Nadroparin and percutaneous transluminal coronary angioplasty in elderly Thais with unstable angina.

Objective: Unstable angina (UA) is one of the leading problems in healthcare management in developing countries where facilities of catheterization laboratory are scarce and well-trained operators who are able to manage acute coronary syndrome often unavailable. In this scenario, strategy to arrive at optimal management to stabilize the condition medically is always a controversy. There is still controversy concerning the optimal management strategy during medical stabilization at places with inadequate catheterization laboratory facilities and a lack of well-trained operators who are able to manage acute coronary syndrome. Furthermore, the choices of medical and invasive management, including the use of percutaneous transluminal coronary angioplasty (PTCA) are still debatable. Curious by the challenge, we launch this prospective randomized controlled study to compare the efficacy of nadroparin with percutaneous transluminal coronary angioplasty (PTCA) in elderly patients with UA or non ST-elevation myocardial infarction (NSTEMI). Methods: Ninety-three elderly patients with UA, whose clinical manifestations were classified according to Braunwald’s classification, were recruited. All patients underwent coronary angiography within 96 hours after hospitalization; those who had angiographic coronary arterial stenosis that was feasible for PTCA were randomized to receive either nadroparin 7,500 IU subcutaneously twice daily for 5 days or PTCA. All clinical events in hospital and post-discharge up to 12 months, including death, composite end point [myocardial infarction (MI), recurrent angina/or ischemia], re-intervention (either PTCA or coronary artery bypass surgery) and rehospitalization, were recorded. Results: Only Forty-six patients were randomized equally into NAD group (n =23) and PTCA group (n =23). There were no statistically significant differences between NAD vs. PTCA regarding their baseline clinical characteristics, ECG, number of diseased vessels involved and outcomes (death and MI). The composite end point occurred more frequently in the NAD group [(34.5% vs. 4.3%); p = 0.01]. After a 12-month follow-up there was no difference in death rate or MI between the two groups but there was a clinically significant difference with regard to post-discharge outcomes in the NAD group, i.e, higher recurrent angina in NAD vs. PTCA (43.5% vs. 23.7%; p = 0.012), requiring additional PTCA (39.1% vs. 21.7%; p = 0.012), rehospitalization (47.8% vs. 30.4%; p = 0.015) and composite endpoint (47.8% vs. 30.4%; p = 0.015). Conclusions: PTCA achieve less composite endpoint than conservative management while nadroparin was easy to administer, but one-third of the patients still experienced recurrent angina or ischemia. PTCA is another option and could be performed safely, resulting in a less recurrent angina and shorter hospital stay. It is suggested that in the elderly with UA, nadroparin may be considered is the initial optimal management where PTCA facility is not available; those with recurrent angina symptoms should be referred afterwards for PTCA.

Changes in hematologic markers in patients with mitral stenosis after successful percutaneous balloon mitral valvuloplasty.

Systemic embolism is a major complication of mitral stenosis which is usually related to a presence of left atrial thrombus. Percutaneous balloon mitral valvuloplasty (PBMV) was previously reported to reduce the incidence of this complication. However, the mechanisms of this beneficial procedure was under investigated. The aim of this study was to investigate the changes in coagulation activity, platelet activity and endocardial function in 29 patients with mitral stenosis after successful PBMV. All subjects had good left ventricular systolic function and 48.3% had atrial fibrillation. There was a significant reduction in thrombin-antithrombin complex (TAT) after a successful procedure and the level of thrombomodulin was also significantly higher one month after successful procedure. However, the level of platelet factor 4 (PF4) and beta-thromboglobulin (beta-TG) were increased after this procedure but not achieved the statistical significance. In conclusion, successful PBMV can reduce the prethrombotic state in patients with mitral stenosis. In addition, it may improve endocardial function of the left atrium in those without atrial fibrillation.

Stent placement compared with balloon angioplasty for obstructed coronary artery disease in Thai elderly patients: initial result and 6 months follow-up.

Percutaneous Old Balloon Angioplasty (POBA) is accepted worldwide for the treatment of obstructive coronary artery disease because this technique is safe, and quick and the patient may return to work earlier than with bypass surgery (particularly elderly patients). But the major problem with POBA is restenosis which occurs between 20-40 per cent. Stent placement has been reported to reduce the restenosis rate to 10-20 per cent. OBJECTIVE: The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in elderly Thai patients with obstructive coronary artery disease. METHOD: The study was a randomized controlled trial. The sample size was 45 lesions in 42 patients who were assigned into 2 groups; 23 in the balloon angioplasty group and 22 in the stent placement group (Crown Stent). Clinical information and coronary angiography were recorded and performed at the time of the index procedure and six months later. RESULTS: There was 100 per cent procedural success in 22 lesions treated in the stent group and 82.6 per cent in the 23 lesions treated in the balloon angioplasty group. Patients in the stent group had a lesser degree of stenosis immediately after the procedure (8.78 +/- 8.63 vs 30.92 +/- 9.01%, p < 0.001) and a greater minimal luminal diameter (MLD) (3.04 +/- 0.44 vs 2.15 +/- 0.33 mm, p < 0.001). There were no major complications in either group during the procedure or during their hospital stay. These were not maintained at the six months follow-up. (26.88 +/- 16.23 vs 33.82 +/- 14.63 mm, p = 0.19, 2.28 +/- 0.67 vs 2.01 +/- 0.51 mm, p = 0.17) for the degree of stenosis and the MLD respectively. The restenosis rate, which was the primary endpoint of the study, was 4.5 per cent in the stent group and 21 per cent in the balloon angioplasty group (p = 0.10). CONCLUSIONS: Stenting in Thai elderly ischemic patients has a higher procedural success rate when compared with balloon angioplasty. The restenosis rate of stenting is also lower than that of balloon angioplasty but did not reach statistical significance. However, both techniques had no major complications either during the procedure or in-hospital.

An abnormal systemic and regional hypercoagulable state in patients with mitral stenosis.

Mitral stenosis still remains a major problem in Southeast Asia including Thailand. It contributes to the morbidity and mortality related to thromboembolism which was associated with the left atrial thrombus. However, the pathogenesis of left atrial thrombus in these patients is not completely understood. Therefore, the objective of this study was to investigate the coagulation and platelet activity including the function of the endocardium in the left atrium and peripheral circulation in patients with mitral stenosis who were free of left atrial thrombus and to compare those hematologic markers activity in the peripheral venous blood between the patients with mitral stenosis and the control. Thirty-six patients with moderate to severe mitral stenosis were included in the study. Most of the patients were in functional class II and 50 per cent had atrial fibrillation. Blood was obtained from the femoral vein, femoral artery, pulmonary artery and left atrium of these patients before heparin was administered to determine the value of various hematologic markers. In the control group, blood for determining the hematologic markers was collected only from the antecubital vein. The results of this study demonstrated that the levels of prothrombin activation fragment 1+2 (F1+2), thrombin-antithrombin III complex (TAT) and Beta-thromboglobulin (beta-TG) in the left atrium of the patients with mitral stenosis were significantly higher than those in the femoral vein and femoral artery, whereas the level of thrombomodulin was significantly lower in the left atrium compared with the femoral artery and vein. When comparing with the control group, the levels of TAT, plasminogen activator inhibitors-1 (PAI-1) from the peripheral vein were significantly higher and the level of thrombomodulin was also significantly lower in the patients with mitral stenosis. In conclusion, the present study demonstrated an abnormal hypercoagulable state of the left atrium and systemic circulation related to the abnormalities of coagulation, platelets and the endocardium which may cause the formation of left atrial thrombus in patients with mitral stenosis.

Early postoperative coronary angiography result in Off-pump Coronary Artery Bypass (OPCAB) patients.

Objective : The purpose of this study was to evaluate the early results of coronary artery bypass without cardiopulmonary bypass (off-pump coronary artery bypass - OPCAB) at Siriraj Hospital. Patients and methods : From September, 2001 to April 2002, eight selected coronary artery disease patients were operated on using the off-pump coronary artery bypass technique. Operative data were collected and postoperative coronary angiography was studied in all patients before discharge. Results : There were no death and no need to resort to the conventional procedure. Postoperative coronary angiography revealed good patency of all 17 grafts. Postoperative cardiac enzymes were elevated in one patient. Conclusion : The early of OPCAB in this study showed good outcomes. Early postoperative angiography demonstrated excellent anastormoses. This procedure needed fewer blood transfusions than the conventional technique. However, long-term follow up of these procedures should be evaluated.

Efficacy and safety of percutaneous metallic mitral valvuloplasty in rheumatic mitral stenosis at Siriraj Hospital.

Mitral stenosis is an important problem that leads to heart failure and stroke in Thailand. The options of treatment at present are either surgical or balloon mitral commissurotomy. However, the cost of balloon is very expensive. To reduce the expense of the procedure, the authors prospectively did a study using a new device called the metallic valvulotome in symptomatic severe mitral stenosis to assess the safety, feasibility and immediate outcomes. Fifty-seven patients were included in the study. The successful outcome achieved by the metallic valvulotome was 96.2 per cent in patients in whom the procedure was actually performed. The mean transmitral gradient, left atrial pressure and pulmonary artery pressure were significantly decreased and the mitral valve area was also significantly increased. Three cases failed the procedure due to inappropriate position of the septal puncture. No death occurred in the study and complications of the procedure included only two cases of hemopericardium. In the future, it is believed that this new innovative device will provide improvement and reduce the cost of the procedure in patients with severe mitral stenosis.

Discordant cardiac troponin results in amphetamine - related rhabdomyolysis.

A case of a patient who developed amphetamine-related rhabdomyolysis and acute renal failure after an intestinal operation is reported. He initially had biochemical evidence of myocardial injury, with a concomitant increase in cardiac marker proteins CK-MB, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) during the acute event. Following intensive treatment and improvement in renal function, levels of all myocardial marker proteins fell towards the normal range. Late in the course of the disease, however, there were re-elevations of CK-MB and cTnT, but not of cTnI, to levels exceeding 14 fold and 8 fold the upper limit of the reference range, respectively. Since, at present the possibility of re-expression of both CK-MB and cTnT in damaged and regenerating skeletal muscle can not be ruled out, the late occurrence of increased CK-MB and cTnT in our patient should not be interpreted as evidence of recurrent myocardial injury.