ABSTRACT
We examined clinical outcomes with proton pump inhibitors (PPI) use within CYP2C19 genotype groups during clopidogrel treatment following acute myocardial infarction (AMI). 2062 patients were genotyped for CYP2C19*2 and *17 variants in TRIUMPH. 12 month clinical outcomes were analyzed among patients discharged on clopidogrel within CYP2C19*2 carrier, CYP2C19*17 carrier, and CYP2C19*1 homozygote genotype groups. PPI use was not associated with a difference in mortality. Among clopidogrel-treated Caucasians following AMI, PPI use was associated with a significantly higher rate of cardiac rehospitalization (HR 1.62, 95% CI 1.19-2.19; P=0.002) compared with no PPI use. PPI users who were carriers of the CYP2C19*17 variant experienced significantly higher rates of cardiac rehospitalization (HR 2.05, 95% CI 1.26-3.33; P=0.003), carriers of the CYP2C19*2 variant had a trend toward increased 1-year cardiac rehospitalization (HR 1.69, 95% CI 0.95-2.99; P=0.07), while no significant differences were observed among CYP2C19*1 homozygotes. These results indicate that the risks associated with PPI use among clopidogrel-treated Caucasian post-MI patients are impacted by CYP2C19 genotype, and suggest knowledge of genotype may be useful for personalizing PPI use among patients following AMI to reduce rehospitalization.
Subject(s)
Cytochrome P-450 CYP2C19/genetics , Genotype , Myocardial Infarction/drug therapy , Myocardial Infarction/genetics , Proton Pump Inhibitors/therapeutic use , Ticlopidine/analogs & derivatives , Adult , Aged , Clopidogrel , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Prospective Studies , Ticlopidine/therapeutic use , Treatment OutcomeSubject(s)
Anticholesteremic Agents/therapeutic use , Coronary Artery Disease/drug therapy , Coronary Circulation/drug effects , Hypercholesterolemia/drug therapy , Lipoproteins, LDL/blood , Vasodilation/drug effects , Coronary Artery Disease/blood , Endothelium, Vascular/drug effects , Humans , Hypercholesterolemia/blood , Treatment OutcomeABSTRACT
Dyspnea and arterial desaturation on upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS) and in some patients it is due to right-to-left shunt across the atrial septal defect (ASD)/patent foramen ovale (PFO). Surgical closure of ASD/PFO has been the only available treatment option. Buttoned device has been used for occlusion of ostium secundum ASD, PFO associated with presumed paradoxical embolism and cerebrovascular accidents and ASD/PFO in association with other congenital heart defects causing right-to-left shunt. The objective of this article is to describe the use of buttoned device in effectively occluding ASD/PFO to relieve hypoxemia of POS. During a 4-year period ending January 2000, 10 patients, ages 71 +/- 9 (range 60-83) years with POS underwent buttoned device closure of their ASD/PFO. Echocardiographic and balloon-stretched atrial defect sizes were 8 +/- 3 mm and 12 +/- 3 mm, respectively. The ASD/PFO were occluded with devices ranging in size from 25 to 40 mm delivered via 9 French, long, blue Cook sheaths; eight had an additional 25- or 35-mm occluder placed on the right atrial side. The oxygen saturation increased (P < 0.001) from 76 +/- 7% (range 69-86%) to 95 +/- 2% (range 92-98%). No complications were encountered. Relief of symptoms was seen in all patients. Follow-up of 1-36 months (median 12 months) revealed persistent improvement of symptoms. Buttoned device occlusion of ASD/PFO to relieve hypoxemia of POS is feasible, safe, and effective and is an excellent alternative to surgery. Cathet Cardiovasc Intervent 2001;54:77-82.
Subject(s)
Balloon Occlusion , Dyspnea/therapy , Heart Septal Defects, Atrial/therapy , Hypoxia/therapy , Prostheses and Implants , Prosthesis Implantation , Aged , Aged, 80 and over , Coronary Angiography , Dyspnea/diagnostic imaging , Dyspnea/etiology , Female , Heart Septal Defects, Atrial/complications , Heart Septal Defects, Atrial/diagnostic imaging , Humans , Hypoxia/diagnostic imaging , Hypoxia/etiology , Male , Middle AgedABSTRACT
To compare relative coronary artery vasodilator reserve (rCVR = CVRtarget/CVRreference) to myocardial perfusion stress imaging, 48 patients with coronary artery stenoses (61% +/- 16%; mean, +/- SD; range, 30%-91%) had measurements of target and reference vessel CVR (Doppler-tipped guidewire). rCVR was computed and compared to stress 201thallium or (99m)technetium-sestamibi myocardial tomography. Compared to 24 patients with negative stress imaging studies, 24 patients with positive stress studies had angiographically more severe stenoses (74% +/- 13% vs. 44% +/- 24%; P = 0.0005) with lower CVR(target) (1.68 +/- 0.55 vs. 2.46 +/- 0.74; P = 0.002) and lower rCVR (0.72 +/- 0.22 vs. 1.0 +/- 0.26; P < 0.003). Based on receiver-operator characteristic (ROC) cut points (CVR > 1.9; rCVR > 0.75), compared to CVR, rCVR had similar agreement (Kappa 0.54 vs. 0.50), sensitivity (63% vs. 71%), specificity (88% vs. 83%), and positive predictive value (83% vs. 81%) with myocardial perfusion tomography. A concordant CVRtarget/rCVR only slightly increased sensitivity, specificity, and positive predictive values (77%, 90%, and 87%, respectively). Although rCVR, like CVR, correlates with stress myocardial perfusion imaging results, rCVR did not have significant incremental prognostic value over CVR alone for myocardial perfusion imaging. However, rCVR does provide additional information regarding the status of the microcirculation in patients with coronary artery disease and complements the CVR for lesion assessment.
Subject(s)
Blood Flow Velocity/physiology , Coronary Disease/physiopathology , Perfusion , Adult , Aged , Coronary Disease/diagnostic imaging , Coronary Vessels/diagnostic imaging , Coronary Vessels/physiopathology , Exercise Test/methods , Female , Heart/diagnostic imaging , Humans , Linear Models , Male , Middle Aged , Predictive Value of Tests , Prevalence , ROC Curve , Sensitivity and Specificity , Tomography, Emission-Computed, Single-PhotonABSTRACT
BACKGROUND: The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) on long-term mortality rates in the presence of various demographic, clinical, and angiographic factors is uncertain in the population of patients suitable for both procedures. METHODS AND RESULTS: In the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial and registry, 3610 patients who were eligible to receive PTCA and CABG were revascularized between 1989 and 1992. Multivariate Cox models were used to identify factors associated with 5-year mortality and cardiac mortality, with particular attention to factors that interact with treatment. Diabetic patients receiving insulin had higher mortality and cardiac mortality rates with PTCA compared with CABG (relative risk [RR] 1.78 and 2.63, respectively, P<0.001), and patients with ST elevation had higher cardiac mortality rates with CABG than with PTCA (RR 4.08, P<0.001). Factors most strongly associated with high overall mortality rates were insulin-treated diabetes, congestive heart failure, kidney failure, and older age. Black race was also associated with higher mortality rates (RR 1.49, P=0.019). CONCLUSIONS: A set of variables was identified that could be used to help select a revascularization procedure and to evaluate risk of long-term mortality in the population of patients considering revascularization.
Subject(s)
Angioplasty, Balloon, Coronary/mortality , Coronary Artery Bypass/mortality , Myocardial Ischemia , Cause of Death , Diabetes Mellitus, Type 2/mortality , Female , Follow-Up Studies , Humans , Male , Middle Aged , Multivariate Analysis , Myocardial Ischemia/mortality , Myocardial Ischemia/surgery , Myocardial Ischemia/therapy , Predictive Value of Tests , Registries , Survival AnalysisABSTRACT
BACKGROUND: Absolute coronary flow velocity reserve (CVR) after stenting may remain abnormal as a result of several different mechanisms. Relative CVR (rCVR=CVR(target)/CVR(reference)) theoretically normalizes for global microcirculatory disturbances and facilitates interpretation of abnormal CVR. METHODS AND RESULTS: To characterize potential mechanisms of poststent physiology, CVR was measured using a Doppler-tipped angioplasty guidewire in 55 patients before and after angioplasty, after stenting, and in an angiographically normal reference vessel. For the group, the percent diameter stenosis decreased from 75+/-13% to 40+/-18% after angioplasty and to 10+/-9% (all P<0.05) after stent placement. After angioplasty, CVR increased from 1.63+/-0.71 to 1.89+/-0.55 (P<0.05) and after stent placement, to 2.48+/-0.75 (P<0.05 versus pre- and postangioplasty). After angioplasty, rCVR increased from 0.64+/-0.26 to 0.75+/-0.23 and after stent placement to 1.00+/-0.34. In 17 patients with CVR(stent) < or = 2.0, increased basal coronary flow, rather than attenuated hyperemia, was responsible in large part for the lower CVR(stent) compared with patients having CVR(stent) >2.0. In 8 patients with CVR(stent) <2.0, a normal rCVR supported global microvascular disease. The subgroup of 9 patients with CVR(stent) <2.0 and abnormal rCVR (16% of the studied patients) may require a pressure-derived fractional flow reserve to differentiate persistent obstruction from diffuse atherosclerotic disease or microvascular stunning. CONCLUSIONS: Although a majority of patients after stenting normalize CVR for the individual circulation (ie, normal CVR or normal rCVR), in those with impaired CVR(stent), the analysis of coronary flow dynamics suggests several different physiological mechanisms. Additional assessment may be required to fully characterize the physiological result for such patients to exclude remediable luminal abnormalities.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Circulation , Coronary Disease/therapy , Stents , Aged , Blood Flow Velocity , Coronary Angiography , Coronary Disease/physiopathology , Female , Humans , Male , Microcirculation , Middle Aged , RecurrenceABSTRACT
BACKGROUND: To test whether later intra-aortic balloon pump (IABP) deflation approaching or simultaneous with left ventricular ejection would improve hemodynamics and myocardial efficiency with the use of new balloon deflation methods, 4 IABP timing techniques were evaluated in 43 patients. METHODS AND RESULTS: Later balloon deflation produced significantly greater percentage changes in mean aortic pressure (6% vs 1%), systolic pressure time index (-27% vs -20%), diastolic pressure time index (35% vs 19%), and the systolic pressure-time index/diastolic pressure-time index ratio (97% vs 51%), respectively. However, these changes increased peak systolic pressure (-15% vs -11%). Cardiac output and stroke volume indexes were not significantly altered over the 4 settings. CONCLUSIONS: These data suggest that systemic hemodynamics and myocardial efficiency may be improved by later balloon deflation approaching left ventricular ejection in comparison to conventional IABP timing.
Subject(s)
Hemodynamics , Intra-Aortic Balloon Pumping/methods , Adult , Aged , Aged, 80 and over , Analysis of Variance , Echocardiography/methods , Echocardiography/statistics & numerical data , Echocardiography, Doppler/methods , Echocardiography, Doppler/statistics & numerical data , Female , Humans , Intra-Aortic Balloon Pumping/instrumentation , Intra-Aortic Balloon Pumping/statistics & numerical data , Linear Models , Male , Middle Aged , Time Factors , United StatesABSTRACT
Previous studies suggest that slow and/or oscillating balloon inflation during coronary angioplasty may decrease the incidence of coronary dissection and improve clinical outcomes. To compare the effect of slow oscillating versus conventional fast inflation techniques on the incidence of severe coronary dissection during angioplasty, 622 patients were randomized to slow oscillating inflation versus fast inflation. Angiographic outcomes of the procedures and in-hospital clinical events were recorded. The primary end point of severe (type C, D, E, F) dissection occurred in 7.7% of patients undergoing slow oscillation and 6.6% of patients undergoing fast inflation (p = 0.87). Major complications (death, urgent coronary artery bypass graft surgery, stroke, abrupt closure, or Q-wave myocardial infarction) occurred in 4.7% of patients undergoing slow oscillation and 3.5% of patients undergoing fast inflation (p = 0.45). The 2 inflation strategies did not differ in the pressure at which the balloon achieved full expansion, angiographic success rate, residual stenosis, and incidence of all minor and/or major complications. We conclude that there is no benefit of slow oscillating inflation over routine fast inflation in angioplasty. Slow oscillating inflation did not dilate lesions at lower pressures, decrease the incidence of dissection or severe dissection, or reduce the incidence of adverse clinical outcomes.
Subject(s)
Angioplasty, Balloon, Coronary/methods , Coronary Disease/therapy , Aged , Aortic Dissection/prevention & control , Angioplasty, Balloon, Coronary/adverse effects , Angioplasty, Balloon, Coronary/instrumentation , Cerebrovascular Disorders/etiology , Cineradiography , Coronary Angiography , Coronary Artery Bypass , Coronary Disease/physiopathology , Coronary Vessels/pathology , Electrocardiography , Female , Humans , Incidence , Male , Middle Aged , Myocardial Infarction/etiology , Recurrence , Survival Rate , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Epicardial and resistance vessel function in the transplanted heart has been evaluated primarily in regions supplied by a single vessel. Heterogeneity of flow among multiple perfusion fields as a marker of early endothelial dysfunction in the microcirculation has not been evaluated previously. This study tested the hypothesis that increased variability of coronary flow reserve (CFR) among multiple vascular regions would be associated with allograft coronary vasculopathy. METHODS AND RESULTS: One hundred six posttransplant patients undergoing cardiac catheterization had measurement of CFR in at least 3 major epicardial vessels. Patients were divided into those with minimal angiographic abnormalities (n=37) and those with no angiographic abnormalities (n=69). The ranges, coefficients of variation, and univariate and multivariate regression analyses of CFR were computed to determine the major clinical factors influencing the degree of variability. The abnormal angiographic group was older (54+/-11 versus 47+/-13 years; P<0.003), had older hearts (35+/-11 versus 27+/-10 years; P<0.005), and were further posttransplant (1626+/-1022 versus 931+/-984 days; P<0.0009). There was no difference in global CFR between groups (normal, 3.4+/-0.8 versus abnormal, 3.4+/-0.7; P=NS). The coefficient of variation of CFR was higher for the abnormal group (16.3+/-8.6% versus 11.0+/-5.5%; P<0. 0006). Univariate and multivariate predictors of increased variability in CFR included angiographic abnormalities, patient age, and body mass index. Both angiographic abnormalities and an elevated CV of CFR were predictive of a combined end point of death, congestive heart failure, or subsequent development of >/=50% coronary stenosis. CONCLUSIONS: These data demonstrate that increased variability of CFR is associated with discernible allograft coronary arteriopathy and is predictive of outcome in patients after heart transplantation.
Subject(s)
Coronary Circulation/physiology , Coronary Vessels/transplantation , Adult , Angiography , Case-Control Studies , Female , Hemodynamics/physiology , Humans , Male , Middle Aged , Multivariate Analysis , Predictive Value of Tests , Transplantation, HomologousABSTRACT
Although cardiac involvement has been commonly described in HIV-infected patients, cardiac tamponade is an unusual feature of AIDS-related non-Hodgkin's lymphoma. We describe an AIDS patient with undiagnosed non-Hodgkin's lymphoma presenting with hemodynamics of pericardial tamponade.
Subject(s)
Burkitt Lymphoma/complications , Cardiac Tamponade/physiopathology , Hemodynamics , Lymphoma, AIDS-Related/complications , Burkitt Lymphoma/diagnosis , Cardiac Catheterization , Cardiac Tamponade/etiology , Cardiac Tamponade/surgery , Echocardiography , Electrocardiography , HIV , Humans , Lymphoma, AIDS-Related/diagnosis , Male , Middle Aged , Paracentesis , Tomography, X-Ray ComputedABSTRACT
The application of absolute coronary velocity reserve, relative coronary velocity reserve, and pressure-derived fractional flow reserve of the myocardium may have influence on decision making for angioplasty and stenting in patients after myocardial infarction. This case highlights the use and limitations of these techniques in the setting of myocardial infarction where absolute coronary flow reserve may be commonly compromised. The role for absolute, relative coronary, and fractional flow reserve are discussed.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Circulation , Myocardial Infarction/physiopathology , Stents , Adult , Aged , Cineangiography , Coronary Angiography , Electrocardiography , Humans , Male , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/therapySubject(s)
Bioprosthesis , Heart Valve Prosthesis , Hemodynamics/physiology , Mitral Valve Stenosis/surgery , Postoperative Complications/physiopathology , Rheumatic Heart Disease/surgery , Aged , Cardiac Output/physiology , Equipment Failure Analysis , Exercise Test , Female , Humans , Mitral Valve/physiopathology , Mitral Valve Stenosis/physiopathology , Postoperative Complications/diagnosis , Pulmonary Wedge Pressure/physiology , Rheumatic Heart Disease/physiopathology , Ventricular Function, Left/physiologyABSTRACT
OBJECTIVES: This study sought to examine the mechanism of increasing coronary flow reserve after balloon angioplasty and stenting. BACKGROUND: Coronary vasodilatory reserve (CVR) does not improve after percutaneous transluminal coronary angioplasty in > or = 50% of patients, postulated to be due to impaired microvascular circulation or inadequate lumen expansion despite adequate angiographic results. METHODS: To demonstrate the role of coronary lumen expansion, serial coronary flow velocity (0.014-in. Doppler guide wire) was measured in 42 patients before and after balloon angioplasty and again after stent placement. A subset (n = 17) also underwent intravascular ultrasound (IVUS) imaging of the target sites after angioplasty and stenting. CVR (velocity) was computed as the ratio of adenosine-induced maximal hyperemic to basal average peak velocity. RESULTS: The percent diameter stenosis decreased from (mean +/- SD) 84 +/- 13% to 37 +/- 18% after angioplasty and to 8 +/- 8% after stenting (both p < 0.05). CVR was minimally changed from 1.70 +/- 0.79 at baseline to 1.89 +/- 0.56 (p = NS) after angioplasty but increased to 2.49 +/- 0.68 after stent placement (p < 0.01 vs. before and after angioplasty). IVUS lumen cross-sectional area was significantly larger after stenting than after angioplasty (8.39 +/- 2.09 vs. 5.10 +/- 2.03 mm2, p < 0.05). Anatomic variables were related to increasing coronary flow velocity reserve (CVR vs. IVUS lumen area: r = 0.47, p < 0.005; CVR vs. quantitative coronary angiographic percent area stenosis: r = 0.58, p < 0.0001). CONCLUSIONS: In most cases, increases in CVR were associated with increases in coronary lumen cross-sectional area. These data suggest that impaired CVR after angioplasty is often related to the degree of residual narrowing, which at times may not be appreciated by angiography. A physiologically complemented approach to balloon angioplasty may improve procedural outcome.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Disease/therapy , Coronary Vessels/physiopathology , Stents , Ultrasonography, Interventional , Vasodilation , Constriction, Pathologic , Coronary Angiography , Coronary Disease/diagnostic imaging , Coronary Disease/physiopathology , Coronary Vessels/diagnostic imaging , Coronary Vessels/pathology , Humans , Regional Blood FlowABSTRACT
Coronary angiography incompletely delineates the physiologic consequences of many epicardial stenoses. Intracoronary translesional flow velocity measurements using the Doppler flow wire during cardiac catheterization provide immediate data discriminating the physiologic significance of coronary stenoses. The validity and accuracy of the flow wire for analyzing lesion hemodynamic significance have been confirmed in multiple studies. Flow velocity analysis provides objective criteria for refining the selection of cases for revascularization, and prospective clinical data have confirmed the safety of deferring intervention on lesions with normal physiologic assessment. Translesional and distal coronary flow velocity dynamics during procedures also provide immediate data assessing the physiologic adequacy of intervention. Impaired postintervention distal coronary flow velocity and vasodilator reserve can predict subsequent clinical events, and comparisons of flow velocity indices prestenting and poststenting suggest that physiologically inadequate results of angioplasty may be improved by additional intervention. Flow velocity assessment may also have utility in profiling the adequacy of infarct artery reperfusion following acute myocardial infarction. Evidence has been accumulated to support use of Doppler flow velocity analysis as a clinically relevant technique for improving both diagnostic and therapeutic aspects of cardiovascular medicine.