patients vs 28% inperipheral atherosclerotic disease patients; p= 0.0063 OR 2.54; 95% IC= 1.28-5.00) and by areas (85.7% ID genotype in lower extremities + abdominal aorta area and 87.5% in lower extremities + abdominal aorta + carotid artery area vs 14.3% and 12.5% in coronary group, respectively; p Conclusions . This is a preliminary study with reduced number ofpatients. A possible genetic predetermination of the atherosclerotic disease initial point (coronary or peripheral arterial disease) is suggested.

Valor pronóstico del SPECT de perfusión miocárdica en pacientes coronarios con enfermedad multivaso y disfunción ventricular izquierda, comparando revascularizados y no revascularizados

We investigated the prognostic value of 99mTc-Tetrofosmin myocardial SPECT (99mTc-TF) in dysfunctional multivessel coronary disease patients who underwent revascularization (RV) or only medical treatment (MT). In 78 coronary patients with 2-3 diseased vessels and left ventricular ejection fraction (EF) <= 40% (24 10%), we have assessed the extension of the stress perfusion defect, and percent of reversibility (R) by quantification of stress-rest myocardial SPECT 99mTc-TF bull's eyes (2 days-protocol), lung/heart ratio (LH) calculated in the original stress SPECT images, and EF by equilibrium radionuclide ventriculography obtained at 24 h. A R value >= 8% was used to identify viable (V) patients. A total of 28 patients underwent RV and 50 only received MT. After a mean follow-up of 22.9 20 months (3-60), they were considered as coronary events (CE): cardiac death, non-fatal infarction and heart transplant. CE rate was 20.5% (16/78). No significant differences were found in the pre-revascularization study characteristics, except a significantly higher mean R value in RV (10.6 9.5%) than in MT patients (6.4 7.8%) p: 0.03, and the main difference was that RV patients showed less CE 2/28 (7%) than the MT group 14/50 (28%) p: 0.02. The CE rate was lower in V patients who underwent RV (6%) than in V patients with MT (45%) p: 0.03, but no significant difference was obtained in non-V patients between RV (7%) and MT (16%) groups. In viable patients, the corresponding survival curves (Kaplan-Meier) showed a CE-free survival at 5 years of 79% in patients RV and of 42% in MT patients, p: 0.03, without significant difference in non-V patients. Patients with viable myocardium by myocardial SPECT have a good prognosis after revascularization, and show higher risk of CE if they are only medically treated. Myocardial viability is an indispensable assessment in prognosis evaluation and, above all, in therapeutic decision making in dysfunctional multivessel coronary disease patients.

Coronary artery compliance is lower in coronary disease patients compared with cardiac transplant recipients

Coronary artery compliance is lower in coronary disease patients compared with cardiac transplant recipients

Implantable dual-chamber cardioverter-defibrillator-pacemaker

The fifth generation of implantable cardioverter-defibrillators offer enhanced modes of detection of atrial and ventricular arrhythmias, antitachycardia pacing and shocks, multiprogrammability, intracardiac electrogram storage, and all functions of antibradycardia dual-chamber pacing including rate responsiveness and mode switching. There is no consensus on the indications for dual-chamber pacemaker defibrillator systems. This review focuses on the four major options of newer devices that might benefit patients: 1) permanent dual-chamber pacing in ischemic coronary disease patients, 2) detection and management of atrial fibrillation or other atrial tachyarrhythmias, 3) some newer indications for pacing, and 4) the suppression of inappropriate interventions. On the basis of published data, newer indications for the dual-chamber systems, advantages and limitations, and future perspectives are discussed.

Beat-to-beat QT interval variability in coronary patients

Changes in ventricular repolarization have been described in patients after myocardial infarction, whereas data for coronary patients without prior myocardial infarction are lacking. This study was designed to evaluate ventricular repolarization in coronary patients with effort angina pectoris. Beat-to-beat QT interval variability (QTV) using 5-minute resting high-resolution ECG recordings was measured in 26 men (mean age 62.1 years) with effort angina pectoris and without prior myocardial infarction, and in 30 age-matched men without clinically evident coronary heart disease (controls). To evaluate the degree of coronary artery disease in coronary patients, coronary angiography was performed. Coronary patients displayed significantly higher values of QTV compared with the control patients (P<.001). Rate adaptation of QT interval correlated significantly with the degree of coronary artery disease in the study group patients (P<.05). The significant association between QTV and coronary heart disease suggests altered ventricular repolarization in coronary patients without prior myocardial infarction.

Gammagrafía miocárdica con doble isótopo (201Tl en reposo/99mTc-tetrofosmin en esfuerzo) en la detección de hipoperfusión reversible

The dual-isotope technique (rest 201Tl and stress 99mTc-sestamibi) is useful to assess myocardial perfusion in coronary disease patients. 99mTc-labeled tetrofosmin is a radiopharmaceutical whose characteristics are similar to sestamibi. Thus, we decided to use it to detect reversible myocardial hypoperfusion in patients with a background of myocardial infarction and ischemia. A sequential dual-isotope scintigraphy (3 mCi rest 201Tl and 25 mCi stress 99mTc-tetrofosmin) with 24-hour 201Tl redistribution (RD) was performed in 20 patients with previously confirmed myocardial infarction and clinical and ergometric signs of ischemia. Each patient also underwent a stress-redistribution protocol with redistribution at 4 and 24 hours post injection with 201Tl scintigraphy within two weeks of the first study. The qualitative uptake analysis showed no significant differences in the number of myocardial segments with severe reduction of tracer uptake on stress that improved at rest or in RD images, even if 24-hour RD images were considered. The quantitative global uptake analysis showed a similar defect reversibility with both protocols; however if 24-hour RD images were considered the uptake improvement was significant only when compared with the rest 201Tl images in dual-isotope scintigraphy protocol (75+/-8% vs. 81+/-9% of peak activity, rest vs. 24-hour RD; p<0.01) and not when compared with the 4-hour RD in the 201Tl scintigraphy. On the other hand, when only the segments with severely reduced uptake (<50% of peak activity) were analyzed, the 24-hour RD improved myocardial uptake significantly (p<0.001 vs. rest and vs 4-hour RD) in both protocols. We conclude that a sequential dual-isotope rest 201Tl/stress 99mTc-tetrofosmin scintigraphy is comparable with stress-redistribution 201Tl scintigraphy to detect reversible myocardial hypoperfusion; however in both cases, the addition of 24-hour images increases its usefulness in severely hypoperfused segments, if the uptake of the radiopharmaceutic is quantified.

Benefits of Raising HDL Levels

For many coronary-disease patients, a low HDL-cholesterol level is their primary lipid abnormality. However, the value of modifying HDL levels is not

One‐year outcome in multivessel coronary disease patients undergoing coronary stenting

The purpose of this study was to assess 1-year clinical outcome of patients with multivessel coronary artery disease (CAD) who underwent coronary stenting and were prospectively enrolled in the Registro Impianto Stent Endocoronarico (RISE). Of 939 consecutive patients included in the registry, 377 patients with angiographic evidence of multivessel CAD had a 1-year clinical follow-up. All patients underwent PTCA and single or multiple stenting in at least one vessel. Angiographic optimization was usually performed by using high-pressure balloon dilation. After the procedure, continuation of aspirin (at least 250 mg/day) was recommended, whereas the use of anticoagulation or ticlopidine was determined by the physician in charge of the patient in the various centers. Major adverse cardiac events were defined as death, Q-wave or non–Q-wave myocardial infarction and target vessel revascularization. Mean age of patients (311 men, 66 women) was 60 ± 10 years. Globally, there were 596 stents implanted (72% Palmaz-Schatz stents) in 434 vessels. In about 75% of the procedures, an inflation pressure > 12 atm was used. Angiographic success rate was 98.5%. After stenting, 77% of patients received antiplatelet treatment with ticlopidine and aspirin. During hospitalization, there were 34 major adverse cardiac events in 24 patients. At 1-year follow-up, 309 patients were alive and event-free; cumulative incidence of death, myocardial infarction, and repeat revascularization were 2.9%, 4.7%, and 10.8%, respectively. By Cox regression analysis, multiple stents implantation (HR 1.72, 95% CI 1–2.97), left anterior descending artery revascularization (HR 1.86, 95% CI 1.01–3.42), use of inflation pressure > 12 atm (HR 0.93, 95% CI 0.89–0.97), ticlopidine therapy (HR 0.41, 95% CI 0.23–0.74), and stent length (HR 1.03, 95% CI 1.01–1.05) were associated with 1-year major cardiac events. In patients with multivessel CAD undergoing stent implantation in at least one vessel, 1-year follow-up is favorable and the need for repeat revascularization procedures, based on clinical data, is lower than previously reported for conventional PTCA. Cathet. Cardiovasc. Intervent. 48:343–349, 1999. © 1999 Wiley-Liss, Inc.

One-year outcome in multivessel coronary disease patients undergoing coronary stenting.

The purpose of this study was to assess 1-year clinical outcome of patients with multivessel coronary artery disease (CAD) who underwent coronary stenting and were prospectively enrolled in the Registro Impianto Stent Endocoronarico (RISE). Of 939 consecutive patients included in the registry, 377 patients with angiographic evidence of multivessel CAD had a 1-year clinical follow-up. All patients underwent PTCA and single or multiple stenting in at least one vessel. Angiographic optimization was usually performed by using high-pressure balloon dilation. After the procedure, continuation of aspirin (at least 250 mg/day) was recommended, whereas the use of anticoagulation or ticlopidine was determined by the physician in charge of the patient in the various centers. Major adverse cardiac events were defined as death, Q-wave or non-Q-wave myocardial infarction and target vessel revascularization. Mean age of patients (311 men, 66 women) was 60 +/- 10 years. Globally, there were 596 stents implanted (72% Palmaz-Schatz stents) in 434 vessels. In about 75% of the procedures, an inflation pressure > 12 atm was used. Angiographic success rate was 98.5%. After stenting, 77% of patients received antiplatelet treatment with ticlopidine and aspirin. During hospitalization, there were 34 major adverse cardiac events in 24 patients. At 1-year follow-up, 309 patients were alive and event-free; cumulative incidence of death, myocardial infarction, and repeat revascularization were 2.9%, 4.7%, and 10.8%, respectively. By Cox regression analysis, multiple stents implantation (HR 1.72, 95% CI 1-2.97), left anterior descending artery revascularization (HR 1.86, 95% CI 1.01-3.42), use of inflation pressure > 12 atm (HR 0.93, 95% CI 0.89-0.97), ticlopidine therapy (HR 0.41, 95% CI 0.23-0.74), and stent length (HR 1.03, 95% CI 1.01-1.05) were associated with 1-year major cardiac events. In patients with multivessel CAD undergoing stent implantation in at least one vessel, 1-year follow-up is favorable and the need for repeat revascularization procedures, based on clinical data, is lower than previously reported for conventional PTCA. Cathet. Cardiovasc. Intervent. 48:343-349, 1999.

Cardiac Assessment with Thallium Scanning Prior to Aortic Aneurysm Repair

Coronary artery disease occurs commonly in patients with aortic aneurysms and is a major cause of morbidity and mortality. The role of screening and intervention for cardiac disease prior to aneurysm repair is controversial. The outcome after cardiac screening with thallium scanning and/or angiography in 102 consecutive patients undergoing aortic aneurysm repair was documented. Significant coronary artery disease was found in 34 (33%) patients and two patients had either coronary artery bypass or angioplasty prior to aneurysm repair. There was no cardiac mortality after aneurysm repair and the overall mortality on an intention-to-treat basis was 2%. There was good correlation between prior history of cardiac events, electrocardiography (ECG) and the results of screening with thallium scanning and angiography. There was no correlation between cardiac history. ECG and the incidence of cardiac events in the postoperative period. Significant coronary artery disease was found in 33% of patients without a cardiac history or abnormal ECG. Cardiac screening with thallium scanning confirmed a high incidence of significant coronary disease in patients with aortic aneurysm. In this study, cardiac intervention followed by expedient aneurysm repair in 20 patients was associated with zero mortality. The short-term benefit of such a policy is difficult to prove and its main advantage may be better long-term survival.

Cardiac assessment with thallium scanning prior to aortic aneurysm repair

Coronary artery disease occurs commonly in patients with aortic aneurysms and is a major cause of morbidity and mortality. The role of screening and intervention for cardiac disease prior to aneurysm repair is controversial. The outcome after cardiac screening with thallium scanning and/or angiography in 102 consecutive patients undergoing aortic aneurysm repair was documented. Significant coronary artery disease was found in 34 (33%) patients and two patients had either coronary artery bypass or angioplasty prior to aneurysm repair. There was no cardiac mortality after aneurysm repair and the overall mortality on an intention-to-treat basis was 2%. There was good correlation between prior history of cardiac events, electrocardiography (ECG) and the results of screening with thallium scanning and angiography. There was no correlation between cardiac history, ECG and the incidence of cardiac events in the postoperative period. Significant coronary artery disease was found in 33% of patients without a cardiac history or abnormal ECG. Cardiac screening with thallium scanning confirmed a high incidence of significant coronary disease in patients with aortic aneurysm. In this study, cardiac intervention followed by expedient aneurysm repair in 20 patients was associated with zero mortality. The short-term benefit of such a policy is difficult to prove and its main advantage may be better long-term survival.

α-Tocopherol Supplementation for Men with Existing Coronary Artery Disease: A Feasibility Study

Background. Recent studies have suggested that α-tocopherol supplementation can help reduce the incidence of coronary disease. Our objectives were to determine the feasibility of providing α-tocopherol supplements to male veterans with existing coronary artery disease and determine its effects on α-tocopherol levels and the susceptibility of low-density lipoprotein (LDL) to oxidation.Methods. Fifty-seven percent of 138 coronary disease patients were willing to participate in a placebo-controlled trial −25% were already taking antioxidants. Thirty-nine men were randomly assigned to either 400 mg/day of α-tocopherol (n = 27) or placebo (n = 12). α-Tocopherol levels and LDL oxidation (measured by formation of thiobarbituric acid-reactive substance) were measured at baseline and at 6 months.Results. Thirty-three subjects (22 α-tocopherol, 11 placebo) completed the study; 3 subjects withdrew after suffering coronary disease events. Supplement compliance exceeded 90% and α-tocopherol was well tolerated. The α-tocopherol group had a significantly greater mean increase in lipid-adjusted α-tocopherol levels (73% vs. −4.6%, P < 0.0001), but oxidized LDL did not change significantly.Conclusions. A secondary prevention trial among veterans would be feasible because the rates of enrollment, completion, compliance, and clinical events were high. α-Tocopherol supplements did not decrease the susceptibility of LDL to oxidation, suggesting that higher dosages or longer duration of supplementation may be required for secondary prevention.

Heart failure due to ischaemic heart disease: epidemiology, pathophysiology and progression.

Ischaemic heart disease is the most common underlying cause of heart failure in industrialised countries. Its manifestations are protean with myocardial infarction being only one important facet. The prognosis of patients with heart failure due to ischaemic heart disease also appears to be worse than that associated with many other aetiologies. The presence of ischaemic heart disease may influence both the efficacy and choice of treatment. Agents such as digoxin and amlodipine appear less effective in patients with ischaemic heart disease while ACE inhibitors and beta-blockers appear as or more effective in patients with ischaemic heart disease. Many have expressed an opinion about how coronary disease should be managed in the patient with heart failure supported by little or no evidence. There are major theoretical and practical concerns about the use of anti-coagulant, anti-platelet and statin therapy in patients with heart failure as well as major theoretical benefits. Only randomised controlled trials will resolve these issues. The same may be said of revascularisation. Fortunately trials addressing all these areas are under way. This should put the management of coronary disease in patients with heart failure on a firm evidence-based footing.

Cholesterol in peripheral vascular disease--a suitable case for treatment?

We assessed the prevalence of conventional risk factors for ischaemic heart disease in patients with peripheral vascular disease, and the scope for preventative treatment with lipid-lowering therapy in this group, by retrospectively reviewing 299 patients who had undergone peripheral angiography in 1996. A total of 278 patients had severe peripheral vascular disease; 44% were current smokers at the time of their angiogram, and 36% had a history of coronary artery disease (either myocardial infarction, coronary artery bypass surgery, coronary angioplasty or angina). Cholesterol had been measured in 80 (27%) patients, of whom 26 (9%) were receiving treatment for hypercholesterolaemia. Patients with a history of ischaemic heart disease were more likely to have had their cholesterol measured (50% vs. 15%; p < 0.001). Hypertension (defined as systolic > 160 mmHg or diastolic > 90 mmHg) was present in 44%. There was no difference in the distribution of risk factors between those with and those without known ischaemic heart disease. There is a high prevalence of modifiable risk factors for coronary disease in patients with severe peripheral vascular disease. Effective prevention is available for coronary artery disease, but we found low levels of treatment. There is considerable scope for intervention to reduce the risk of coronary disease in such patients.