Determinants of coronary artery bypass graft patency: 64 multidetector computed tomography versus coronary angiography

Multi-detector computed tomography [MDCT] of the coronary arteries is currently considered as a promising alternative to conventional coronary angiography [CA] in both native coronary arteries and coronary artery bypass grafts. The purpose of this study was to compare the diagnostic accuracy of 64 MDCT with that of invasive angiography in the detection of graft disease, and to investigate the clinical value of 64 MDCT in determining the factors affecting graft patency. Fifty symptomatic patients, 7.2 +/- 5.1 years after bypass surgery, were referred for 64 MDCT coronary angiography and standard invasive coronary angiography. Two independent, blinded observers assessed separately the results of both. The study included 174 grafts, 65 arterial grafts [37.4%] and 109 venous grafts [62.6%], The arterial grafts are 50 left internal mammary arteries [LIMA], 3 right internal mammary arteries [RIMA], and 12 radial artery grafts [RA]. 496 segments were analyzed and yielded, Per-segment detection of graft disease, a 99% sensitivity [89/90] and 100% specificity [379/379]. Patients with diseased grafts had older surgery [8.68 +/- 4.32 vs. 4.79 +/- 3.98 year p<0.001]. There were more patent arterial than venous grafts [54/65 vs. 66/109 p<0.01], and more patent LIMA than RA grafts [44/50 vs. 7/12 p<0.05]. The target vessels included 63 SVG to RCA and branches, 21 SVG to LCX-marginal, 25 SVG to LAD-Diagonals, 6 arterial grafts to LCX-marginal, and 59 to LAD- Diagonals. There were more patent grafts targeting LAD-Diagonals than others [73/174 [42%] vs. 47/174 [27%] p<0.001]. The target vessels size was larger in patent than diseased grafts in both arterial [2.74 +/- 0.44 mm vs. 2.0 +/- 0.63mm p<0.01] and venous [2.05 +/- 0.6mm vs. 1.55 +/- 0.7mm p_0.001] grafts. The target vessel lesions were tighter in patent than diseased grafts in both arterial [95.76 +/- 4.38% vs. 89.91 +/- 4.25% p<0.001] and venous grafes [92.21 +/- 5.98% vs. 79.28 +/- 16.4% p<0.001]. 64 MDCT can accurately delineate the patency and disease of bypass coronary grafts. LIMA to LAD remains the best optional graft. Large caliber target vessels with tight lesions are major determinant of grafts patency

Transthoracic doppler coronary flow patterns in patients with anterior myocardial infarction undergoing rescue percutaneous coronary intervention: angiographic, function recovery short and long term clinical correlates

Noninvasive Transthoracic Doppler [TTD] recording is a feasible attractive method to characterize different coronary flow velocity [CFV] patterns, however, its clinical application in the setting of percutaneous coronary intervention [PCI] need to be emphasized. To correlate CFV patterns of left anterior descending artery [LAD] with angiographic data, and to determine its impact on left ventricular [LV] function recovery and clinical outcomes following rescue PCI in patients with anterior myocardial infarction. Forty consecutive patients were studied 12 hours after PCI with stenting using high frequency transducer and 2nd harmonic imaging of LAD, to measure diastolic flow data [peak and mean diastolic velocities [PDV and MDV], deceleration time [DEC], pressure half time [P1/2]], and to record retrograde systolic wave [RSW]. Coronary angiographic data included epicardial flow grade [TIMI], and myocardial blush grade [MB]. LV function recovery was determined by percent changes of Tissue Doppler peak systolic myocardial velocity of middle septum [TDMV]. Clinical outcomes included short term [in hospital-three months], and long term [two years] major cardiac events [MACES]. Following PCI 32 pts achieved TIMI flow grade III flow [80%], while 26 patients had MB grade III [65%]. PDV and MDV were significantly higher in TIMI grade III [43.7 +/- 10.2 vs. 19.9 +/- 4.4 cm/sec p<0.014, and 20.41 +/- 7.8 vs. 11.32 +/- 4.92 cm/sec p<0.007 respectively], while DEC time and P1/2 time were significantly longer in MB grade III [383.96 +/- 82.36 vs. 174.24 +/- 62.92 msec p<0.001, and 134.1 +/- 38.18 vs. 76.9 +/- 15.49 msec p<0.001 respectively]. RSW was recorded in 22 pts [55%]. RSW correlated to lower MB grades than TIMI [14/22 vs. 0/18 P<0.0001 and 4/22 vs. 4/18 p=0.75 respectively], and associated with lower percent changes of TDMV [41.18 +/- 57.81% vs. 160.25 +/- 109.69% p<0.01]. All patients achieved 24 months follow up. Survival free events correlated more to higher grade of myocardial blush and absences of RSW but not correlated with TIMI flow grade [Kaplan-meier survival curve. p=0.0004, 0.007, and 0.32 respectively]. Noninvasive Transthoracic Doppler study of coronary flow provides intimate correlation to essential angiographic, functional, and clinical data in the setting of rescue PCI. Coronary flow velocities correlated with epicardial flow grade while time intervals related to myocardial blush grade. Clear recording of systolic retrograde Have is associated with impaired left ventricular function and poor clinical outcome

Impact of drug-eluting stents on treatment of long lesions in diabetic patients

The study was designed to evaluate in-hospital and mid-term clinical outcomes of drug-eluting stents in treatment of long lesions in diabetic versus non-diabetic patients. We studied 100 diabetic and 200 non-diabetic patients with long lesions >/= 20 mm treated with either Cypher or Taxus stents. The majority of the patients were males with a mean age over sixty years in both groups. Both groups were almost matched as regards demographic and clinical characteristics. The majority of patients in both groups presented with unstable angina [49% diabetics and 46.5% non-diabetics]. The incidence of multivessel disease was higher within the diabetic population The mean lesion length in diabetic group was 34.24 +/- 13.48 mm versus 36.68 +/- 16.32 mm in non-diabetic [p=0.11]. The mean percentage of multiple stents per lesion was 40.5% in diabetic patients versus 46.6% in non-diabetic patients [p=0.16]. The in-hospital Major Adverse Cardiac Events [MACE] rate was 10% in diabetic patients versus 7.5% in non-diabetic patients [p=0.25]. Only 2 patients [0.66%] had subacute stent thrombosis while there was no late stent thrombosis. After a mean clinical follow-up period of 328 +/- 127 days, there was no statistical difference between the two groups, in terms of survival [96.88%for diabetic vs. 98.96%for non-diabetic group at 15 months, p=0.29], While the midterm clinical outcome showed higher rate of MACE in uncontrolled diabetics [23.07%] than controlled diabetics [11.36%][p=0.016]. In selected group of patients, the stenting of long lesion with DES may be a good alternative to surgery with excellent mid-term outcome. Also, diabetes mellitus in the era of Drug-Eluting Stents [DES] has limited impact on outcome after PCI in long lesions when the glycemic state is well controlled

Percutaneous coronary interventions in patients with last remaining vessel disease

High-risk patients especially those with severe left ventricular dysfunction and having last single remaining vessel [SRV] for percutaneous coronary intervention [PCI] were excluded from all randomized trials. To evaluate the feasibility of PCI and long-term follow-up of these patients with last SRV. Between October 2000 and September 2005, 42 patients who consecutively underwent PCI in our center and fulfilled the criteria of SRV were followed-up for 2 years. The in-hospital outcome was excellent without any Major Adverse Cardiac Events [MACE]. At 30-day, 4.8% died suddenly and 2.4% had non-fatal non-Q wave Myocardial Infarction [MI] leaving us with 7.1% total MACE. The long term follow-up showed excellent results with a total MACE of 25%: Cardiac death of 8.3%, non cardiac [5.5%], and Target vessel Revasculariation [TVR] was 11.1%. At 2 years, those who died showed significantly more depressed systolic function, they were all diabetics [DM] and needed more than one stent than those who survived. Ejection fraction [EF] was 24.5 +/- 5.1 vs 35.2 +/- 7.9, P=0.006, DM, 100% vs 64.5%, P=0.109, and 100%vs 19.4%, P=0.0002 consecutively. The data show that PCI in last SRV is feasible, safe with an acceptable 30-days and 2 years mortality rate

Risk stratification in patients with coronary artery disease: the impact of aortic stiffness

Identification of individuals at high risk of coronary heart disease and future events is an important challenge for primary prevention of cardio-vascular disease. Intra-vascular ultrasound confirmed. the link between aortic stiffness and coronary atheromatous plaques, beside the proved relation between aortic elasticity and coronary endothelial function. The purpose of the present study was to assess the value of non-invasive assessment of aortic elastic properties by tissue Doppler versus conventional measures in predicting coronary artery disease and long-term risk of major coronary events. 48 pts with documented coronary artery disease [CAD] were compared to 12 pts with normal coronary angiogram. Ascending [A SC] aortic diameters and pulse pressure were used to calculateo aortic stiffness index. Pulsed wave velocity [PWV] measured as the time taken by the pulse wave to travel along the thoracic aorta. Systolic [SW] and diastolic [EW and A W] velocity waves of ASC and descending [DSC.] aortic wall were measured by tissue Doppler imaging. Patients with CAD had significantly higher Aortic stiffness index [14.77 +/- 5.31 vs. 8.94 +/- 1.76, p=0.0001], faster PWV [13.73 +/- 1.25 vs. 5.82 +/- 1.19 mlsec, p=0.0001], and slower ASC aortic wall velocities [SW [8.87 +/- 3.23 vs. 13.02 +/- 1, 3 cm/sec, p=0.003], EW [9.34 +/- 3.14 vs. By multivariate Cox model analysis, aortic stiffness [relative risk: 95% Cl: 6.4-10.6; P=0.001], SW velocity of ASC aorta [relative risk: 95% CI: 6.2-8.1; P=0.001], and PWV [relative risk: 95% CI: 12.5-15.92; P=0.01], were the strongest predictors of progression to any end-point. In patients with coronary artery disease, aortic stiffness properties are independent risk factors and predictors of major coronary events. Tissue Doppler recording of ascending aortic wall velocity is simple, non-invasive measurement of aortic elastic properties with good correlation and comparable prognostic value to conventional aortic stiffness parameters

Results of percutaneous coronary intervention in the elderly patients >/= 75 years presenting with acute coronary syndromes

In the setting of Percutaneous Coronary Intervention [PCI], older age [>/= 75 years] is one of the most major variables associated with an increased risk of complications. To investigate the prognosis of an invasive treatment in the elderly patients presenting with acute coronary syndromes [ACS[s]] in the clinical practice. Between September 2002 and March 2006, 219 patients aged 75 years or more presented with ACSS were reviewed. They were divided into two main groups: 84 [38.4%] underwent coronary angiography then revascularization, and 135 [61.6%] were treated medically. In the invasive group PCI was performed in [81%] of the patients whereas [19%] underwent coronary. Artery bypass grafting [CABG] within the hospital stay. In-hospital death/myocardial infarction [20.7% vs 10.7%, P=0.004] and 30-day outcome death / myocardial infarction [13.6% vs 2.6%, p=0.001] occurred significantly less often in patients with invasive strategy. The mean follow-up time was 26 +/- 12 months. Long-term follow-up showed a trend towards less hard end point events in the invasive group but this was not statistically significant [30% vs 20.1%, p=0.1]. The whole population was divided into a second two main groups: 44 patients presented with ST elevation myocardial infarction [STEMI] and 175 with non-ST elevation myocardial infarction [NSTEMI]. In-hospital as well as the long-term follow-up hard end point events were significantly less in the invasive group in patients with NSTEMI rather than the STEMI group; [18.9% vs 9.4% p=0.04], [25.3% vs 13%, p=0.04] and [29.2% vs 15%, p=0.1], [53.3% vs 50%, p= 0.5] consecutively. In clinical practice, an invasive strategy in the elderly patients presenting with NSTEMI improved in-hospital and 2 years outcome

Cutaneous manifestations of diabetes mellitus

To study the prevalence of cutaneous disorders in patients with diabetes mellitus. All diabetic patients attending the Department of Dermatology, Al-Farwaniya Hospital, Kuwait, and diabetic in-patients with skin disorders were examined over a period of 18 months from March 2004 to August 2005. A total of 106 diabetic patients displaying 1 or more dermatological manifestations were identified and thoroughly examined for any skin disorder. The diabetic profile of the patients was obtained from medical records. Of the 106 patients, 69 had only 1 cutaneous manifestation, 27 had 2, 6 had 3 and 4 had 4. Infections [68.0%] were the major cutaneous manifestations with fungal infection occurring in 41 patients followed by bacteria in 27. The second most common presenting symptom was pruritus. Hypertension [74%] was the most common systemic complication, and most of the diabetic patients who developed cutaneous manifestations were in the 40- to 60-year age group. The data show that infections were the most common cutaneous manifestation and hypertension the most common systemic complication

Impact of a clinical pathway for acute myocardial infarction on length of stay and quality of care in intensive care units of the critical care department of Alexandria Main University Hospital

A clinical pathway defines the optimal care process, sequencing and timing of interventions for a particular diagnosis or procedure. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this study is to determine whether clinical pathway implementation would alter process of care, hospital stay and mortality rates for acute myocardial infarction at Alexandria Main University Hospital. The study consisted of three phases: pre-intervention phase, development and dissemination of a clinical pathway for acute myocardial infarction and post- intervention evaluation phase. Process and outcome indicators were used to assess the quality of care provided to patients with acute myocardial infarction before and after implementation of the pathway. Results revealed that 4 process indicators out of 7 showed significant improvement namely, the utilization of thrombolytic therapy [from 76.9 to 88.5%], B-blockers at admission [from 28.5% to 50.0%], ACE inhibitors at discharge [from 61.2% to 75.2%] and smoking cessation counselling [from zero to 86.7%]. There was also reduction of variation in length of ICU stay as 67.7% achieved length of stay goal of 3 days after implementation of the pathway. ICU mortality was decreased from 20.8% to 6.9% after implementation of the pathway. These data suggest that the implemented acute myocardial infarction pathway lead to improved patient care and utilization of resources by providing a structured framework and educational guide to assist in the delivery of care to patients admitted with myocardial infarction

Early clinical and angiographic outcome of coronary stenting in thrombus-containing lesions

Percutaneous coronary intervention [PCI] and coronary stenting of thrombus-containing lesions have frequently been associated with an increased risk of adverse outcome. However, the strength of this association has varied and with the new antiplatelet agents and stents, it is not clear whether thrombus is still a risk factor after PCi. The study evaluated the early [in-hospital] clinical and angiographic outcomes of patients undergoing coronary stenting in lesions with angiographic evidence of intracoronary thrombus, A retrospective study comparing two groups of patients: Group I included 64 patients who undetwent stent implantation in a single thrombus containing lesion, Group II included 293 patients who underwent stent implantation in a single non-thrombus containing lesion during the same time period [between June 1997 and April 2001]. Both groups were matched as regards the baseline clinical characteristics except that significantly more patients of group I were presented by unstable angina compared with group II: 65.08% versus 47.78% [P<0.01]. Patients with thrombus [Group I] have significantly more RCA as the target vessel; 46.03% vs 30.03% [P<0.01] and significantly more complex lesion morphology; 42.86% vs 26.28% [P<005] compared with patients without thrombus [Group II]. The target vessel size and the baseline percent diameter stenosis were significantly higher In group I than group II [P<0.001 and P<0.01 respectively]. Similarly the largest balloon diameter and the mean number of inflations were significantly higher in group 1 than group II [P<0.001 and P<0.001 respectively]. Significantly more patients in group I received the GPIIb/I1Ia antagonist, tirofiban [Aggrastat] than group Ii; 20.63% vs 4.10% [P<0.001] although its use was rather limited in both groups. The angiographic success was almost identical for both groups 95.24% in group I vs 96.25% in group II. There were no statistically significant differences between both groups regarding all parameters of in-hospital outcomes, However, there was a trend towards more adverse events in group I compared to group II that did not reach statistical significance [Death: 1.59% vs 0.34%, Q-Mi: 3.17% vs 1.71%, Acute closure: 4.76% vs 2.05%, Repeat PCI: 4.76% vs 2.38%, Emergency CABG: 0% vs 0%, and Procedural success: 88.8% vs 94.28%]. Coronary stenting can be safely performed in patients with thrombus-containing lesions with excellent angiographic outcome and acceptable, though less favorable in-hospital clinical outcome

Mechanism of angina in patients with systemic hypertension and normal coronary angiogram

the purpose of this study was to investigate the changes in the coronary flow reserve in hypertensive patients with angina and normal coronary arteries, and its relation with coronary vasomotor response. the study population consisted of thirty hypertensive patients with angina and normal coronary angiogram [group I [non-LVH] n = 15 without left ventricular hypertrophy, group II [LVH] n = 15 with left ventricular hypertrophy and a matched healthy control group [group III n = 10]. Coronary velocity was monitored by means of transesophageal Doppler echocardiography basely and during infusion of [0.56 mg/kg per 4-minute] dipyridamole. Coronary flow reserve [CFR] was assessed as the ratio of mean diastolic velocity after dipyridamole and basal diastolic velocity. Coronary vasomotion was assessed by means of coronary catheterization as the changes in arterial caliber by acetylcholine and papaverine. Left ventricular mass, dimensions and function were measured by transthoracic echocardiography, Electrocardiography [ECG] changes were recorded by resting and exercise stress ECG. compared with the control group, CFR was decreased in both hypertensive groups [non-LVH = 1.56 +/- 0.22, LVH = 1.46 +/- 0.14, control = 3.49 +/- 0.60, P < 0.001]. The reduction in CFR depends on both an increase in resting coronary flow, and an impaired in maximal vasodilator capacity. Hypertensive patients who showed a positive exercise test have significant high resting mean diastolic coronary flow velocity [p < 0.01], and CFR showed positive correlation with exercise duration and rate-pressure product. Left ventricular mass had no effect on CFR, and wall stress was the major discriminating variable between non-LVH and LVH groups. imparied coronary flow reserve in hypertensive patients is the mechanism for the clinical syndrome of angina pectoris, abnormal electrocardigram but normal coronary arteries