Number Of Diseased Coronary Vessels Research Articles

Association of serum levels of glycated albumin, C-reactive protein and tumor necrosis factor-α with the severity of coronary artery disease and renal impairment in patients with type 2 diabetes mellitus

Objectives: This study aimed to determine whether elevated serum levels of glycated albumin, high-sensitivity C-reactive protein (hsCRP) and tumor necrosis factor (TNF)-α were related to an increased risk for coronary artery disease (CAD) and renal insufficiency in patients with type 2 diabetes mellitus (T2DM). Design and methods: Serum levels of glycated albumin, hsCRP, TNF-α and blood glycosylated hemoglobin A1c (HbA1c) were measured in 317 consecutive patients with T2DM and 309 normal controls. Patients with T2DM were grouped based upon coronary angiographic findings (Group I: 151 patients with normal coronary arteries; Group II: 166 patients with significant coronary stenosis [> 70% luminal diameter narrowing]) and renal functional status evaluated by estimated creatinine clearance (CrCl) (normal renal function group: 187 patients with CrCl > 90 mL/min; mild renal insufficiency group: 103 patients with CrCl 60–90 mL/min; moderate renal insufficiency group: 27 patients with CrCl 30–60 mL/min). Multivariate analysis was performed to determine independent risk factors for CAD and renal insufficiency in patients with T2DM. Results: Serum levels of glycated albumin, hsCRP and TNF-α were significantly higher in Group II than in controls ( P < 0.01) and Group I ( P < 0.01). A significant difference was found in glycated albumin, hsCRP and TNF-α levels among diabetic patients with mild, moderate renal insufficiency and normal renal function ( P < 0.05). These biochemical measurements correlated significantly with number of diseased coronary vessels ( P < 0.01) and status of renal function ( P < 0.05). No difference existed in HbA1c levels between Group II and Group I, and among patients with various CrCL stages. Multivariate analysis revealed that male gender, old age and serum levels of glycated albumin, hsCRP, TNF-α and lipoprotein (a) were independent risk factors for CAD, and older age, hypertension and glycated albumin were for CrCl < 60 mL/min in diabetes. Conclusions: Increased serum levels of glycated albumin, hsCRP and TNF-α are associated with the presence and severity of CAD and renal impairment in patients with T2DM.

Improved graft patency rates and mid-term outcome of diabetic patients undergoing total arterial myocardial revascularization.

Objectives:Diabetes negatively affects the outcome of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) or coronary surgery. However, data are lacking with respect to the impact of arterial revascularization in the diabetic population.Methods:Between 1999 and 2003, 100 of 491 diabetics underwent coronary artery bypass graft surgery (CABG) with total arterial grafting (Group 1, G1); these patients were compared with 100 diabetics undergoing conventional CABG with saphenous veins (Group 2, G2), who were matched for Euroscore and other risk factors such as age, obesity, hypertension, left ventricular ejection fraction (LVEF), previous myocardial infarction and chronic obstructive pulmonary disease (COPD).Results:Both groups had a similar number of diseased coronary vessels (G1=2.6 vs G2= 2.7) and received a similar degree of myocardial revascularization (grafted vessels: G1=2.2 vs G2=2.4). Early outcome was comparable between the groups in terms of ventilatory support (G1=10.8±6 vs G2=10.4±5 hours), intensive care unit (ICU) stay (G1=24±12 vs G2=25±14 hours) and major post-operative complications such as atrial fibrillation (G1=26% vs G2=28%), peri-operative myocardial infarction (G1=1% vs G2=2%)and prolonged ventilatory support (G1=6% vs G2=5%). Hospital mortality was 2% in G1 and 3% in G2. Angiography was performed at a mean follow-up of 34 months in 65.9% and 71.1% of hospital survivors of G1 and G2 respectively: patients of G1 showed a significantly higher patency rate (G1=96% vs G2=83.6%, p=0.02). Additionally, patients of G1 showed a significantly lower incidence of recurrent myocardial ischemia (G1=7 pts. vs G2=18 pts., p=0.03), late myocardial infarction (G1=2 pts. vs G2=10 pts., p=0.03) and need for coronary reintervention (G1=1 pt. vs G2=12 pts, p=0.004).Conclusions:Total arterial grafting in diabetic patients significantly improved the benefits of coronary surgery providing at mid term a higher graft patency rate with a lower incidence of cardiac related events.

Determination of interobserver variability for identifying inducible left ventricular wall motion abnormalities during dobutamine stress magnetic resonance imaging

To determine the interobserver variability for identifying inducible left ventricular (LV) wall motion abnormalities during high-dose dobutamine/atropine stress cardiovascular magnetic resonance (DSMR). Four readers from various institutions were supplied with the image data from 150 consecutive DSMR examinations and asked to grade wall motion and image quality throughout graded doses of dobutamine infusion administered to achieve 85% of the maximum age-predicted heart rate. Inducible ischaemia was identified if more than one segment demonstrated a new or worsening LV wall motion abnormality, and significant stenosis was defined as > or =50% luminal diameter reduction by quantitative contrast coronary angiography. Seventy-seven patients (51%) had luminal narrowings > or =50%. Diagnostic performance (sensitivity, specificity, diagnostic accuracy) of all readers was 78.2, 87.0 and 82.5%. Disagreement between two readers occurred in every seventh examination. Agreement on the presence or absence of inducible wall motion abnormalities was moderate (mean kappa value 0.59, range 0.52-0.76). Diagnostic performance and disagreement were independent of the presence of luminal narrowings > or =50% or the number of diseased coronary vessels. Image quality was regarded excellent in 89.3% of standard views. In the setting of multiple observers from different institutions performing a diagnostic reading of DSMR examinations carried out at a single centre, the interobserver variability was low for identifying inducible LV wall motion abnormalities indicative of coronary arterial luminal narrowings > or =50%.

Arterial wave reflection is associated with severity of extracoronary atherosclerosis in patients with coronary artery disease

Arterial wave reflection is a major determinant of left ventricular function, coronary perfusion and cardiovascular risk. We investigated whether arterial wave reflection may detect atherosclerosis of peripheral arteries in patients with documented coronary artery disease (CAD). Radial artery applanation tonometry and pulse wave analysis was performed in 184 patients with documented CAD at coronary angiography; central blood pressures and augmentation index (AI) were measured. Ankle-brachial (ABI) index and intima-media thickness (IMT) were used as indices of atherosclerosis of the lower limbs and the carotid arteries respectively. Patients with abnormal IMT (> 0.7 mm, first tertile) or ABI (< 0.94, first tertile) had higher AI than patients with lower IMT or higher ABI (24 +/- 17 versus 17 +/- 16% and 23 +/- 18 versus 18 +/- 13%, respectively, P < 0.05). In multivariate analysis, increasing AI was associated with age, female gender, heart rate, mean blood pressure, hyperlipidaemia, and use of statins (regression coefficient (beta) = 0.50, beta = 0.15, beta = -0.60, beta = 0.23, beta = 0.16 and beta = -0.14, respectively, P < 0.05). Increasing AI was associated with an adjusted-odds ratio of 1.035 [95% confidence interval (CI), 1.005-1.066], P = 0.02 for an abnormal IMT and of 1.08 (95% CI, 1.024-1.146), P = 0.005 for ABI after adjustment for age, gender, heart rate, height, blood pressure, atherosclerotic risk factors, obesity and medication. No relation was found between AI and Gensini score or for the number of diseased coronary vessels. Augmentation index is a marker of extensive extracoronary atherosclerosis in patients with CAD.

Increased apoptosis in remote non-infarcted myocardium in multivessel coronary disease

Background: Multivessel coronary disease after myocardial infarction is a major risk factor for unfavorable cardiac remodeling and death due to pump failure, but underlying pathophysiologic mechanisms are still uncompletely established. Post-infarction myocardial apoptosis has been recently implicated as a cause of ongoing cell loss leading to cardiac failure. Our aim was to assess the role of post-infarction myocardial apoptosis and pro-apoptotic factor expression in the non-infarcted remote myocardium of subjects with multivessel coronary disease. Methods: Twenty-one males dying after recent myocardial infarction with permanent occlusion of the infarct-related artery were selected at autopsy. Apoptosis was assessed at viable myocardial regions remote from infarction by co-staining for in situ end-labeling of DNA fragmentation and cleaved caspase-3. Expression of pro-apoptotic factor bax and hypoxia-induced factor-1alpha was evaluated by immunohistochemistry. Results: Subjects with multivessel disease ( N=11) showed a significantly two-fold higher myocardial apoptosis in comparison to subjects with single vessel disease ( N=10) (0.9% vs. 0.5%, p=0.013). Similarly, myocardial bax expression was increased in patients with multivessel disease (3.0% vs. 1.4%, p=0.029). Stratification for the number of diseased coronary vessels confirmed the association between extent of coronary disease and apoptotic rates ( p=0.022). Even in subjects dying over 30 days after infarction multivessel disease remained predictive of enhanced myocardiocyte apoptosis at remote regions ( p=0.033). Conclusions: Post-infarction myocardial apoptosis and bax expression in remote left ventricular regions are significantly increased in male patients with multivessel coronary disease in comparison to those with isolated infarct-related artery occlusion. These findings suggest that apoptotic cell loss in the viable non-infarcted myocardium, possibly due ongoing ischemia, may play a relevant role in the unfavorable clinical course typical of multivessel disease after myocardial infarction.

Pronóstico a largo plazo de las mujeres con síndrome coronario agudo sin elevación del segmento ST

Women with ST-segment-elevation myocardial infarction have a worse prognosis than men. However, information about the prognosis of women with non-ST-segment-elevation acute coronary syndromes (NSTEACS) is scarce. The aim of this study was to determine if the long-term prognosis of men and women with NSTEACS differs. Case-control study. In a consecutive series of 300 patients admitted for a NSTEACS and ischemic ECG changes, we compared the clinical characteristics, in-hospital and long-term follow-up of 95 women and 95 men matched for age, presence of diabetes, and past history of hypertension. The median age of patients was 69 years, 36% had diabetes, and 65% had a history of hypertension. There were no gender differences in the history of angina or hypercholesterolemia, clinical presentation, number of patients with ST-segment depression, and CK-MB elevation. However, smoking, coronary artery disease, and peripheral vascular disease were less frequent in women. Treatment at admission and at discharge was similar in men and women, as was the use of in-hospital diagnostic and therapeutic procedures (echocardiography: 80 vs 88%; coronary angiography: 57 vs 59%; percutaneous coronary intervention: 17 vs 14%; coronary surgery 13 vs. 11%). Women had a better mean ejection fraction (55 13 vs 49 14%; p < 0.01) and fewer stenosed coronary vessels (1.4 1.1 vs 2.2 0.9; p < 0.01). There were no differences in the frequency of recurrent angina (28 vs 25%), death, or infarction (both 3.2%) during hospitalization. However, during a 30-month follow-up the incidence of death, myocardial infarction, or a new episode of NSTEACS was significantly lower in women with a relative risk (RR) of 0.53 (95% CI: 0.33-0.86; p < 0.01). This apparently better prognosis persisted after adjusting for clinical data and ejection fraction (RR: 0.57 (0.33-0.98); p < 0.05), but disappeared after adjusting for the number of diseased coronary vessels (RR: 0.71 (0.35-1.47); p = 0.36). Women with NSTEACS had a better long-term prognosis than men. This better prognosis was independent of the patients' clinical characteristics and treatment, and could be explained by a less severe and less extensive coronary artery disease.

Depression and 1-Year Prognosis in Unstable Angina

Depression is common after acute myocardial infarction and is associated with an increased risk of mortality for at least 18 months. The prevalence and prognostic impact of depression in patients with unstable angina, who account for a substantial portion of acute coronary syndrome admissions, have not been examined. Interviews were carried out in hospital with 430 patients with unstable angina who did not require coronary artery bypass surgery before hospital discharge. Depression was assessed using the 21-item self-report Beck Depression Inventory and was defined as a score of 10 or higher. The primary outcome was 1-year cardiac death or nonfatal myocardial infarction. The Beck Depression Inventory identified depression in 41.4% of patients. Depressed patients were more likely to experience cardiac death or nonfatal myocardial infarction than other patients (odds ratio, 4.68; 95% confidence interval, 1.94-11.27; P<.001). The impact of depression remained after controlling for other significant prognostic factors, including baseline electrocardiographic evidence of ischemia, left ventricular ejection fraction, and the number of diseased coronary vessels (adjusted odds ratio, 6.73; 95% confidence interval, 2.43-18.64; P<.001). Depression is common following an episode of unstable angina and is associated with an increased risk of major cardiac events during the following year.

Association of Angiotensin-Converting Enzyme Gene Polymorphism and Angiotensin-Converting Enzyme Activity in Korean patients with Coronary Artery Disease

Background:Insertion/Deletion (I/D polymorphism of the angiotensin converting enzyme (ACE gene has been postulated as a risk factor for coronary artery disease. However, controversies exist whether deletion polymorphism in the ACE gene and/or high levels of ACE activity may be a risk factor for coronary artery disease (CAD. We investigated the association of the I/D polymorphism of the ACE gene and serum ACE activity in Korean patients with CAD. Methods:Study subjects were 629 patients who underwent coronary angiography. CAD group (n=477 was subdivided according to either clinical manifestation or the number of diseased vessels on angiography. The control group comprised 152 patients who did not have a significant coronary lesion. Low risk group (n=65 was defined as subjects with age <55 years, a body mass index (BMI <26 kg/m 2 and a plasma ApoB <125 mg/dl. Results:1 The genotype and allele frequencies of ACE gene polymorphism were not different between control (DD:DI:II=0.20:0.48:0.32, D:I=0.44:0.56 and CAD group (DD:DI:II= 0.18:0.46:0.36, D:I=0.41:0.59. 2 When the CAD group was subdivided into stable angina (SA and acute coronary syndrome (ACS group, neither ACE genotype nor allele frequencies differed between the SA and ACS group. 3 There was no significant association between the ACE polymorphism and the severity of CAD, as assessed by the number of diseased coronary vessels. 4 A significant difference in serum ACE activity was apparent among ACE genotypes in both controls and CAD subjects. Serum ACE activity in individuals with the DD genotype was significantly greater than that in individuals with DI or II genotypes. 5 There was no difference in serum ACE activity between controls and the CAD subjects of all genotypes or of the same genotype. 6 There was no association between the ACE polymorphism or serum ACE activity and CAD in

Plasma sialic acid and coronary artery atheromatous load in patients with stable chest pain

Serum or plasma sialic acid and C-reactive protein have recently been shown to be cardiovascular risk factors. Our aim was to determine whether plasma sialic acid or C-reactive protein concentration correlate with atheromatous load on coronary angiography. Plasma sialic acid concentration and plasma C-reactive protein concentration were determined in 128 consecutive patients attending day case coronary angiography. Patients were excluded for previous coronary angioplasty, coronary artery bypass grafting, recent myocardial infarction, acute or chronic inflammatory disease and proximal occlusions precluding analysis of distal coronary anatomy. Total cholesterol, triglyceride, HDL cholesterol and glucose concentrations were assayed on fasting samples of venous blood. Angiograms were graded according to a semisubjective scoring system. There was no significant correlation between plasma sialic acid (r=0.19, P=0.07), or C-reactive protein concentration (r=0.17, P=0.13) and atheromatous load. There was no significant correlation between sialic acid (P=0.13), or C-reactive protein concentration (P=0.32) and the number of diseased coronary vessels. The difference in plasma sialic acid concentration between those with normal coronary angiograms and those with coronary artery disease did not reach significance (P=0.08). Plasma sialic acid concentration correlated with C-reactive protein (r=0.58, P=0.0001), serum triglyceride (r=0.32, P=0.002), and blood cholesterol concentration (r=0.22, P=0.04). Plasma sialic acid concentration does not correlate with atheromatous load on coronary angiography in patients with stable angina.

Moderate Hyperhomocyst(e)inemia Is Associated with the Presence of Coronary Artery Disease and the Severity of Coronary Atherosclerosis in Koreans

To examine whether moderate hyperhomocyst(e)inemia is associated with coronary artery disease and the number of diseased coronary vessels in Koreans, we investigated 201 patients with angiographically documented coronary artery disease and 187 healthy subjects without evidence of stroke and coronary artery disease. The mean plasma total homocysteine in patients was higher than in controls (10.3 μmol/L; 95% confidence interval, 7.0–13.6 vs. 8.9 μmol/L; 6.0–11.8) ( p=0.005). The prevalence of moderate hyperhomocyst(e)inemia, defined as the top 90th percentile in controls (13.2 μmol/L), was higher in patients than in controls (23.9% vs. 10.2%, p=0.001). Plasma homocyst(e)ine levels were not correlated to age, body mass index, levels of serum cholesterol, creatinine, and uric acid. Based on multiple logistic regression analyses with adjustment for total cholesterol, hypertension, smoking status, diabetes, age, and body mass index, the adjusted odds ratio of moderate hyperhomocyst(e)inemia for coronary artery disease was 1.53 (95% confidence interval: 1.39–1.65, p=0.0001). Moderate hyperhomocyst(e)inemia, diabetes mellitus, and old age were more prevalent in patients with triple-vessel disease than in single- or double-vessel disease ( p=0.02). Multiple logistic regression analysis revealed that moderate hyperhomocyst(e)inemia was a significant predictor of triple-vessel disease with odds ratio of 2.78 (95% confidence interval: 1.08–7.10, p=0.02). We conclude that moderate hyperhomocyst(e)inemia is an independent risk factor for coronary artery disease, and also related significantly to the presence of triple-vessel disease.

Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting

Background. The long-term benefits of double versus single internal mammary artery (IMA) coronary bypass grafting have not yet been established. Methods. Six hundred patients were studied retrospectively 10 years after coronary revascularization using saphenous vein grafts (SVGs) only or single or double IMA grafts. Results. Patients with double IMA grafts were younger and were more likely to have diabetes, left main coronary stenosis, and three-vessel coronary artery disease than patients with SVGs or single IMA grafts. Patients with SVGs and double IMA grafts had a greater number of diseased coronary vessels and a greater number of coronary bypass grafts per patient than patients with single IMA grafts (mean ± SEM, 2.8 ± 1.0, 2.8 ± 0.7, 2.1 ± 0.8 grafts per patient, respectively, p < 0.0001). Actuarial survival rates 10 years after placement of SVGs and single and double IMA grafts averaged 83% ± 6%, 90% ± 4%, and 87% ± 8%, respectively ( p = 0.03). Cox regression analysis showed that diabetes (relative risk, 2.03; 95% confidence interval, 1.55 to 2.66) and chronic pulmonary obstructive disease (relative risk, 2.20; 95% confidence interval, 1.58 to 3.80) increased, whereas an IMA graft on the left anterior descending coronary artery significantly decreased, the risk of death after operation (relative risk, 0.45; 95% confidence interval, 0.36 to 0.57) throughout the follow-up period. Conclusions. Use of an IMA graft on the left anterior descending coronary artery improves survival compared with use of an SVG. Although patients with double IMA grafts had a greater number of poor prognosis risk factors before operation, their 10-year survival rate was similar to that of patients with a single IMA graft.

Estrogen replacement therapy and outcome of coronary balloon angioplasty in postmenopausal women

Estrogen replacement therapy (ERT) in women after menopause is associated with prevention of clinical coronary artery disease. However, few studies have investigated possible benefits from ERT in postmenopausal women undergoing treatment for established coronary disease. We therefore retrospectively reviewed the clinical outcomes of 428 postmenopausal women undergoing percutanious transluminal coronary balloon angioplasty (PTCA) to test the hypothesis that ERT has a beneficial effect in this setting. The women were divided into 2 groups based on ERT status at the time of the procedure. Estrogen users were younger (60 ± 10 vs 68 ± 9 years, p <0.001), more commonly had family histories of coronary heart disease (54% vs 41%, p = 0.04), had less incidence of hypertension (63% vs 76%, p = 0.02), and had slightly fewer diseased vessels per patient (1.3 ± 0.5 vs 1.5 ± 0.7, p = 0.03) compared with nonusers. No in-hospital deaths occurred in estrogen users compared with 5% hospital mortality in nonusers (p = 0.01). The combined outcome of death or myocardial infarction (MI) also was lower in estrogen users (4% vs 12%, p = 0.04). Of 348 women discharged after successful PTCA, 336 (97%) were able to be contacted at an average follow-up interval of 22 ± 17 months (range 5 to 82). Estrogen users had superior event-free survival both for death as well as for death or nonfatal MI. Repeat revascularizations were similar in both groups (32% vs 24%, p = 0.15). In a Cox proportional-hazards model, nonusers had 4 times the likelihood of death after angioplasty compared with estrogen users (OR = 4.025, 95% CI = 1.3 to 13.4, p = 0.02). We conclude that estrogen replacement may offer protection against clinical coronary events in postmenopausal women who already have established coronary disease and are undergoing balloon angioplasty. The benefit was independent of age, smoking, presence of diabetes mellitus, or the number of diseased coronary vessels. However, it did not include a reduction in repeat revascularization procedures, suggesting no reduction in restenosis.

Dispersions of the QT Interval in Postmyocardial Infarction Patients Presenting With Ventricular Tachycardia or With Ventricular Fibrillation

Increased QT interval dispersion is associated with ventricular arrhythmias. The aim of this study was to examine if in postmyocardial infarction patients with impaired left ventricular function, increased QT dispersion is associated with ventricular tachycardia (VT) and ventricular fibrillation (VF). Measures of QT dispersion, calculated as maximum–minimum (D) and standard deviation (SD) of QT end, QT apex, JT end, JT apex, and T end intervals in the 12-lead electrocardiogram, were compared in patients who late after myocardial infarction experienced sustained VT (VT group) only, VF (VF group) only, or had no ventricular arrhythmias (controls). The 25 patients in each group were individually matched for age, gender, number of diseased coronary vessels, location of the previous myocardial infarction, and left ventricular ejection fraction. Dispersion measures of QT end, QT apex, and JT apex intervals separated VT group from controls, but none of the measures separated the VF group from controls. QT endD was 49 ± 18 ms in controls, 57 ± 18 ms in the VF group (controls vs VF group, p = NS), and 65 ± 29 ms in the VT group (controls vs VT group, p <0.05). VT group had increased QT apexSD, JT apexSD, and JT apexD compared with the VF group. The cycle length of induced sustained monomorphic VT, present in 19 VT and 19 VF patients, correlated with several dispersion indexes in the VT group, but not with those in the VF group. Thus, in postmyocardial infarction patients with a severely damaged left ventricle, increased QT dispersion is associated with susceptibility to sustained VT, but not to VF.

Improved outcome after coronary bypass surgery in patients with ischemic cardiomyopathy and residual myocardial viability.

Although residual myocardial viability in patients with coronary artery disease and extensive regional asynergy is associated with improved ventricular function after coronary bypass surgery, the relationship between viability and clinical outcome after surgery is unclear. We hypothesized that patients with poor ventricular function and predominantly viable myocardium have a better outcome after bypass surgery compared with those with less viability. Seventy patients with multivessel coronary artery disease and left ventricular ejection fractions < 40% who underwent preoperative quantitative 201Tl scintigraphy before coronary bypass surgery were analyzed retrospectively. 201Tl scintigrams were reviewed blindly, and each segment was assigned a score based on defect magnitude. Segmental viability scores were summed and divided by the number of segments visualized to determine a viability index. The viability index was significantly related to 3-year survival free of cardiac event (cardiac death or heart transplant) after bypass surgery (P=.011) and was independent of age, ejection fraction, and number of diseased coronary vessels. Patients with greater viability (group 1; viability index > 0.67; n=33) were similar to patients with less viability (group 2; viability index < or = 0.67; n=37) with respect to age, comorbidities, and extent of coronary artery disease. There were 6 cardiac deaths and no heart transplants in group 1 patients and 15 cardiac deaths and two transplants in group 2 patients. Survival free of cardiac death or transplantation was significantly better in group 1 patients on Kaplan-Meier analysis (P=.018). We conclude that resting 201Tl scintigraphy may be useful in preoperative risk stratification for identification of patients more likely to benefit from surgical revascularization.

Dehydroepiandrosterone and coronary atherosclerosis.

Tissue culture, animal model, and epidemiologic studies suggest that dehydroepiandrosterone (DEHA) may inhibit atherosclerosis through its potent antiproliferative effects. To examine the relation between DHEA and a direct measure of coronary atherosclerosis, plasma DHEA, and DHEA sulfate (DHEAS) levels were determined in 206 middle-aged patients undergoing coronary angiography. Plasma DHEAS levels were lower in subjects with at least one > or = 50% stenosis than in those with no stenosis > 50% (p = 0.05) and was inversely associated with the number of diseased coronary vessels and the extent of coronary atherosclerosis (p = 0.05 and 0.01, respectively). Cardiac allograft vasculopathy is dominated by abnormal cellular proliferation and, therefore, may be uniquely influenced by DHEA. To study this, 61 cardiac allograft recipients with at least one annual follow-up cardiac catheterization were studied. Plasma levels of total and free DHEA were inversely related to the development of accelerated coronary allograft vasculopathy (p = 0.005 and 0.003, respectively). Furthermore, the time to development of accelerated allograft vasculopathy was shorter in subjects with low levels of total and free DHEA (p = 0.062 and 0.046, respectively). These data suggest that low plasma levels of DHEA may facilitate, and high levels may retard, the development of coronary atherosclerosis and coronary allograft vasculopathy.

Operation for unstable angina pectoris: Factors influencing adverse in-hospital outcome

Coronary artery bypass grafting for the treatment of unstable angina is still associated with increased operative risk and postoperative morbidity. The impact of the extended use of arterial grafts on early results is incompletely defined. In a 7-year period (1986 to 1993), 474 patients (average age, 65 years; range, 34 to 85 years) underwent coronary artery bypass grafting for the treatment of unstable angina. Sixty-eight patients were operated on emergently and 406 urgently. They received an average of 3.0 distal anastomoses (range, 1 to 6). Seventy-nine patients had exclusively venous grafts, 316 had one internal thoracic artery graft, 79 had bilateral internal thoracic artery grafts, and 20 had inferior epigastric artery grafts. Sequential internal thoracic artery grafting was performed in 70 patients. Redo operations were performed in 26 patients. Thirty-four patients (7.2%) experienced a new myocardial infarction. Eighty-nine patients (18.8%) had an intraaortic balloon pump inserted preoperatively, intraoperatively, or postoperatively. Eight patients (1.7%) died intraoperatively and 24 patients (5.1%) died postoperatively. Seventy-seven patients (16.2%) had an adverse outcome, as shown by the need for an intraaortic balloon pump (intraoperatively or postoperatively) or hospital death, or by both. Forty variables were examined by multivariate analysis for their influence on the occurrence of an adverse outcome. Aortic cross-clamp time (p = 0.0004), transfer from the intensive care unit (p = 0.0023), female sex (p = 0.0023), operation performed in early years (p = 0.0041), left ventricular aneurysm (p = 0.0068), the number of diseased coronary vessels (p = 0.0312), and reoperation (p = 0.0318) were all found to be significant independent predictors of increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Statistics notes: Multiple significance tests: the Bonferroni method

Many published papers include large numbers of significance tests. These may be difficult to interpret because if we go on testing long enough we will inevitably find something which is “significant.” We must beware of attaching too much importance to a lone significant result among a mass of non-significant ones. It may be the one in 20 which we expect by chance alone. Lee et al simulated a clinical trial of the treatment of coronary artery disease by allocating 1073 patient records from past cases into two “treatment” groups at random.1 They then analysed the outcome as if it were a genuine trial of two treatments. The analysis was quite detailed and thorough. As we would expect, it failed to show any significant difference in survival between those patients allocated to the two treatments. Patients were then subdivided by two variables which affect prognosis, the number of diseased coronary vessels and whether the left ventricular contraction pattern was normal or abnormal. A significant difference in survival between the two “treatment” groups was found in those patients with three diseased vessels (the maximum) and abnormal ventricular contraction. As this would be the subset of patients with the worst prognosis, the finding would be easy to account for by saying that the superior “treatment” …

Influence of left ventricular hypertrophy on left ventricular function during dynamic exercise in the presence or absence of coronary artery disease

Objectives. We investigated the influence of left ventricular hypertrophy in the presence or absence of coronary artery disease on hemodynamic characteristics during exercise in subjects without previous myocardial infarction.Background. Left ventricular hypertrophy has been found to increase the vulnerability of the myocardium to the development of ischemia. However, the independent influences of left ventricular hypertrophy and coronary artery disease have not been assessed in humans.Methods. Symptom-limited supine leg exercise tests were performed by 78 patients. They were classified into the following subgroups: no coronary artery disease or left ventricular hypertrophy (group I, n = 30), left ventricular hypertrophy only (group II, n = 12), coronary artery disease only (group III, n = 20) and both left ventricular hypertrophy and coronary artery disease (group IV, n = 16). Mean left ventricular mass index was 105, 158, 109 and 159 g/m2in groups I to IV, respectively.Results. Pulmonary artery wedge pressure increased from 6 ± 3 (mean ± SD) mm Hg at rest to 10 ± 5 mm Hg at peak exercise in group I, from 8 ± 2 to 18 ± 8 mm Hg in group II (p < 0.05 vs. group I), from 6 ± 3 to 23 ± 6 mm Hg in group III (p < 0.01 vs. group I) and from 8 ± 4 to 30 ± 7 mm Hg in group IV (p < 0.01 vs. group I; p < 0.01 vs. group II; p < 0.05 vs. group III). Multiple regression analysis showed that the number of diseased coronary vessels and left ventricular mass index were independent predictors of peak pulmonary artery wedge pressure (F = 59.2 and 19.1, respectively; multiple correlation coefficient r = 0.74, p < 0.0001).Conclusions. Left ventricular hypertrophy and coronary artery disease independently increased left ventricular filling pressure during supine leg exercise. Severe left ventricular dysfunction was induced by exercise when both conditions were present.

Factors influencing changes in the signal-averaged electrocardiogram within the first year after a first myocardial infarction

One hundred twenty-nine patients were prospectively studied after a first myocardial infarction. A first signal-averaged electrocardiogram (SAECG-1) was performed in the acute phase (within 48 hours after onset of symptoms) and a second one (SAECG-2) in the late phase (6 to 18 months after hospital discharge). We studied the influence of nine parameters on the evolution of the signal-averaged electrocardiogram: age, gender, myocardial infarction location, number of diseased coronary vessels, infarct-related coronary artery patency, use of thrombolytic therapy or percutaneous transluminal coronary angioplasty in the acute phase, left ventricular ejection fraction, and recurrence of ischemic events. No follow-up data were available in 15 patients. Of the remaining 114 patients, an ischemic event occurred in 25 (22%). The signal-averaged electrocardiogram remained unchanged in 97 (85%) (remaining normal in 78 and abnormal in 19). It became abnormal in 13 (11.5%) and became normal in 4 (3.5%). In patients with a normal SAECG-1, two factors were associated with the change to an abnormal SAECG-2: (1) an ischemic event occurred in 11 (85%) of 13 patients whose SAECG-2 was abnormal compared with only 13 (17%) of 78 patients whose SAECG-2 remained normal (p < 0.0001), and (2) 100% of patients with an abnormal SAECG-2 had an inferior myocardial infarction compared with 54% of patients with a normal SAECG-2 (p = 0.004). In conclusion, our findings suggest that in the setting of myocardial infarction, changes from an early (<48 hours) normal to a late (>6 months) abnormal signal-averaged electrocardiogram is highly indicative of recurrences of ischemic events and an inferior location of the myocardial infarction.

Long-term survival in patients with coronary artery disease: Importance of peripheral vascular disease

Objectives. The purpose of this study was to determine the importance of peripheral arterial disease in predicting long-term survival in patients with clinically evident coronary artery disease.Background. Patients in the Coronary Artery Surgery Study (CASS) Registry were followed up for >10 years.Methods. Survival in 2,296 patients with peripheral arterial disease was compared with that of 13,953 patients without peripheral arterial disease using Kaplan-Meier survival curves. All patients had known stable coronary artery disease. Clinical, electrocardiographic (ECG), chest X-ray film and catheterizalion variables of the two groups were compared using the chi-square statistic or the two-sample t test. The independent effect of peripheral arterial disease (as well as other variables) on mortality was determined utilizing a Cox proportional hazards model.Results. Patients with peripheral vascular disease were more likely to have hypertension, diabetes, family history of coronary artery disease, previous angina or myocardial infarction, previous coronary bypass surgery or to have smoked. They also had a higher incidence of congestive heart failure, ECG abnormality and modestly increased frequency of three-vessel disease. Independent correlates of long-term mortality for the entire cohort included age, smoking, diabetes, number of diseased coronary vessels, left ventricular function, hypertension, pulmonary disease, anginal class, previous myocardial infarction and peripheral vascular disease (all p < 0.061). At any point in time, patients with peripheral vascular disease had a 25% greater likelihood of mortality than patients without peripheral vascular disease (multivariate chi-square 25.83, hazard ratio 1.25, 95% confidence interval 1.15 to 1.36, p < 0.0001).Conclusions. Peripheral vascular disease is a strong, independent predictor of long-term mortality in patients with stable coronary artery disease. Aggressive attempts at secondary disease prevention are warranted in this high risk group.