GP IIb/IIIa inhibitors in coronary artery disease management: what the latest trials tell us.
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Recent clinical trials have refined our understanding of how the glycoprotein (GP) IIb/IIIa inhibitors should best be used. These trials examined whether there are clinical differences between agents, whether empiric use of GP IIb/IIIa inhibitors in acute coronary syndromes is justified, and whether these drugs might allow for early invasive management in acute coronary syndromes. (+info)
Intravascular gamma radiation for in-stent restenosis in saphenous-vein bypass grafts.
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BACKGROUND: Intracoronary radiation therapy is effective in reducing the recurrence of in-stent stenosis in native coronary arteries. We examined the effects of intravascular gamma radiation in patients with in-stent restenosis of saphenous-vein bypass grafts. METHODS: A total of 120 patients with in-stent restenosis in saphenous-vein grafts, the majority of whom had diffuse lesions, underwent balloon angioplasty, atherectomy, additional stenting, or a combination of these procedures. If the intervention was successful, the patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium-192 or nonradioactive seeds. The prescribed dose, delivered at a distance of 2 mm from the source, was 14 to 15 Gy in vessels that were 2.5 to 4.0 mm in diameter and 18 Gy in vessels with a diameter that exceeded 4.0 mm. The primary end points were death from cardiac causes, Q-wave myocardial infarction, revascularization of the target vessel, and a composite of these events at 12 months. RESULTS: Revascularization and radiation therapy were successfully accomplished in all patients. At six months, the restenosis rate was lower in the 60 patients assigned to the iridium-192 group than in the 60 assigned to the placebo group (21 percent vs. 44 percent, P=0.005). At 12 months, the rate of revascularization of the target lesion was 70 percent lower in the iridium-192 group than in the placebo group (17 percent vs. 57 percent, P<0.001), and the rate of major cardiac events was 49 percent lower (32 percent vs. 63 percent, P<0.001). CONCLUSIONS: The results of our study support the use of gamma-radiation therapy for the treatment of in-stent restenosis in patients with bypass grafts. (+info)
Combined percutaneous treatment for pulmonary valve stenosis and atrial septal defect in an adult patient.
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Pulmonary valve stenosis and atrial septal defect are common forms of congenital heart disease; however, their association is relatively rare. When the two conditions are present simultaneously, significant left-to-right shunt is often prevented by the outflow obstruction, which protects the pulmonary bed until adulthood. This work describes a case of simultaneous percutaneous treatment of both congenital malformations. Although these procedures have been applied in isolation as methods of treatment, this case demonstrates the feasibility and effectiveness of a combined percutaneous treatment. (+info)
Smooth muscle cell outgrowth from human atherosclerotic plaque: implications for the assessment of lesion biology.
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OBJECTIVES: The purpose of this study was to determine whether the kinetics of smooth muscle cell outgrowth from in vitro explants of human atherosclerotic tissue is dependent on the nature of the atherosclerotic lesion in vivo. BACKGROUND: The use of techniques for percutaneous in vivo extraction of atherosclerotic plaque has provided the opportunity to study human atheroma-derived smooth muscle cells in culture. However, because of cell selection and changes in phenotype, in vitro findings may not always reflect the biologic properties of the vessel wall, particularly if cells are in culture for prolonged periods. In contrast, studies with nonhuman cells have suggested that the rate at which cells grow out of tissue explants is closely related to the status of the cells in vivo. METHODS: Atherosclerotic tissue from 41 lesions, including primary plaques (from peripheral arteries and venous bypass conduits) and restenotic lesions (from peripheral arteries and venous conduits) were divided into a total of 1,596 fragments and placed in culture on fibronectin-coated wells. Explant outgrowth was scored over the ensuing 1 month to determine the prevalence and time course of smooth muscle cell outgrowth and the total cellular accumulation. RESULTS: Explant fragments from 40 (98%) of the 41 lesions yielded an outgrowth of smooth muscle cells, confirmed by immunocytochemistry. The mean proportion of adherent explant fragments yielding outgrowth, per lesion, was 69 +/- 4% and was higher in restenotic tissue (81 +/- 3%) than in primary tissue (56 +/- 6%, p < 0.001). For primary lesions, initiation of outgrowth was half-maximal by 8.7 +/- 0.4 days; for restenotic explants, initiation of outgrowth was considerably faster (half-maximal by 5.9 +/- 0.6 days, p < 0.001). Similarly, accumulation of smooth muscle cells around an explant was significantly greater for restenotic lesions (2,791 +/- 631 cells/explant) than for primary lesions (653 +/- 144 cells/explant, p < 0.01). Labeling of first-passage cells with [3H]-thymidine indicated that cells from restenotic lesions had a 1.3-fold greater incorporation rate than did cells from primary lesions (p < 0.05). CONCLUSIONS: Smooth muscle cells may be reliably cultivated by explant outgrowth from a variety of human atherosclerotic plaque types obtained intraoperatively or percutaneously. The kinetics of outgrowth from restenotic tissue is distinctly different from that of outgrowth from primary tissue, suggesting a relation between the in vitro outgrowth behavior and the biology of the lesion in vivo. Assessment of smooth muscle cell outgrowth from human atherosclerotic plaque may thus represent a practical and reliable means to investigate the biologic behavior, including growth characteristics, of individual atherosclerotic lesions from human subjects. This technique may also offer a suitable assay system for evaluating therapies designed to inhibit lesion proliferation. (+info)
Mortality risk conferred by small elevations of creatine kinase-MB isoenzyme after percutaneous coronary intervention.
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OBJECTIVES: The aim of this study was to assess whether small creatine kinase-MB isoenzyme (CK-MB) elevations after percutaneous coronary intervention (PCI) affect the subsequent mortality risk. BACKGROUND: Several studies have evaluated the relationship of CK-MB levels after PCI with the subsequent risk of death. While there is consensus that elevations exceeding 5 times the upper limit of normal increase mortality significantly, there is uncertainty about the exact clinical impact of smaller CK-MB elevations. METHODS: We performed a meta-analysis of seven studies with CK-MB measurements and survival outcomes on 23230 subjects who underwent PCI. Data were combined with random effects models. RESULTS: Mean follow-up was 6 to 34 months per study. By random effects, 19% (95% confidence interval [CI], 16% to 23%) had one- to five-fold CK-MB elevations, while only 6% (95% CI, 5% to 9%) had >5-fold elevations. Compared with subjects with normal CK-MB, there was a dose-response relationship with relative risks for death being 1.5 (95% CI, 1.2 to 1.8, no between-study heterogeneity) with one- to three-fold CK-MB elevations, 1.8 (95% CI, 1.4 to 2.4, no between-study heterogeneity) with three- to five-fold CK-MB elevations, and 3.1 (95% CI, 2.3 to 4.2, borderline between-study heterogeneity) with over five-fold CK-MB elevations (p < 0.001 for all). CONCLUSIONS: Any increase in CK-MB after PCI is associated with a small, but statistically and clinically significant, increase in the subsequent risk of death. (+info)
Endoluminal perspective volume rendering of coronary arteries using electron-beam computed tomography.
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Remarkable progress has been made in the treatment of coronary heart diseases because of a variety of new interventional devices, but as each new device or procedure has suitability for a particular type of patient or purpose, patient selection is increasingly important. Endoluminal perspective volume renderings of the coronary arteries of a 70-year-old male with old myocardial infarction and recurrent chest pain were carried out using electron-beam computed tomography. Conventional coronary angiography had revealed significant stenosis of the distal portion of the left anterior descending branch, and subsequent conventional balloon angioplasty had failed to expand the stenotic site. Perspective volume rendering images can distinguish differences in objects and evaluate the cross sectional area of the lumen and the morphology of calcification. In the present patient, a huge mass of calcified plaque occupied most of the lumen at a site corresponding to the angiographic site of stenosis. According to this finding, rotational atherectomy was indicated and had a good outcome. The qualitative information for characterizing and determining the morphology of atherosclerotic plaque provided by perspective volume rendering may be useful in selecting the appropriate intervention. (+info)
Testing the performance of the ENRICHD Social Support Instrument in cardiac patients.
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BACKGROUND: Previous investigations suggest an important role of social support in the outcomes of patients treated for ischemic heart disease. The ENRICHD Social Support Instrument (ESSI) is a 7-item self-report survey that assesses social support. Validity and reliability of the ESSI, however, has not been formally tested in patients undergoing percutaneous coronary intervention (PCI). METHODS: The ESSI, along with the Short Form-36 (SF-36), was sequentially administered to a cohort of 271 patients undergoing PCI. The test-retest reliability was examined with an intra-class correlation coefficient by comparing scores among 174 patients who completed both instruments 5 and 6 months after their procedure. Internal reliability was assessed using Cronbach's alpha at the time of patients' baseline procedure. The concurrent validity of the ESSI was assessed by comparing scores between depressed (MHI-5 score < 44) vs. non-depressed patients. The correlation between the ESSI and the SF-36 Social Functioning sub-scale, an accepted measure of social functioning, was also examined. RESULTS: Test-retest reliability showed no significant differences in mean scores among ESSI questionnaires administered 1 month apart (27.8+/-1.4 vs 27.8+/-1.5, p = 0.98). The intra-class correlation coefficient was 0.94 and Cronbach's alpha was 0.88. Mean ESSI scores were significantly lower among depressed vs. non-depressed patients (24.6+/-1.7 vs 27+/-1.4, p < 0.018) and a positive albeit modest correlation with social functioning was seen (r = 0.19, p = 0.002). CONCLUSION: The ESSI appears to be a valid and reliable measure of social support in patients undergoing treatment for coronary artery disease. It may prove to be a valuable method of controlling for patient variability in outcomes studies where the outcomes are related to patients' social support. (+info)
OBJECTIVE: The purpose of this study was to examine the results of remote superficial femoral artery endarterectomy (RSFAE) in conjunction with distal aSpire stenting. METHODS: RSFAE is a minimally invasive procedure performed through a limited groin incision. Forty patients were included in the study. The indications for the procedure were claudication in 36 patients and limb salvage in 4 patients. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy. The distal atheromatous plaque was "tacked" with the aSpire stent, which is an expandable polytetrafluoroethylene-covered nitinol stent with high radial strength, yet is flexible and able to withstand compressive forces proximal to the knee joint. Before stent deployment, if the stent position is not optimal it can be wrapped down, repositioned, and re-expanded. Therefore, not only is the plaque end point tacked, but the collateral vessels may be preserved. All patients underwent follow-up examination with serial color-flow ultrasound scanning. RESULTS: The mean length of endarterectomized superficial femoral artery was 26.2 cm +/- 6.2 cm (range, 13-41 cm). The primary cumulative patency rate by means of life table analysis was 68.6% +/- 13.5% (SE) at 18 months (mean, 13.2 months; range, 1-31 months). During follow-up percutaneous transluminal balloon or stent angioplasty was necessary in 6 patients, for a primary assisted patency rate of 88.5% +/- 8.5% at 18 months. The locations of recurrent stenoses after RSFAE were evenly distributed along the endarterectomized artery. There were no deaths and one wound complication, and mean hospital length of stay was only 2.1 +/- 0.5 days. CONCLUSIONS: RSFAE with distal aSpire stenting is a safe and moderately durable procedure. If long-term patency rates are similar to those of above-knee femoropopliteal bypass graft, this procedure may prove to be a minimally invasive adjunct for the treatment of superficial femoral artery occlusive disease. (+info)