Endothelial dysfunction: therapy revisited (brief excerpts) (round table discussion on 18/01/2001 at Mumbai).

Indians have highest incidence of coronary heart disease. Here it occurs much more prematurely. Endothelial dysfunction has been increasingly recognised as an early event for the development of various cardiovascular disease. Long acting nifedipine has a definite role to play in reversing endothelial dysfunction.

Comparison of clinical outcome of fixed-dose subcutaneous low molecular weight heparin (tinzaparin) with conventional heparin in unstable angina: a pilot study.

Forty patients who were hospitalized for unstable angina were randomized to receive treatment with either regular heparin (Group I) in conventional dose as continuous infusion for 5 days or fixed-dose low molecular weight heparin (LMWH) (Group II), 3500 units subcutaneous twice daily for a period of 5 days. Both the groups were evenly matched with regard to age, sex presence of risk factors and adjunctive drug therapy. The clinical endpoints at the end of 5 day therapy were: recurrence of angina, occurrence of myocardial infarction and need for urgent revascularization. In Group I, 6 out of 20 patients had recurrence of angina, of whom 3 required urgent coronary angiography and revascularization. In Group II, 4 out of 20 patients had recurrence of angina, of whom one patient required urgent angiography and angioplasty. There were no bleeding complications in either of the groups. The recurrent anginal episodes in the conventional heparin group correlated with low aPTT values at the time of angina. Thus, this pilot study suggests that LMWH is equally effective in the treatment of unstable angina, the advantage of LMWH being the ease of administration and no need for monitoring aPTT levels during therapy.

Percutaneous transluminal coronary angioplasty (PTCA) in unstable angina.

We performed percutaneous transluminal coronary angioplasty in 33 highly selected patients of unstable angina, a majority of whom were initially stabilized by medical therapy. All these patients had single vessel disease with type A lesion. The initial success rate was 91% with recurrence of 17% at the end of 1 year.

Prognostic significance of predischarge 2D-echocardiography after first transmural myocardial infarction.

Predischarge two dimensional echocardiography (2D Echo) was performed in 45 survivors of first transmural myocardial infarction to assess its value in predicting major cardiac complications (MCC) during convalescence. Wall motion score was derived for each patient by analysing endocardial motion in 11 left ventricular segments. In 18 months follow up 11 of 14 patients (78%) who had major cardiac complications had wall motion score of at least 5. Wall motion score of less than 5 was present in 29 of the 31 (94%) of patients in asymptomatic group. Non-invasively obtained wall motion score helps in risk stratification of survivors of AMI. Wall motion score at predischarge 2D Echo or more identifies high risk cases from a relatively asymptomatic group (Killip Class I & II).

Coronary arteriographic findings soon after non Q wave myocardial infarction.

We performed early coronary arteriography in 27 patients (23 males, 4 females) having non Q wave MI. Infarct related vessel (IRV) was totally blocked in 25.9%, whereas 66.7% had severe residual stenosis (greater than or equal to 70%). Left main was involved in 7.5%, and at least 2 major coronary arteries were involved in 51.8%. Visible collaterals were seen in 11%. We feel, as compared to transmural MI, where total occlusion of IRV is common, the higher incidence of subtotal occlusion of IRV with severe residual stenosis, poor collaterals and significant involvement of at least one other major coronary artery may be responsible for observation of early recurrent ischemic episodes in non Q wave MI.

Pulsed Doppler derived indices in predicting noninvasively, pulmonary arterial pressures.

The pulsed doppler (P.D.) signals obtained in RVOT just below the pulmonary leaflets were used to calculate acceleration time (AcT), pre-ejection period (PEP) and their ratios. These indices were correlated in 31 patients (2 1/2-49 yrs. age) having varying cardiac lesions to Pulmonary arterial pressure (P.A.P) measured during cardiac catheterisation. The mean values of AcT for those with normal PAP was 137 +/- 19.9ms, as compared to 105 +/- 37 ms in those in whom PAP greater than 20mm of Hg. (t = 3.0.p less than .01). The P value was less than 0.001 when comparison was between normal PAP and severe PH. The ratios of PEP upon AcT was 0.87 +/- 0.18 for normal PAP, as compared to 1.39 +/- 0.74 in those with PH (t = 0.31, p less than 0.01). The PEP/AcT predicted systolic PAP 35.49 PEP/AcT + 3.22 (r = 0.77, p less than 0.001). The mean PAP was best predicted by 23.94 PEP/AcT + 2.44 (r = 0.75, p less than 0.001). The quantitative assessment showed presence of presystolic 'a' wave in all with normal PAP; this was absent in all the 9 patients with severe PH (MAPA greater than 40mm of Hg.). We conclude that noninvasively obtained P.D. derived indices can help accurately to predict PAP.