New-onset Angina Research Articles

An audit of a specialist nurse-led rapid-access chest pain clinic

Objective: Rapid-access chest pain clinics, typically run by doctors, allow the rapid assessment of suspected new-onset angina. Five years ago specialist nurse-led rapid-access chest pain clinics were established at Royal Albert Edward Infirmary. The objective of this audit was to assess safety and effectiveness of these clinics. Method: Retrospective data were collected from all patients from January 2002 to December 2006. Results: GPs referred 1464 patients. Of those, 1349 (92.14%) patients were seen within the 14-day government target. The clinic had 1417 (96.8%) patients who under went exercise testing and 234 (16%) of these were positive. Of those patients 143 (61.8%) under went cardiac catheterization. Coronary artery disease was found in 110 patients. Eighty one patients under went revascularization and 29 patients were treated medically. Conclusions: This audit demonstrates that specialist nurse–led rapid -access chest pain clinics are safe and effective. They identify patients who are more likely to have coronary artery disease, therefore allowing early medical/surgical intervention and reducing patient morbidity and mortality. The burden on doctors is reduced and government targets are met.

Video-assisted thoracic surgical resection of giant cardiac lipoma: A case report

We describe the case of a 73-year-old man, with a history of previous coronary artery by-pass, who presented at our division for new onset of angina, hypotension and dyspnea due to a primary giant para-cardiac lipoma. The success of complete resection of the mass achieved by means of video-assisted thoracic surgical procedure demonstrated the efficacy and safeness of this method in the treatment of benign cardiac tumours.

Anomalous Left Main Coronary Artery From the Main Pulmonary Artery in an Elderly Patient

Anomalous origin of the left main coronary from the pulmonary trunk in an elderly patient is extremely rare. We report a 73-year-old woman who presented with new onset of angina and atrial fibrillation. Evaluation revealed anomalous origin of the left main coronary artery from the main pulmonary artery and tight proximal left anterior descending coronary artery stenosis. The patient underwent primary closure of the anomalous left main coronary artery orifice within the pulmonary artery, aorta-to-left anterior descending coronary artery saphenous vein bypass grafting and Maze procedure. Six months postoperatively the patient was asymptomatic and a Thallium stress test was negative for ischemia.

Rewards and opportunities in rapid-access chest-pain clinics

Rapid-access chest-pain clinics have existed in some areas for several years, but the introduction of the National Service Framework for Coronary Heart Disease (DH, 2000) made a ‘rapid-access’ approach to assessment and management of new-onset stable angina the gold standard. However, little has been written about the development of these clinics and there is little research evidence that they are a cost-effective approach to the organization of patient care. This paper offers an insight into the development of chest-pain clinics and describes one model of a nurse-led service.

The initial management of stable angina in Europe, from the Euro Heart Survey

In order to assess adherence to guidelines and international variability in management, the Euro Heart Survey of Newly Presenting Angina prospectively studied medical therapy, percutaneous coronary intervention (PCI), and surgery in patients with new-onset stable angina in Europe. Consecutive patients, 3779 in total, with a clinical diagnosis of stable angina by a cardiologist were enrolled. After initial assessment by a cardiologist, 78% were treated with aspirin, 48% with a statin, and 67% with a beta-blocker. ACE-inhibitors were prescribed by the cardiologist in 37% overall. Revascularization rates were low, with only 501 (13%) patients having PCI or coronary bypass surgery performed or planned. However, when restricted to patients with coronary disease documented within 4 weeks of assessment, over 50% had revascularization performed or planned. Among other factors, the national rate of angiography and availability of invasive facilities significantly predicted the likelihood of revascularization, OR 2.4 and 2.0, respectively. This survey shows a shortfall between guidelines and practice with regard to the use of evidence-based drug therapy and evidence that revascularization rates are strongly influenced by non-clinical, in addition to clinical, factors.

4P-0996 Probucol can reduce Cu(II) to Cu(I) but is not a prooxidant for partially oxidised low density lipoprotein

This study sought to assess the long-term predictive value and net reclassification for risk of cardiovascular disease (CVD) of biomarkers reflecting oxidation-specific epitopes (OSEs).OSEs are immunogenic, proinflammatory, and proatherogenic. The long-term predictive value and net reclassification of OSEs for risk of CVD events are not known.Oxidized phospholipids on apolipoprotein B-100 (OxPL/apoB) and immunoglobulin (Ig)-G (IgG) and IgM autoantibodies to malondialdehyde-modified, low-density lipoprotein (MDA-LDL) and copper-oxidized LDL (Cu-OxLDL) were measured in 765 subjects in 1995 and 656 subjects in 2000 in the Bruneck study, representing 45- to 84-year-old men and women from the general community.Over 15 years of follow-up, 138 subjects reached the primary endpoint of incident CVD (ischemic stroke, myocardial infarction, new-onset unstable angina, acute coronary interventions, and vascular death). In a multivariable Cox model, the highest tertile of OxPL/apoB was associated with higher risk of CVD (hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.5 to 3.7) and stroke (HR: 3.6; 95% CI: 1.8 to 7.4) compared with the lowest tertile. IgG Cu-OxLDLs were associated with higher risk of CVD, whereas IgM MDA-LDLs were associated with lower risk. Using OxPL/apoB, IgG Cu-OxLDL, and IgM MDA-LDL variables, the area under the curve (AUC) for CVD risk prediction increased from 0.664 (95% CI: 0.629 to 0.697) to 0.705 (95% CI: 0.672 to 0.737) (p = 0.048). The net reclassification index (NRI) was 0.163 (p = 0.0044) and 0.332 (p < 0.0001) in all subjects (n = 765) and in subjects with intermediate risk (n = 305), respectively. Of 627 subjects who remained free of CVD, 108 were correctly reclassified to a lower risk category, and 83 were reclassified to a higher category (categories: 15-year risk <15%, 15% to 30%, >30%).OSE biomarkers predict 15-year CVD and stroke outcomes and provide potential clinical utility by reclassifying a significant proportion of individuals into higher or lower risk categories after traditional risk assessment.

Toll-like receptor 4 polymorphisms and atherogenesis in humans

This study sought to assess the long-term predictive value and net reclassification for risk of cardiovascular disease (CVD) of biomarkers reflecting oxidation-specific epitopes (OSEs).OSEs are immunogenic, proinflammatory, and proatherogenic. The long-term predictive value and net reclassification of OSEs for risk of CVD events are not known.Oxidized phospholipids on apolipoprotein B-100 (OxPL/apoB) and immunoglobulin (Ig)-G (IgG) and IgM autoantibodies to malondialdehyde-modified, low-density lipoprotein (MDA-LDL) and copper-oxidized LDL (Cu-OxLDL) were measured in 765 subjects in 1995 and 656 subjects in 2000 in the Bruneck study, representing 45- to 84-year-old men and women from the general community.Over 15 years of follow-up, 138 subjects reached the primary endpoint of incident CVD (ischemic stroke, myocardial infarction, new-onset unstable angina, acute coronary interventions, and vascular death). In a multivariable Cox model, the highest tertile of OxPL/apoB was associated with higher risk of CVD (hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.5 to 3.7) and stroke (HR: 3.6; 95% CI: 1.8 to 7.4) compared with the lowest tertile. IgG Cu-OxLDLs were associated with higher risk of CVD, whereas IgM MDA-LDLs were associated with lower risk. Using OxPL/apoB, IgG Cu-OxLDL, and IgM MDA-LDL variables, the area under the curve (AUC) for CVD risk prediction increased from 0.664 (95% CI: 0.629 to 0.697) to 0.705 (95% CI: 0.672 to 0.737) (p = 0.048). The net reclassification index (NRI) was 0.163 (p = 0.0044) and 0.332 (p < 0.0001) in all subjects (n = 765) and in subjects with intermediate risk (n = 305), respectively. Of 627 subjects who remained free of CVD, 108 were correctly reclassified to a lower risk category, and 83 were reclassified to a higher category (categories: 15-year risk <15%, 15% to 30%, >30%).OSE biomarkers predict 15-year CVD and stroke outcomes and provide potential clinical utility by reclassifying a significant proportion of individuals into higher or lower risk categories after traditional risk assessment.

Changing profile of patients undergoing redo-coronary artery surgery

To outline the changes of the patient population undergoing redo-coronary artery bypass surgery (RECABG). Preoperative data of 582 first RECABGs, January 1987-June 2000 were analyzed. Group A: 1987-1991 (n=193); group B: 1992-1995 (n=201); and group C: 1996-June 2000 (n=188). These 582 RECABGs represent about 8.5% of the performed bypass surgeries during this period. Mean age (P=<0.001), percentage of patients with kidney disease (P=0.001), a preoperative PTCA (P<0.001) increased. Significant more elective operations (P<0.001) and lesser urgent operations (P=0.001) were performed in group C. There is a significant different distribution of vessel disease over the three periods (P=0.04). Significant more patients had a patent IMA graft (P<0.001). The angina-free period after CABG (P<0.001), the time period between both operations (P<0.001) and the period between the new onset of angina and the RECABG (P=0.012) increased significantly. Despite the importance of progression of atherosclerosis of any sort decrease significantly (P<0.001) over the whole study, there is a significant increase of patients reoperated for isolated progression of the disease in the native coronary arteries (P<0.001) in group C. The impact of late GF was not different for the total group (P=0.82), however, the percentage of RECABGs for isolated late GF increased significantly between group A and B (P<0.001) but there was a decrease from B to C, however, not significant (P=0.067). During the past few years there is a trend in RECABG of older patients, with more coexisting diseases. There are an increasing number of patients with patent arterial grafts, an increase of the event-free period after the CABG, the period between the CABG and RECABG and of the time period between the onset of new angina and the RECABG. Although the impact of atherosclerosis, as angiographic indication, decreased over the total group, there is the significant increase of the percentage of patients reoperated because of isolated progression of atherosclerosis in the native coronary arteries.

49-Year-Old Woman With Chest Pain

49-Year-Old Woman With Chest Pain

82-Year-Old Man With Recurrent Syncope

82-Year-Old Man With Recurrent Syncope

C-reactive protein as a marker for cardiac ischemic events in the year after a first, uncomplicated myocardial infarction

The prognostic role of C-reactive protein levels in patients with a first acute myocardial infarction, an uncomplicated in-hospital course, and the absence of residual ischemia on a predischarge ergometer test and with an echocardiographic ejection fraction ≥50% has not been described. C-reactive protein was determined during hospitalization in 64 patients (55 men, mean age 64.6 ± 10.4 years). The patients were followed up for 13 ± 4 months and the following cardiac events were recorded: cardiac death, new-onset angina pectoris, and recurrent myocardial infarction. Patients who developed cardiac events during the follow-up period had significantly higher C-reactive protein values than patients without events (3.61 ± 2.83 vs 1.48 ± 2.07 mg/dl, p <0.001). The probability of cumulative end points was: 6%, 12%, 31%, and 56% (p = 0.006; RR 3.55; confidence interval 1.56 to 8.04), respectively, in patients stratified by quartiles of C-reactive protein (<0.45, 0.45 to 0.93, 0.93 to 2.55 and >2.55 mg/dl). In the Cox regression model, only increased C-reactive protein levels were independently related to the incidence of subsequent cardiac events (chi-square 9.8, p = 0.001). Thus, increased C-reactive protein levels are associated with a worse outcome among patients with a first acute myocardial infarction, an uncomplicated in-hospital course without residual ischemia on the ergometer test, and with normal left ventricular function.

Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction.

Ischemic heart disease includes a wide spectrum of conditions, ranging from silent ischemia and exertion-induced angina, through unstable angina, to acute MI. Unstable angina occupies the center of this spectrum, causing disability and risk greater than that of chronic stable angina but less than that of acute MI1 (Fig 1⇓). Although non–Q-wave MI for many years was considered prognostically similar to unstable angina, recent longitudinal studies indicate that it is similar to Q-wave infarction2 3 (Fig 2⇓). Figure 1. Cumulative 6-month mortality from ischemic heart disease. Diagnosis on admission to hospital (n=21 761; 1985 to 1992). From Duke Cardiovascular Database. Reproduced with permission from Reference 1. Figure 2. Top, Cumulative 1-year combined death or MI among patients with Q-wave and non–Q-wave MI treated with fibrinolysis. Reproduced with permission from Reference 2. Bottom, Risk of subsequent cardiac events in stable convalescing patients after first non–Q-wave and Q-wave MI. Reproduced with permission from Reference 3. The concept of unstable angina has emerged from observations of frequent symptoms preceding acute MI, followed by prospective documentation that unstable symptoms frequently culminated in acute MI. The syndrome was rapidly accepted as a well-defined clinical entity as specific clinical manifestations, pathophysiological mechanisms, laboratory findings, and treatment became better characterized. Unstable angina is currently one of the leading causes of hospital admission for CAD, and non–Q-wave MI accounts for >30% of admissions for acute MI.1 4 Yet, the diagnosis of unstable angina remains clinical, based on symptom recognition. The physician caring for patients with unstable angina is in a privileged position of recognizing rapidly evolving CAD and being able to intervene to prevent irreversible left ventricular damage and progression of CAD. Unstable angina is classically described as a heterogeneous disease, referring to a wide spectrum of clinical manifestations from stable angina to MI, of disease …

New-onset angina preceding acute myocardial infarction is associated with improved contractile recovery after thrombolysis.

Ischaemic preconditioning reduces myocardial infarct size in animal models. Clinical data suggest that episodes of angina immediately before acute myocardial infarction may be associated with smaller infarct size in man. However, it is unclear whether ischaemic episodes preceding acute myocardial infarction also affect contractile recovery in patients. In this study we investigated the recovery of regional myocardial function after thrombolysis in two groups of patients at their first Q-wave acute myocardial infarction; in one group (n = 42) myocardial infarction occurred unheralded, whereas patients of the second group (n = 48) had experienced new-onset angina in the 48 h that preceded infarction. Echocardiographic analysis of myocardial regional function in the infarct area was done at 2, 24 and 72 h after thrombolysis, and at 1 week, and 1 and 3 months follow-up. Peak level of MB-creatine kinase was significantly lower in patients with new-onset angina (96 +/- 47 as compared with 221 +/- 108 IU.l-1, P < 0.01), as was the area under the MB-creatine kinase curve (1321 +/- 876 as compared to 3879 +/- 1555 U.l-1/36 h, P < 0.01). Hypokinetic segments were fewer in patients with pre-infarction angina. Similarly, wall motion score improved significantly earlier in patients who had new-onset angina before acute myocardial infarction. Thus, contractile recovery was more rapid in patients with previous angina than in those in whom infarction occurred unheralded. Complications during the in-hospital outcome and other variables considered during the 4-week follow-up were similar between groups. Patients who experienced new-onset angina before acute myocardial infarction showed better recovery of regional function after thrombolysis. Our study supports the hypothesis that brief periods of ischaemia immediately before myocardial infarction may precondition the human heart, thus improving contractile recovery.

Myocardial Ischemia in a Patient With Chronic Refractory Idiopathic Thrombocytopenic Purpura

The importance of platelets in the development of ischemic coronary syndromes has been documented in animal models. The use of antiplatelet agents in coronary artery disease is well established. Theoretically, qualitative and quantitative depression of platelet function should prevent the development of arterial occlusion. Myocardial ischemia occurring with chronic idiopathic thrombocytopenia has been rarely documented.1-3 We describe a patient with non—Q-wave myocardial infarction (MI) and chronic refractory idiopathic thrombocytopenic purpura (ITP). Report of a Case. A 52-year-old premenopausal woman presented to our institution with new-onset unstable angina. Her medical history included chronic refractory ITP diagnosed at age 39 years and treated by splenectomy, prednisone, danazol, and intermittent intravenous immunoglobulin. After age 39 years, our patient also suffered from diabetes mellitus, hypertension, and hepatitis C. She was a nonsmoker and not taking aspirin. Her blood pressure was 180/100 mm Hg, and pulse, 90 bpm. The results of a physical examination were

Effect of Chronic and Acute Thyroid Hormone Reduction on Perioperative Outcome

Effect of Chronic and Acute Thyroid Hormone Reduction on Perioperative Outcome

Moderate alcohol consumption and risk for angina pectoris or myocardial infarction in U.S. male physicians.

Although previous studies have found that moderate alcohol intake decreases the risk for myocardial infarction, many clinicians question the validity of this finding. Furthermore, the relation of moderate drinking to the risk for other events, such as angina pectoris, is not known. To determine whether moderate alcohol intake decreases the risk for angina pectoris or myocardial infarction in apparently healthy men. Prospective cohort study. United States. 22,071 apparently healthy male physicians who were 40 to 84 years of age between 1981 and 1984. Responses to annual questionnaires. Through 1994, 1368 cases of new-onset angina and 690 cases of myocardial infarction had been documented. In multivariate analyses that controlled for several potential confounders, alcohol intake was strongly and inversely associated with the risk for each event (P for trend < 0.001). Compared with men who consumed less than one drink per week, those who consumed one drink per day had relative risks of 0.69 (95% CI, 0.59 to 0.81) for angina and 0.65 (CI, 0.52 to 0.81) for myocardial infarction. These associations were seen when either nondrinkers or occasional drinkers were used as the reference group. Moderate drinking decreases the risk for angina pectoris and myocardial infarction in apparently healthy men.

Causes of coronary events after successful coronary angioplasty.

To determine the causes and incidence of coronary events after successful coronary angioplasty. We evaluated retrospectively follow-up angiograms of 60 patients with coronary events (27 with myocardial infarction, 33 with new-onset angina pectoris) from among 930 consecutive patients who underwent successful elective angioplasty between February 1985 and April 1994. Patients who had undergone percutaneous transluminal coronary angioplasty to bypass grafts were excluded. No fatal cardiac events occurred within 6 months of percutaneous transluminal angioplasty; 10 occurred thereafter. Fifteen patients who developed early (3.9 +/- 1.8 months) restenosis showed non-Q-wave infarction resulting from severe restenosis at the previously dilated site. In patients without early restenosis, cardiac events developed not from the previously dilated site, but from previously undilated, non-obstructive sites. Furthermore, it was found that the patency of the previously dilated site remained good for a long period of time (41 +/- 23 months) in 96% (43 of 45) of these patients. These findings indicate that the vast majority of cardiac events in patients without early restenosis resulted from new lesions distant from the previous angioplasty site. Fatal cardiac events resulting from early restenosis were rare. In patients with no evidence of restenosis, long-term patency remained good. However, a proportion of these patients developed cardiac events resulting from lesions distant from the previous angioplasty site and hence careful long-term follow-up is essential.

Multicenter study of creatine kinase-MB use: effect on chest pain clinical decision making.

To determine whether creatine kinase-MB isomer (CK-MB) levels affect initial physician decisions regarding patients with potential cardiac chest pain. A prospective, multicenter, observational cohort study was performed at seven university teaching hospital EDs. Hemodynamically stable chest pain patients > or = 25 years old and without ST-segment elevation on their ECGs were observed with one to two sets of CK-MB level determinations obtained three hours apart prior to disposition. The physicians committed to a dichotomous (yes/no) absolute decision regarding the diagnosis of myocardial infarction (MI), need for hospital admission, and need for coronary care unit (CCU) admission both before and after enzyme results were obtained. The physicians ranked the perceived importance of initial history and physical, serial clinical observation, initial ECG, and CK-MB level to their decision making (rank score: 1 = most important, 4 = least important). Of the 1,042 patients enrolled, 777 (74.6%) were admitted to the hospital. For the 67 MI patients (8.6% of the admissions), changes in absolute decisions about the diagnosis of MI and planned CCU admission were associated with increased CK-MB importance (p = 0.04 and p = 0.02, respectively). Of the 146 patients who had new-onset angina or unstable angina, changes in absolute decisions were not associated with CK-MB importance. No patient who had MI or unstable angina was released from the ED. There were three of 67 (4%) MI patients and one of 146 (1%) unstable/new-onset angina patients initially slated for release home who were admitted to the hospital. For a minority of the patients who had subsequently proven MI, the CK-MB result helped guide disposition decisions. The CK-MB availability did not adversely impact the disposition of the patients who had unstable or new-onset angina.

Arteriographic Morphology and Intracoronary Thrombus in Patients with Unstable Angina, Non-Q Wave Myocardial Infarction and Stable Angina Pectoris

Coronary artery lesions were compared in 71 patients with unstable angina, 15 patients with non-Q wave myocardial infarction (MI), and 40 patients with stable angina. In the unstable angina group, 29 patients had new-onset angina, 31 had crescendo angina, and 11 had rest angina. In a subgroup of patients with unstable angina, three-vessel disease was less frequently (P < 0.05) seen in patients with new-onset angina (10.3%) than in the patients with crescendo angina (51.6%) or rest angina (54.5%). An angina-producing artery could be identified in 59 patients with unstable angina, in 11 with non-Q wave MI, and in 30 with stable angina. Type II eccentric stenosis (asymmetric narrowing with narrow neck and overhanging irregular edges) was present in 31 patients (52.5%; P < 0.01) with unstable angina, in 7 (63.6%; P < 0.01) with non-Q wave MI, and in only 2 (6.7%) with stable angina. Abrupt occlusion of a vessel was observed in 7 patients (11.9%) with unstable angina and in 2 (18.2%) with non-Q wave MI. None of the patients with stable angina had this type of occlusion. In the group of unstable angina and non-Q wave MI, angiographic evidence of intracoronary thrombi was present in 16 (27.1%) and 3 patients (27.3%), respectively, but in stable angina in only 1 patient (3.3%; P < 0.05). Intracoronary thrombi were most frequently found in rest angina (88%; P < 0.001) and crescendo angina (33.3%; P < 0.01) compared with new-onset angina (3.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

797-1 Differential Expression of Tissue Factor Protein in Directional Atherectomy Specimens from Patients with Stable and Unstable Coronary Syndromes

Tissue factor (TF) is a cell membrane-associated protein that catalyzes the rate-limiting step of the extrinsic coagulation pathway, which is the major source of thrombin production in-vivo . To examine the potential role that TF may play in the pathogenesis of different coronary syndromes, we studied directional coronary atherectomy specimens ftom 57 patients, using immunohistochemical techniques. Patients were classified according to their admission diagnosis as having either an unstable coronary syndrome, which required the presence of rest angina or post-infarction (&lt;1 week) angina, or stable coronary syndromes which included stable, progressive and newonset angina without rest chest pain. Lesions were also classified as a denovo or a restenosis lesion. Frozen sections were examined for the presence of TF using a murine IgG monoclonal antibody against human tissue factor. Samples were read independently by two investigators without knowledge of the clinical information. The results were expressed dichotomously as positive or negative using human skin sections as a positive control and a nonsense murine monoclonal antibody as a negative control. Statistical analysis were performed using a Chi-Square or Fischer's Exact Test. For the entire study group, TF was detected in 15 (45%) of 33 patients with unstable coronary syndromes versus only 3 (13%) of 24 patients with stable coronary syndromes; p ≤ 0.02. Moreover, within the subgroup of patients with unstable coronary syndromes, TF protein was detected in 14 (61%) of 23 patients with de-novo lesions versus only 1 (10%) of 10 patients with rest angina from a restenosis lesion; p ≤ 0.01. An additional 7 patients with stable coronary syndromes due to a restenosis lesion were also all negative for TF, for an overall incidence of only 1 (6%) of 17 restenosis lesions. In conclusion, tissue factor is readily detected in atherectomy specimens from de-novo lesions in patients with unstable coronary syndromes, suggesting a role for this protein in the pathogenesis of this disease process. Conversely, tissue factor is rarely detected in patients with restenosis lesions even if the clinical presentation is an unstable coronary syndrome. These results may have implications in regard to the management of patients with unstable angina from de-novo lesions and all patients with recurrent symptoms from restenosis lesions.