Multivessel Coronary Artery Disease Patients Research Articles

In brief

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

A Clinical and Angiographic Study of the XIENCE V Everolimus-Eluting Coronary Stent System in the Treatment of Patients With Multivessel Coronary Artery Disease: The EXECUTIVE Trial (EXecutive RCT: Evaluating XIENCE V in a Multi Vessel Disease)

This study sought to investigate the efficacy and performance of the XIENCE V everolimus-eluting stent (EES) (Abbott Vascular, Santa Clara, California) in the treatment of de novo coronary lesions in patients with 2- to 3-vessel multivessel coronary artery disease (MV-CAD). Drug-eluting stents (DES) have emerged as an alternative to conventional coronary artery bypass surgery in patients with MV-CAD although first-generation DES yielded inferior efficacy and safety compared with surgery. Prospective, randomized (1:1), multicenter feasibility trial was designed to assess angiographic efficacy of EES compared with the TAXUS paclitaxel-eluting stent (PES) in 200 patients, and a prospective, open-label, single-arm, controlled registry was designed to analyze the clinical outcome of EES at 1-year follow-up in 400 MV-CAD patients. For the randomized trial, the primary endpoint was in-stent late loss at 9 months. For the registry, the primary endpoint was a composite of all-cause death, myocardial infarction, and ischemia-driven target vessel revascularization at 12 months. The primary endpoint per single lesion was significantly lower in the EES group compared with the PES group (-0.03 ± 0.49 mm vs. 0.23 ± 0.51 mm, p = 0.001). Similar results were observed when analyzing all lesions (0.05 ± 0.51 mm vs. 0.24 ± 0.50 mm, p < 0.001). Clinical outcome at 1 year yielded a composite of major adverse cardiac events of 9.2% in the single-arm registry, and 11.1% and 16.5% in the EES and PES randomized groups, respectively (p = 0.30). The EXECUTIVE trial was a randomized pilot trial dedicated to the comparison of the efficacy of 2 different DES among patients with 2- to 3-vessel MV-CAD. The study shows lower in-stent late loss at 9 months with the EES XIENCE V compared with the PES TAXUS Libertè, and a low major adverse cardiac event rate at 1 year in patients with 2-to 3-vessel MV-CAD. (EXECUTIVE [EXecutive RCT: Evaluating XIENCE V in a Multi Vessel Disease]; NCT00531011).

Impact of diabetes on 10-year outcomes of patients with multivessel coronary artery disease in the Medicine, Angioplasty, or Surgery Study II (MASS II) trial

Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population. It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality. Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes (P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively (P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively (P = .031).Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT (P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively (P = .005 for CABG vs MT). Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with non-diabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.

Prognostic Impact of Left Main Coronary Artery Revascularization in Multivessel Coronary Artery Disease

The proliferation of our understanding for LMCA stenosis and the evolution of contemporary bypass surgery and stent-assisted percutaneous coronary intervention (PCI) have led to substantial clinical uncertainty regarding the prognostic impact of LMCA revascularization. We evaluated whether the left main coronary artery (LMCA) revascularization is associated with the incremental risk of adverse clinical outcomes in multivessel coronary artery disease patients.

Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction

There are evidence-based guidelines for staging of patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), but we are not aware of any evidence comparing the strategy of complete revascularization (CR) with PCI in the index admission versus the strategy of staging in a subsequent admission for patients with coronary artery disease without STEMI. PCI patients without STEMI undergoing PCI in New York between 2007 and 2009 were separated into 2 groups: those with acute coronary syndrome but no STEMI, and those without acute coronary syndrome. For each group, patients who underwent CR in the index admission were then propensity matched to patients staged within 60 days to obtain CR based on 17 patient risk factors related to longer-term mortality, and 3-year mortality rates were compared for the propensity-matched groups. Outcomes were also compared for preselected subgroups. For propensity-matched patients without acute coronary syndrome, the all-cause mortality rates at 3 years for patients who underwent CR in the index hospitalization and patients staged for CR within 60 days of discharge were 5.62% and 5.97%, P=0.93, respectively. For propensity-matched patients with acute coronary syndrome but without STEMI, the all-cause mortality rates at 3 years for patients who underwent CR in the index hospitalization and patients staged for CR within 60 days of discharge were 6.59% and 5.92%, P=0.41, respectively. Patients with coronary artery disease without STEMI do not have significantly lower 3-year mortality rates with staged PCI than when they undergo CR in the index admission.

Higher incidence of death in multi-vessel coronary artery disease patients associated with polymorphisms in chromosome 9p21

BackgroundWe investigated whether 9p21 polymorphisms are associated with cardiovascular events in a group of 611 patients enrolled in the Medical, Angioplasty or Surgery Study II (MASS II), a randomized trial comparing treatments for patients with coronary artery disease (CAD) and preserved left ventricular function.MethodsThe participants of the MASS II were genotyped for 9p21 polymorphisms (rs10757274, rs2383206, rs10757278 and rs1333049). Survival curves were calculated with the Kaplan–Meier method and compared with the log-rank statistic. We assessed the relationship between baseline variables and the composite end-point of death, death from cardiac causes and myocardial infarction using a Cox proportional hazards survival model.ResultsWe observed significant differences between patients within each polymorphism genotype group for baseline characteristics. The frequency of diabetes was lower in patients carrying GG genotype for rs10757274, rs2383206 and rs10757278 (29.4%, 32.8%, 32.0%) compared to patients carrying AA or AG genotypes (49.1% and 39.2%, p = 0.01; 52.4% and 40.1%, p = 0.01; 47.8% and 37.9%, p = 0.04; respectively).Significant differences in genotype frequencies between double and triple vessel disease patients were observed for the rs10757274, rs10757278 and rs1333049. Finally, there was a higher incidence of overall mortality in patients with the GG genotype for rs2383206 compared to patients with AA and AG genotypes (19.5%, 11.9%, 11.0%, respectively; p = 0.04). Moreover, the rs2383206 was still significantly associated with a 1.75-fold increased risk of overall mortality (p = 0.02) even after adjustment of a Cox multivariate model for age, previous myocardial infarction, diabetes, smoking and type of coronary anatomy.ConclusionsOur data are in accordance to previous evidence that chromosome 9p21 genetic variation may constitute a genetic modulator in the cardiovascular system in different scenarios. In patients with established CAD, we observed an association between the rs2383206 and higher incidence of overall mortality and death from cardiac causes in patients with multi-vessel CAD.

Benefit of Complete Revascularization in Patients With Multivessel Coronary Disease in the Drug-Eluting Stent Era

The benefit of complete (CR) vs. incomplete revascularization (IR) with drug-eluting stent (DES), unlike with bypass grafting, is not well established in patients with multivessel coronary artery disease (MVD). Consecutive patients from a single center DES registry who were newly diagnosed as having MVD and who underwent successful percutaneous coronary intervention between March 2003 and December 2009 were traced for the occurrence of death, myocardial infarction (MI), and repeat revascularization. Among 845 patients (337 with CR and 508 with IR), propensity score-matched 275 pairs were followed for a median of 3.9 years. The adjusted hazard ratio (HR) of CR [95% confidence interval] was 0.66 [0.34-1.28] for death; 0.51 [0.28-0.95] for death and MI; 0.84 [0.60-1.19] for death, MI, and repeat revascularization. The observed benefit of CR was also cardiac-specific. The adjusted HR of CR for cardiac death and MI was 0.39 [0.16-0.96]. In 3 subgroups of patients with diabetes (n=191), ejection fraction <55% (n=153) and estimated glomerular filtration rate (eGFR) <60 ml/min (n=170), the benefit of CR was pronounced with the adjusted HR for cardiac death and MI of 0.27 [0.08-0.93], 0.18 [0.05-0.68] and 0.27 [0.07-0.99], respectively. In MVD patients treated with DES, CR was associated with the long-term benefit in reducing any or cardiac death and MI. The main beneficiaries of CR were those with diabetes, low ejection fraction and low eGFR.

Comprehensive visualization of multimodal cardiac imaging data for assessment of coronary artery disease: first clinical results of the SMARTVis tool

In clinical practice, both coronary anatomy and myocardial perfusion information are needed to assess coronary artery disease (CAD). The extent and severity of coronary stenoses can be determined using computed tomography coronary angiography (CTCA); the presence and amount of ischemia can be identified using myocardial perfusion imaging, such as perfusion magnetic resonance imaging (PMR). To determine which specific stenosis is associated with which ischemic region, experts use assumptions on coronary perfusion territories. Due to the high variability between patient's coronary artery anatomies, as well as the uncertain relation between perfusion territories and supplying coronary arteries, patient-specific systems are needed. We present a patient-specific visualization system, called Synchronized Multimodal heART Visualization (SMARTVis), for relating coronary stenoses and perfusion deficits derived from CTCA and PMR, respectively. The system consists of the following comprehensive components: (1) two or three-dimensional fusion of anatomical and functional information, (2) automatic detection and ranking of coronary stenoses, (3) estimation of patient-specific coronary perfusion territories. The potential benefits of the SMARTVis tool in assessing CAD were investigated through a case-study evaluation (conventional vs. SMARTVis tool): two experts analyzed four cases of patients with suspected multivessel coronary artery disease. When using the SMARTVis tool, a more reliable estimation of the relation between perfusion deficits and stenoses led to a more accurate diagnosis, as well as a better interobserver diagnosis agreement. The SMARTVis comprehensive visualization system can be effectively used to assess disease status in multivessel CAD patients, offering valuable new options for the diagnosis and management of these patients.

FFR-Guided Percutaneous Intervention in Multivessel Coronary Artery Disease: A Real Game Changer

Introduction: The use of physiologically guided percutaneous coronary intervention (PCI) has been demonstrated to be superior to traditional angiographically guided intervention for both clinical outcomes and economic impact based on the data of the FAME study (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) [1]. The 1-year outcome of using fractional flow reserve (FFR) to guide coronary intervention in multivessel coronary artery disease (CAD) patients demonstrated reduced end points of myocardial infarction (MI) both early and late as well as the combined end point of death/ MI. Further examination of the FAME data set over 2 years continues to demonstrate significant clinical impact for the routine measurement of FFR in this setting [2]. Fearon et al. now report the economic impact of routine measurement of FFR in patients undergoing multivessel PCI. These findings have important implications for the future practice of coronary intervention. Aims: The aim of this study was to evaluate the economic impact of routine measurement of FFR in patients undergoing multivessel PCI.

Elevated resistin opposed to adiponectin or angiogenin plasma levels as a strong, independent predictive factor for the occurrence of major adverse cardiac and cerebrovascular events in patients with stable multivessel coronary artery disease over 1-year follow-up

SummaryBackgroundAdipokines such as adiponectin and resistin, as well as angiogenin, may be associated with inflammation and atherosclerosis. The relationship between their levels and prognosis in high risk patients is, however, still unclear. The aim of this study was to evaluate the prognostic value of these adipokines in patients with stable multivessel coronary artery disease (MCAD).Material/MethodsThe study group comprised 107 MCAD patients (74% males, mean age 63±8 years). Adiponectin, resistin and angiogenin plasma levels were measured at admission and after 1-year follow-up. Primary end point (major adverse cardiac and cerebrovascular events – MACCE) was defined as cardiac death, nonfatal myocardial infarction, stroke, and hospitalization for angina or heart failure over a 1-year period.ResultsAfter 1-year follow-up, 9 (8%) patients died, all from cardiovascular causes. Primary end point was experienced by 32% of patients. Surgical treatment (CABG) was received by 51% of patients, while 49% were treated medically alone. Total cholesterol concentration levels ≥173 mg/dl were associated with a 7-fold increase (OR 7.3; 95% CI, 1.6–33.0); LDL ≥93.5 mg/dl with a 16-fold increase (OR 16.3; 95% CI, 2.8–93.8), and resistin ≥17.265 ng/ml with a 13-fold increase in MACCE risk (OR 13.5; 95% CI, 2.3–80.3). In multivariate analysis, a medical treatment strategy (p=0.001), a higher CCS class (p=0.004), resistin levels (p=0.003) and a higher Gensini score (p=0.03) were independent predictors of MACCE.ConclusionsIn stable patients with MCAD, elevated plasma resistin (as opposed to adiponectin or angiogenin) is a strong, independent predictive factor for the occurrence of MACCE over 1-year follow-up.

Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial

To examine the incidence of and propensity for non-culprit interventions performed at the time of the primary percutaneous coronary intervention (PCI) and its association with 90-day outcomes. We examined the incidence, propensity for, and associated 90-day outcomes following non-culprit interventions performed at the time of primary PCI among ST-elevation myocardial infarction patients with multi-vessel coronary artery disease (MVD). Of the 5373 patients who underwent primary PCI in the APEX-AMI trial, 2201 had MVD. Of those, 217 (9.9%) underwent non-infarct-related arteries (IRA) PCI, whereas 1984 (90.1%) underwent PCI of the IRA alone. Ninety-day death and death/CHF/shock were higher in the non-IRA group compared with the IRA-only PCI group (12.5 vs. 5.6%, P (log-rank) < 0.001 and 17.4 vs. 12.0%, P (log-rank) = 0.020, respectively). After adjusting for patient and procedural characteristics as well as propensity for performing non-IRA PCI, this procedure remained independently associated with an increased hazard of 90-day mortality [adjusted hazard ratio 2.44, 95% CI (1.55-3.83), P < 0.001]. Non-culprit coronary interventions were performed at the time of primary PCI in 10% of MVD patients and were significantly associated with increased mortality. Our data support current guideline recommendations discouraging the performance of such procedures in stable primary PCI patients. Prospective randomized study of this issue may be warranted.

Impact of multivessel coronary artery disease on early ischemic injury, late clinical outcome, and remodeling in patients with acute myocardial infarction treated by primary coronary angioplasty

The mechanism through which multivessel coronary artery disease (MVD) adversely affects the outcome of patients with ST-elevation myocardial infarction (STEMI) is poorly characterized. We assessed whether the impact of MVD on outcome of STEMI patients is because of ischemic damage after primary percutaneous coronary intervention (PPCI) or to late ischemic events. From August 2005 to 2007, 288 STEMI patients treated by (bare metal) stent-PPCI were prospectively enrolled. The ischemic injury early after PPCI (evaluated by multiparametric approach) and the incidence of late adverse cardiovascular events were compared between the two groups. Compared with single vessel coronary artery disease, MVD patients (n=134) were older, with higher prevalence of diabetes, prior MI, anterior MI and higher collateral score. Myocardial perfusion as assessed by myocardial blush and SigmaST-segment resolution was similar in the two groups as well as the infarct size and microvascular obstruction as assessed by Troponin I and by the delayed enhancement of cardiac magnetic resonance. At clinical (98% complete) and echocardiogaphic (94% complete) follow-up (median 32 months) MVD patients showed a higher incidence of re-MI (6.1 vs. 1.3%), and urgent revascularization (8.3 vs. 2.7%) and worse left ventricular remodeling than single vessel disease patients. At propensity adjusted analysis MVD was an independent predictor of re-MI (odds ratio: 5.7) and ventricular remodeling (odds ratio: 2.2). The impact of MVD on clinical outcome and remodeling of STEMI patients is not because of the extent of ischemic damage observed after PPCI, but to recurrent ischemic events during follow-up.

Hypoxia regulates resistin in vascular smooth muscle cells, what next?

Hypoxia regulates resistin in vascular smooth muscle cells, what next?

Complete versus incomplete revascularization in patients with multivessel disease undergoing percutaneous coronary intervention with drug‐eluting stents

To investigate the long-term prognostic implications of complete versus incomplete revascularization in multivessel coronary artery disease (MVD) patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). Coronary artery bypass grafting (CABG) in patients with MVD provides better outcomes when complete revascularization is achieved. There is a paucity of data on the outcomes of complete versus incomplete revascularization of MVD patients undergoing PCI, and currently there is no data available with DES. Patients with MVD undergoing PCI with DES (sirolimus- or paclitaxel-eluting stent) were included. Comparisons of long-term outcomes between completely versus incompletely revascularized patients were made. The primary outcome measure was the composite of cardiac death, nonfatal myocardial infarction (MI), or any revascularization. Secondary endpoints were the components of the composite endpoint. A total of 508 patients were considered for this analysis: 212 (41.7%) and 296 (58.3%) had complete and incomplete revascularization, respectively. The median follow-up was 27.0 (interquartile range: 23.0-37.1) months. After adjusting for baseline characteristics, the hazard ratio (HR, 95% confidence interval) for complete revascularization was 0.43 (0.29-0.63, P < 0.0001) for the primary composite endpoint. Complete revascularization was associated with better outcomes for components of the composite endpoint: 0.37 (0.15-0.92, P = 0.03) for cardiac death, 0.34 (0.16-0.75 P = 0.008) for the composite of cardiac death or MI and 0.45 (0.29-0.69, P = 0.0003) for any repeat revascularization. This association was confirmed in a propensity-matched population. Complete revascularization with DES of MVD patients is associated with lower rates of long-term adverse events.

Outcome of Off-Pump Coronary Artery Bypass in Renal Dialysis Patients

Renal dialysis patients are a subgroup at major operative risk when undergoing coronary artery bypass grafting (CABG). Even though CABG without cardiopulmonary bypass (CPB) has decreased the surgical risk and provided good short-term results, the long-term survival seems uncertain. We report here on the long-term outcome of CABG without CPB in renal dialysis patients. From 1998 to 2002, 44 renal dialysis patients underwent elective CABG without CPB, including 17 minimally invasive direct coronary artery bypass (MIDCAB) and 27 off-pump CABG (OPCAB) procedures. There were 5 one-vessel, 12 two-vessel and 27 multi-vessel coronary artery disease patients, who mainly had left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) grafting with an additional saphenous vein graft to non-LAD coronaries. All 44 patients were followed up for 44.4 +/- 31.2 months. Three (6.8 %) surgical deaths within 30 days occurred and 25 late mortalities happened over a period of 2 - 79 months. The 5-year cumulative rate of total survival is 38.2 % and the freedom from cardiac death is 70.9 %. Using hazard analysis, old age (> 60 years) and incomplete coronary revascularization was found to significantly affect the total survival. CABG without CPB provided an acceptable surgical mortality and morbidity. The high incidence of non-cardiac death associated with dialysis complications had an adverse impact on the overall outcome. The LITA bypass operation method combined with intensive care for dialysis complications would hopefully fulfill the goal to improve the short- and long-term results in this subgroup.

Off-pump coronary artery surgery is the future of coronary bypass surgery?

Objective: In the last few years, off-pump coronary artery bypass grafting (OPCAB) has gained widespread diffusion and being increasingly reported to show better outcomes compared with conventional on pump coronary artery bypass surgery, despite the lack of sufficient evidence from randomized trials. We examined our early experience with this technique mainly in high risk, elderly and multivessel coronary artery disease patients.

Hybrid Coronary Artery Revascularization: Logistics and Program Development

Planning hybrid coronary artery revascularization--a combination of cardiac surgery with percutaneous procedures--requires, at first sight, a very complex logistical setup. Technical and equipment related details should be defined as early as possible in order to have time for training of all OR personnel involved. The most challenging aspect in OR-located hybrid coronary revascularization remains a very close cooperation of cardiac surgeons and interventional cardiologists. This teamwork does include indication findings and subsequent referral of multivessel coronary artery disease patients to hybrid procedures, as well as high individual flexibility of interventionalists and surgeons. The major prerequisite for this cooperation is a mutual acceptance of different revascularization approaches and the intent to combine their most striking advantages. Intraoperative graft angiography during coronary artery bypass grafting (CABG) procedures is one important step toward simultaneous hybrid coronary revascularization procedures. We describe our experience with on table angiography using a mobile C-arm for intraoperative imaging. This fluoroscopy system can in selected cases be used for simultaneous hybrid procedures.

Angiographic Characteristics of Renal Arterial Disease over the Spectrum of Coronary Artery Disease

Background/Aim: The angiographic characteristics of renal artery stenoses (RAS) in patients with coronary artery disease (CAD) have not been yet fully investigated. We sought to evaluate the angiographic characteristics of RAS in patients with CAD. Methods: The medical records of consecutive patients who underwentcoronary angiography in a single public institution over a 12-month period were evaluated. The patients who underwent coincident diagnostic renal angiography to evaluate renal vessels on the basis of clinical criteria and who had at least one-vessel CAD were analyzed. Moderate (50–70%) to severe (70–100%) arterial stenoses were noted as significant angiographic findings. The types of stenosis (ostial, true renal, mixed) and presence and location of calcium were recorded. Results: Angiographically significant RAS were reported in 40 (19.5%) of 205 consecutive patients (mean age 67.1 ± 12.8 years, mean serum creatinine concentration 2.1 ± 0.5 mg/dl, mean glomerular filtration rate 52 ± 13 ml/min) for a total of 55 lesions. The RAS severity was moderate in 30.9% (17/55), severe in 69.1% (38/55), ostial in 27.2% (15/55), true renal in 10.9% (6/55), and mixed in 61.8% (34/55) of the patients. The mean lesion length was 16 ± 1.8 mm. Patients with ≧3-vessel CAD had a statistically significantly higher prevalence of mixed calcified RAS (18/24, 75%). Logistic regression analyses revealed ≧3-vessel CAD (odds ratio 9.917, p = 0.002), age >65 years (odds ratio 3.817, p = 0.036), and ≧3 risk factors (odds ratio 2.8, p = 0.048) as independent predictors of RAS. Conclusion: RAS in multivessel CAD patients seems to have a peculiar angiographic pattern, such as a higher prevalence of mixed calcified lesions and poststenotic enlargement, that should be taken in account when dealing with RAS.

Incidence of balanced ischemia in patients with dipyridamole perfusion imaging

Background: Exercise and pharmacological myocardial perfusion imaging (MPI) are reliable techniques for the detection of coronary artery disease (CAD). One theoretical problem with dipyridamole however, is balanced ischemia, which may result in falsely normal perfusion images in patients with multi-vessel disease. Purpose: to evaluate the incidence of multi-vessel CAD in patients with normal dipyridamole MPI. Methods: This was a retrospective analysis of patients who had dipyridamole sestamibi stress testing followed by cardiac catheterization within six months. Coronary stenoses were considered significant if ≥ 60% of the mean luminal diameter. Patients with coronary artery bypass and acute myocardial infarction were excluded. In addition, a group of 94 patients with a low likelihood of CAD were selected to estimate the normalcy rate of the test. Results: A total of 6597 dipyridamole stress tests were performed from July 1995 to June 2002 and 480 patients had a catheterization. Of those patients, 78 (1.2% of total) had normal MPI. These patients had been catheterized due to the high clinical suspicion of CAD. Catheterization revealed 49 normal and 29 abnormal studies. Of the 402 patients with abnormal MPI, catheterization showed 95 normal and 307 abnormal studies. Sensitivity was 91.4% with a normalcy rate of 83%. The extent of CAD is shown in the table. Extent of Coronary Artery Disease # Diseased Vessels Nml MPI, Abn Cath Abn MPI, Abn Cath 1 16 (55%) 92 (30%) 2 9 (31%) 106 (35%) 3 4 (14%) 109 (36%) Conclusions: Patients are rarely referred for catheterization with normal dipyridamole MPI. If those patients receiving catheterization most had normal coronary arteries (63%). Those with falsely normal imaging rarely had three-vessel disease (14%) and thus were not likely related to balanced ischemia.

Effects of coronary artery bypass surgery on diastolic and systolic parameters of left ventricle in Type II diabetic patients

Diabetes mellitus itself can cause systolic and diastolic dysfunctions of the left ventricle in the absence of atherosclerotic coronary artery disease. Effects of coronary bypass surgery on the left ventricular functions of Type II diabetic patients having atherosclerotic coronary artery disease were investigated. Forty-eight Type II diabetic and 63 nondiabetic multivessel coronary artery disease patients who had no differences in age, sex, drugs used, number of revascularized arteries and aortic cross-clamp time were included in the study. Doppler echocardiographic examinations before and 6 months after operations were made, and early diastolic flow ( E), atrial contraction ( A), deceleration (DT) and isovolumetric relaxation time (IVRT), E/ A ratio and systolic parameters like end-diastolic volume, end-systolic volume, stroke volume and left ventricular ejection fraction (LVEF) were measured in sequence. Preoperative and postoperative echocardiographic measurements were compared in the same group and between groups by paired t and Student's t tests, respectively. P<.05 was accepted as statistically significant. E, A, E/ A, DT, IVRT and LVEF were significantly improved after coronary bypass surgery in Groups I ( P<.001, P<.01, P<.001, P<.01, P<.0001, P<.01) and II ( P<.05, P<.05, P<.001, P<.001, P<.001, P<.001). Statistical comparison of values between groups showed better recovery in diastolic and systolic functions of diabetic and nondiabetic patients, respectively. It was concluded that Type II diabetic coronary patients by time could gain as much as the same benefit from coronary bypass surgery that nondiabetic patients had.