Strategies For Coronary Artery Disease Research Articles

Mild chronic kidney dysfunction and treatment strategies for stable coronary artery disease

Our objective was to evaluate the association of chronic kidney dysfunction in patients with multivessel chronic coronary artery disease, preserved left ventricular function, and the possible interaction between received treatment and cardiovascular events. The glomerular filtration rate was determined at baseline on 611 patients who were randomized into three treatment groups: medical treatment, percutaneous coronary intervention, and coronary artery bypass surgery. Incidence of myocardial infarction, angina requiring a new revascularization procedure, and death were analyzed during 5 years in each group. Of 611 patients, 112 (18%) were classified as having normal renal function, 349 (57%) were classified as having mild dysfunction, and 150 (25%) were classified as having moderate dysfunction. There were significant differences among the cumulative overall mortality curves among the three renal function groups. Death was observed more frequently in the moderate dysfunction group than the other two groups (P < .001). Interestingly, in patients with mild chronic kidney dysfunction, we observed that coronary artery bypass treatment presented a statistically higher percentage of event-free survival and lower percentage of mortality than did percutaneous coronary intervention or medical treatment Our results confirm that coronary artery disease accompanied by chronic kidney dysfunction has a worse prognosis, regardless of the therapeutic strategy for coronary artery disease, when renal function is at least mildly impaired. Additionally, our data suggest that the different treatment strategies available for stable coronary artery disease may have differential beneficial effects according to the range of glomerular filtration rate strata.

Effects of drug, biobehavioral and exercise therapies on heart rate variability in coronary artery disease: a systematic review

Heart rate variability (HRV) is reported as a surrogate index for clinical outcome in trials of secondary prevention strategies for coronary artery disease (CAD), but a standardized guide for interpreting HRV change is not established. We evaluated HRV change in trials with CAD patients who received conventional medications (beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors), biobehavioral treatment (psychotropics, biofeedback, relaxation) or exercise training. Medline, Pubmed, Psycinfo, the Cochrane database, and Embase were searched until July 2007, without language restriction. We identified 33 randomized controlled trials. Two reviewers independently abstracted all trials using a standardized form. A hierarchy of frequency and time domain HRV indices defined outcome. A random-effects model yielded an overall pooled standardized mean difference (SMD) between treatment and control groups of moderate magnitude across treatment classes, based on a composite of time and frequency domain indices (SMD=0.40, P<0.0001), or only time or frequency indices (SMD=0.37 and 0.43, respectively, both P<0.0001). This change was equivalent to an increase in standard deviation of all normal-to-normal RR intervals of 9.0 ms (95% Confidence Interval, CI, 7.3, 10.7 ms) or a relative increase of 15.9% (95% CI, 13.2, 18.6%). To detect HRV change of this magnitude, a hypothetical trial would require a sample size of 660 patients for conventional medications or 1232 patients for all treatment classes. Pharmacologic, biobehavioral and exercise strategies for secondary prevention of CAD significantly increase HRV. This review provides a framework to assist efforts to evaluate the contribution of HRV change to CAD prognosis.

Late drug-eluting stent thrombosis in unprotected left main coronary artery lesions--sometimes possible, but rarely definite or probable

Beyond relieving angina, revascularization strategies for coronary artery disease (CAD) have focused on the subsequent occurrence of death, myocardial infarction, repeat revascularization, and, more recently, stent thrombosis. Numerous trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have shown the long-term rates of death and myocardial infarction to be similar between these strategies, largely independently of the extent and location of CAD.1,2 The main outcome gap between percutaneous and surgical approaches has been the higher rate of repeat revascularization procedures for those initially undergoing PCI. At 5-year follow-up in the Bypass Angioplasty Revascularization Investigation (BARI) trial,1 54% of patients initially undergoing multivessel balloon angioplasty required a repeat procedure vs. 8% among those assigned to bypass surgery. With the introduction of bare-metal stents (BMS), this gap between PCI and CABG was narrowed. The 5-year follow-up from the Arterial Revascularization Therapies Study (ARTS) trial2 demonstrated the need for repeat target vessel revascularization (TVR) for those undergoing multivessel stent placements vs. CABG to be 30 and 9%, respectively. Most recently, drug-eluting stents (DES) have reshaped the landscape of interventional cardiology by substantially reducing rates of restenosis, and this intuitively should narrow the repeat TVR gap between PCI and bypass surgery further. In particular, the 5-year data from randomized trials comparing BMS and DES3,4 have shown TVR rates to be additionally reduced by one-half to two-thirds with DES, such that the ∼10–15% need for repeat revascularization for the DES cohort at long-term follow-up should be nearing that associated with bypass surgery. Several important CAD subsets, such as chronic total occlusions, complex bifurcation lesions, and stenoses of unprotected left main coronary arteries (ULMCAD), have been considered unattractive or ‘verboten’ for PCI, but are being increasingly considered with the availability of DES. Large-scale trials comparing … *Corresponding author. Tel: +1 859 323 5843, Fax: +1 859 257 3537, Email: Moliterno{at}uky.edu

Herzfrequenzsenkung als Therapieziel: neue Möglichkeiten

Elevated heart rate is associated with increased cardiovascular mortality. Heart rate reduction optimises myocardial oxygen consumption and decreases angina pectoris symptoms. Thus, heart rate control is an important therapeutic strategy in coronary artery disease and, for example, chronic heart failure. The pacemaker current I(f) plays a central role in determining spontaneous activity of the sinus node. Ivabradine, a selective inhibitor of the I(f) channel, reduces heart rate without any effect on cardiac contractility and without lowering blood pressure. While beta-blockers remain the first choice for heart rate reduction, in cases of adverse effects ivabradine may be used to treat stable angina pectoris. Studies evaluating possible further uses, for example in heart failure or after acute myocardial infarction, are still warranted.

Angina and Cardiac Care

Differences in cardiac care according to gender have now been described for 20 years. As early as 1987, Tobin et al1 reported that 40% of male patients with abnormal exercise radionuclide scans were referred for cardiac catheterization, whereas only 4% of the female patients were referred for future testing. Since then, many investigations have continued to describe a less aggressive management strategy for coronary artery disease (CAD) in women than in men in a variety of settings, but predominantly in patients with acute coronary syndromes.2–11 Article p 490 Women are normally protected against CAD as compared with men until elderly age, but once they experience an acute myocardial infarction (MI), they have poorer outcomes than their male counterparts, particularly if they are younger than 60 years.12,13 It is possible that underrecognition and undertreatment of CAD in its early phase in women is a contributory factor. This may lead to 2 possible scenarios: (1) a more advanced or complicated disease at the time of MI due to lack of preventive treatment, and (2) referral bias due to the fact that only the most severely affected or the most symptomatic women with CAD are eventually diagnosed and treated. Angina pectoris is the most common initial presentation of symptomatic CAD in women and therefore represents, in many cases, the starting point in the sequence of healthcare delivery events that may result in gender-related inequalities. If there is lower utilization of noninvasive diagnostic testing at this initial point of care, it may translate into delayed diagnosis, delayed initiation of therapeutic interventions, and ultimately worse outcomes. Recognition of such underutilization, therefore, would shed light on whether the more advanced level of symptom severity, comorbidity, and often worse outcomes of women at the time of an MI are due to earlier undertreatment or …

Inflammation in coronary artery disease: potential role for immunomodulatory therapy

Understanding of the mechanisms underlying atherosclerotic disorders has evolved beyond the view of a progressive collection of lipids and cellular debris in the vascular wall. Current evidence has implicated inflammatory pathways as an important pathogenic mechanism in atherogenesis and plaque destabilization. Although not necessarily the primary event, inflammation and cytokine activation during plaque formation and destabilization may represent a common final pathway to various stimuli. Thus, it seems that not only ‘new’ risk factors, such as infections with various microorganisms, but also classic risk factors for cardiovascular disease, such as hyperlipidemia, hypertension and diabetes, may promote their atherogenic effects through inflammatory rersponses. Indeed, recent reports have suggested that traditional cardiovascular medications may attenuate atherogenesis and enhance plaque stability, at least partly through anti-inflammatory mechanisms. However, uncovering the inflammatory pathways in atherosclerosis has raised the possibility that newer treatment modalities should be more directly targeted against inflammatory mediators. Recently, a series of experimental studies have reported reduction of atherosclerosis by immunomodulatory therapy, such as chemokine blockade, interleukin-10 and immunization/vaccination against oxidized low-density lipoprotein and heat-shock protein. It is conceivable that some of these approaches will be tested clinically and, if successful, they could provide novel treatment strategies in coronary artery disease in humans.

Noncardiac Surgery: Evaluating and Minimizing Cardiac Risk

Perioperative cardiac complications remain a great concern during noncardiac surgeries since a large majority of patients undergoing such procedures are elderly, who have a greater prevalence of coronary artery disease. Thus, it is imperative to assess risk of perioperative cardiac complications in all patients scheduled for noncardiac surgery. The current review attempts to outline a systematic approach to assess cardiac risk for noncardiac surgery and suggest strategies to minimize these risks. This approach uses a combination of the urgency of noncardiac surgery, interval since prior revascularization to noncardiac surgery, the interval between prior evaluation of coronary artery disease, patients clinical risks for cardiac complications, and patients functional status to decide their perioperative cardiac risks. If surgery is urgent or the estimated risk for perioperative event is low, then irrespective of the risk, patients should proceed with noncardiac surgery under the influence of appropriate medical strategy to minimize risk. If patients risk of perioperative events is high, then postponing or canceling surgery and referral for invasive approach to identify and when appropriate revascularize coronary artery disease may help reduce the perioperative cardiac risk. In contrast, patients at intermediate risk for perioperative events may benefit from noninvasive assessment for coronary artery disease and referral for appropriate patients for coronary revascularization based on the results of such noninvasive testing. Medical perioperative strategy that should be part of all patients undergoing noncardiac surgery who have or are at risk for coronary artery disease, should include betablockers, adequate analgesia, monitoring fluid status, and maintaining hematocrit > 30 gm /dl. Finally, the physician-patient interaction during the hospitalization during noncardiac surgery should be recognized as an important opportunity to institute secondary prevention strategies for coronary artery disease in patients at risk for coronary atherosclerosis. Keywords: coronary artery disease, non-cardiac surgery, myocardial infarction, revascularization, electrocardiogram, functional capacity

Cardiovascular Risks in a Military Health Care Beneficiary Population with High Blood Pressure

Prevention strategies for coronary artery disease among hypertensive patients require assessment of other modifiable risk factors in the target population. In this article, we describe the prevalence of other cardiovascular risk factors in military beneficiaries with high blood pressure (HBP). Baseline data from an ongoing randomized clinical trial designed to test effectiveness of a comprehensive HBP intervention are used in the analysis. A total of 147 beneficiaries from a military health system participated in this study. Findings indicate that the rate of HBP control in this sample was suboptimal (32%: blood pressure < 140/90). Other prevalent cardiovascular risk factors include high cholesterol, obesity, and diabetes. Many of these patients (31.3%) are also in the moderate-to-high danger level of developing coronary artery disease in the near future. These findings warrant a regular assessment of cardiovascular risk factors and rigorous behavioral interventions for all beneficiaries of the military health care system.

Coronary atherosclerosis and somatic mutations: an overview of the contributive factors for oxidative DNA damage.

Coronary artery disease (CAD) is a multifactorial process that appears to be caused by the interaction of environmental risk factors with multiple predisposing genes. Genetic research on CAD has traditionally focused on investigation aimed at identifying disease-susceptibility genes. Recent evidence suggests that somatically acquired DNA mutations may also contribute significantly to the pathogenesis of the disease, underlining the similarity between atherosclerotic and carcinogenic processes. The generation of oxidative stress has been emphasized as an important cause of DNA damage in atherosclerosis. This review highlights some of the major atherogenic risk factors as likely mediators in the oxidative modification of DNA. It also examines the hypothesis that an increase in oxidative stress may derive from "oxidatively" damaged mitochondria. Accordingly, further research in this field should be given high priority, since increased somatic DNA damage could be an important pathogenic factor and an additional prognostic predictor, as well as a potential target for therapeutic strategies in coronary artery disease.

Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm.

In the process of establishing a less invasive assessment strategy for coronary artery disease (CAD) in patients with infrarenal abdominal aortic aneurysm (AAA), the incidence of CAD and the surgical and mid-term outcomes were reviewed. From January 1994 through September 2001, 94 elective surgical repairs of AAA were carried out. Preoperative coronary angiography showed 43 patients (45.7%) had CAD: 29 (67.4%) were asymptomatic, 23 had single-vessel disease (1VD), 12 had 2VD and 8 had 3VD. Of the 43 patients with CAD, 19 (44.2%) underwent coronary interventional therapy before aortic surgery (11 percutaneous transluminal coronary angioplasty (PTCA), 8 coronary artery bypass grafting). Eight asymptomatic patients underwent coronary interventional therapy. None of the patients died of cardiac causes or experienced a postoperative cardiac event. During the follow-up period, 10 late deaths occurred: 7 patients with CAD, and 3 cerebrovascular or cardiac deaths. There was no statistical difference in the survival rate between the groups with and without CAD. Two patients with CAD underwent PTCA during the follow-up period. The findings confirm the need for a less invasive assessment strategy of CAD that does not overlook asymptomatic myocardial ischemia, because the incidence of CAD in patients with AAA is high.

Electron-beam tomography coronary calcium scores are superior to framingham risk variables for predicting the measured proximal stenosis burden

Previous studies of electron-beam tomography (EBT) have correlated coronary calcium scores with simplistic visual estimates of disease severity. In a clinical trial designed to evaluate 2 treatment strategies in coronary artery disease (CAD) patients with low levels of high-density lipoprotein cholesterol, we used quantitative coronary angiography to measure composite proximal stenosis burden from the baseline coronary angiogram and assessed the traditional Framingham risk variables in 146 patients. Stenosis burden is the sum, per patient, of percent stenosis for the worst lesion found in each of 9 standard proximal coronary segments. EBT estimates of coronary calcium (Agatston score, calcium volume score) were obtained for 115 of these patients. Stenosis burden was correlated with the calcium scores and risk variables. The best traditional correlates of stenosis burden were smoking status (r = 0.31, p = 0.001), prior myocardial infarction (r = 0.24, p = 0.005), body mass index (r = 0.23, p = 0.005), pack-years smoking (r = 0.20, p = 0.05), and age (r = 0.17, p = 0.04). With adjustment for age, all these correlations improved (eg, body mass index × age [r = 0.28, p = 0.001]). In addition, total cholesterol × age (r = 0.22, p = 0.008), fibrinogen × age (r = 0.19, p = 0.03), and systolic blood pressure × age (r = 0.18, p = 0.03) became significant correlates. Spearman correlations of the calcium scores with stenosis burden were considerably greater (Agatston: r = 0.62, p <0.0001; calcium volume: r = 0.63, p <0.0001). In multivariate regression analysis, calcium score, body mass index, and history of myocardial infarction were independent correlates of stenosis burden (R 2 = 0.45). At a given point in time, the EBT coronary calcium scores are greatly superior to the Framingham risk factors in predicting the measured proximal stenosis burden. Agatston and calcium volume scores are comparably predictive of stenosis burden.

Diagnostic tools and management strategies for coronary artery disease in patients with end-stage renal disease

Patients with renal disease often have coexistent coronary artery disease (CAD). The 5-year survival rates are < 50% and cardiovascular disease accounts for nearly half of the deaths in patients with end-stage renal disease (ESRD) on maintenance dialysis. Renal disease is often caused by hypertension or diabetes mellitus, both very strong risk factors for the development of CAD. Other patients develop hypertension after the onset of their renal disease. These coexistent diseases partially contribute to the increased incidence of CAD in the renal patient. Managing physicians must maintain a high index of suspicion and interpret the results of diagnostic studies with this high pretest probability in mind. Consideration should be given for screening for the presence of ischemic heart disease in patients with ESRD and no symptoms, especially if being considered as renal transplant recipients. It remains most important to adequately treat the associated risk factors and specifically, aggressively control the blood pressure. This report discusses the known and suspected reasons for the highly associated coexistent CAD, methods for diagnosing and risk-stratifying CAD, and renal-specific guidelines for appropriate treatment.

Diagnostic testing strategies for coronary artery disease: Special issues related to gender

Early reports of the prevalence, diagnosis, and outcomes of coronary artery disease (CAD) in women have led to the acceptance of several myths concerning noninvasive diagnostic studies in women. Many of the myths can be explained by age-related differences in prevalence, methodological errors that exclude women from enrollment, worse clinical baseline risk profiles, comorbid diseases at the time of interventions, and smaller coronary vessels. Awareness of these age-related prevalence factors in women and the potential for delaying the onset of CAD by estrogen treatment in postmenopausal women must be considered in assessing the accuracy of diagnostic studies. The critical role of noninvasive testing in women is to diagnose CAD accurately in a population with a lower prevalence of disease prior to the development of more severe clinical manifestations when therapeutic interventions have a higher risk and a poor outcome. Exercise radionuclide ventriculography has lower specificity in women, which may be due to gender differences in the response to excercise. Radionuclide perfusion imaging for the detection of CAD is accurate, there is extensive published literature, and it is used widely. High-dose dipyridamole in combination with echocardiography is not widespread in the United States; most pharmacologic echocardiographic studies are performed using dobutamine, and there are no reports on gender differences using dobutamine echocardiography. At this time, however, there is a paucity of published data on accuracy and no information on the prognostic value of this method. Both perfusion imaging and echocardiography have a better diagnostic accuracy than electrocardiographic stress testing. Myocardial perfusion imaging with thallium-201 or Tc-99m sestamibi identifies not just the presence or absence of CAD, it also prognostically identifies those patients with more severe disease who may benefit from invasive diagnostic testing and possible therapeutic interventions. Technetium-99m perfusion agents offer several advantages over thallium-201 : less attenuation, the ability to measure first-pass ejection fraction, and gated image acquisition. All 3 of these characteristics are expected to improve both sensitivity and specificity in women. Early reports of the prevalence, diagnosis, and outcomes of coronary artery disease (CAD) in women have led to the acceptance of several myths concerning noninvasive diagnostic studies in women. Many of the myths can be explained by age-related differences in prevalence, methodological errors that exclude women from enrollment, worse clinical baseline risk profiles, comorbid diseases at the time of interventions, and smaller coronary vessels. Awareness of these age-related prevalence factors in women and the potential for delaying the onset of CAD by estrogen treatment in postmenopausal women must be considered in assessing the accuracy of diagnostic studies. The critical role of noninvasive testing in women is to diagnose CAD accurately in a population with a lower prevalence of disease prior to the development of more severe clinical manifestations when therapeutic interventions have a higher risk and a poor outcome. Exercise radionuclide ventriculography has lower specificity in women, which may be due to gender differences in the response to excercise. Radionuclide perfusion imaging for the detection of CAD is accurate, there is extensive published literature, and it is used widely. High-dose dipyridamole in combination with echocardiography is not widespread in the United States; most pharmacologic echocardiographic studies are performed using dobutamine, and there are no reports on gender differences using dobutamine echocardiography. At this time, however, there is a paucity of published data on accuracy and no information on the prognostic value of this method. Both perfusion imaging and echocardiography have a better diagnostic accuracy than electrocardiographic stress testing. Myocardial perfusion imaging with thallium-201 or Tc-99m sestamibi identifies not just the presence or absence of CAD, it also prognostically identifies those patients with more severe disease who may benefit from invasive diagnostic testing and possible therapeutic interventions. Technetium-99m perfusion agents offer several advantages over thallium-201 : less attenuation, the ability to measure first-pass ejection fraction, and gated image acquisition. All 3 of these characteristics are expected to improve both sensitivity and specificity in women.

Diagnostic testing strategies for coronary artery disease: Special issues related to gender

Early reports of the prevalence, diagnosis, and outcomes of coronary artery disease (CAD) in women have led to the acceptance of several myths concerning noninvasive diagnostic studies in women. Many of the myths can be explained by age-related differences in prevalence, methodological errors that exclude women from enrollment, worse clinical baseline risk profiles, comorbid diseases at the time of interventions, and smaller coronary vessels. Awareness of these age-related prevalence factors in women and the potential for delaying the onset of CAD by estrogen treatment in postmenopausal women must be considered in assessing the accuracy of diagnostic studies. The critical role of noninvasive testing in women is to diagnose CAD accurately in a population with a lower prevalence of disease prior to the development of more severe clinical manifestations when therapeutic interventions have a high risk and a poor outcome. Exercise radionuclide ventriculography has lower specificity in women, which may be due to gender differences in the response to exercise. Radionuclide perfusion imaging for the detection of CAD is accurate, there is extensive published literature, and it is used widely. High-dose dipyridamole in combination with echocardiography is not widespread in the United States; most pharmacologic echocardiographic studies are performed using dobutamine, and there are no reports on gender differences using dobutamine echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness analysis in heart disease, part III: Ischemia, congestive heart failure, and arrhythmias

Cost-effectiveness analyses were reviewed in the following diagnostic and treatment categories: acute myocardial infarction (MI) and diagnostic strategies for coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure (CHF), and arrhythmias. In the case of acute MI, coronary care units, as presently used, are rather expensive but could be made much more efficient with more effective triage and resource utilization; reperfusion via thrombolysis is cost-effective, as are β-blockers and angiotensin-converting enzyme (ACE) inhibitors post-MI in appropriate patients. Cost-effectiveness of CAD screening tests depends strongly on the prevalence of disease in the population studied. Cost-effectiveness of CABG surgery depends on targeting; eg, it is highly effective for such conditions as left-main and three-vessel disease but not for lesser disease. PTCA appears to be cost-effective in situations where there is clinical consensus for its use, eg, severe ischemia and one-vessel disease, but requires further analysis based on randomized data; coronary stents also appear to be cost-effective. In preliminary analysis, ACE inhibition for CHF dominates, ie, saves both money and lives. Cardiac transplant appears to be cost-effective but requires further study. For arrhythmias, implantable cardioverter defibrillators are cost-effective, especially the transvenous device, in life-threatening situations; radiofrequency ablation is also cost-effective in patients with Wolff-Parkinson-White syndrome apart from asymptomatic individuals; and pacemakers have not been analyzed except in the case of biofascicular block, where results were variable depending on the situation and preceding tests.

Impact of preintervention intravascular ultrasound imaging on transcatheter treatment strategies in coronary artery disease

Preintervention intravascular ultrasound (IVUS) imaging was performed in 313 target lesions in 301 patients. Revascularization strategy intended before imaging was compared with the treatment actually performed; there was a change in therapy in 124 lesions (40%) in 121 patients (40%). This induced: (1) assessment of lesion severity leading to revascularization when none had been planned (n = 20, 6%), (2) avoiding surgery or catheter-based revascularization that had originally been planned (n = 21, 7%), and (3) assessment of lesion composition leading to a change in revascularization strategy (n = 20, 6%) or for selecting the revascularization strategy (n = 63, 20%). Nine of these 121 patients were referred for coronary artery bypass graft surgery. IWS minimal lumen diameter correlated well with angiography (r = 0.83); however, a disagreement was the reason for deciding to perform or not to perform revascularization in 41 lesions (13%). IWS assessment of target lesion calcification, eccentricity and unusual morphology were the reasons for changing or selecting specific devices: (1) concentric and eccentric lesions with significant superficial calcium were treated with rotational atherectomy, excimer laser angioplasty or surgery; (2) eccentric lesions that did not contain significant superficial calcium were treated with directional atherectomy; (3) dissections and true aneurysms were treated with stent placement even if calcified; (4) thrombus-containing lesions in vein grafts were treated with thrombolytic therapy or extraction atherectomy, or both; and (5) fibrotic vein graft lesions were treated with balloon angloplasty or scent placement.

Reperfusion and revascularization strategies for coronary artery disease in women

Reperfusion and revascularization strategies for coronary artery disease in women

Reperfusion and Revascularization Strategies for Coronary Artery Disease in Women

One third of all deaths in women in the United States each year are attributable to coronary heart disease. Gender differences exist in the course and management of patients with coronary heart disease. Few randomized trials have been conducted in women to evaluate effective therapeutic strategies. With the aim of developing rational approaches to women with coronary heart disease, we review gender-related outcomes with coronary revascularization and reperfusion therapies. English-language journal articles and reviews on the subject of women with coronary heart disease or gender-specific responses to coronary heart disease management, from 1970 through 1992, identified through MEDLINE searching. Selected studies included only randomized controlled trials for topics related to thrombolysis, and articles considered to contribute significantly to the topic of women with coronary artery disease in the case of angioplasty and coronary artery bypass grafting. Two reviewers participated in extracting the data with the aim of presenting a balanced and comprehensive review of the subject. Thrombolysis in acute myocardial infarction reduces mortality in men and women, although women may have a reduced mortality benefit compared with men. Angioplasty and the newer interventional devices result in greater procedural morbidity but similar if not better long-term outcomes in women. Women may have a greater mortality rate than men with coronary artery bypass surgery, although studies suggest that outcome after bypass surgery may depend more on coronary size and preoperative risk factors than on gender itself. The existence of gender differences in the course of coronary heart disease and response to revascularization and reperfusion strategies suggests the need for unique clinical approaches to the female patient with coronary heart disease and stresses the importance of developing randomized trials that enroll adequate numbers of women and that are designed to answer gender-specific questions.

Treatment strategy for coronary artery disease: a balancing act

Treatment strategy for coronary artery disease: a balancing act

Combination of ambulatory electrocardiographic monitoring and psychological testing in coronary artery disease patients.

Ambulatory electrocardiographic monitoring and psychological testing were performed in 100 patients with chronic stable myocardial infarction. These patients were divided into four groups according to their chest pain and transient ST-segment depression by Holter monitoring during the follow-up period: group A, 40 patients without complications; group B, 20 patients with silent myocardial ischemia; group C, 14 patients with episodes of chest pain alone; and group D, 26 patients with postinfarction angina. Whereas group B had silent myocardial ischemia and extroversion, groups C and D were characterized by introversion and neuroticism. The frequency of multi-vessel disease was 41% for group A, 53% for group B, 8% for group C and 70% for group D. The patients of group B not only received treatment for coronary artery disease but also behavioral counseling and those of group C received psychotherapy. The results support the view that a combination of Holter monitoring and psychological testing is clinically useful for the development of therapeutic strategies for coronary artery disease.