Enhanced external counterpulsation for the treatment of angina pectoris.

The treatment of refractory chronic angina pectoris presents an increasing problem for all physicians caring for patients with coronary artery disease because of the large number of individuals who have either failed multiple revascularization procedures or are not appropriate candidates for such procedures. The aim of this study was to review the safety, efficacy, and clinical applicability of a noninvasive technique (external counterpulsation) for the treatment of angina pectoris. A MEDLINE search for all English language abstracts, meeting presentations, journal articles, and reviews from 1960 through December 2005 was conducted. Of the 194 citations in the literature, 60 appeared before 1983 when the enhanced version of the technique (the one that is presently used) was first reported. Criteria for further evaluation of the 134 post-1983 citations were either (1) randomized trial, (2) observational study of at least 10 patients, or (3) investigations into possible mechanisms. Of the 134 citations, 45 were used for data extraction. Observational studies from the United States, Asia, and Europe have demonstrated improvement in symptoms, reduction in anginal episodes, better quality of life, and improved exercise performance in over 5000 patients. The only randomized study (Multicenter Study of Enhanced External Counterpulsation) confirmed these findings as well as the continuation of clinical benefits at least 1 year posttreatment. Although the mechanisms by which diastolic augmentation achieves these beneficial results are still under investigation, this is a promising noninvasive therapy in a group of patients with limited treatment options.

Silent myocardial ischemia: recent developments.

Silent myocardial ischemia is now in its fourth decade of recognition as a clinical syndrome within the spectrum of coronary artery disease. Prior decades have seen important research into the pathophysiology, detection, prevalence, prognosis, and therapy of this syndrome. More recent developments have continued to add data to each of these areas, with particular emphasis on the comparative value of various diagnostic procedures and the effect of therapy on prognosis. While controversy still exists concerning proper screening guidelines for the asymptomatic population, there is a growing consensus that some form of stress testing in high-risk individuals (ie, those with multiple coronary risk factors) is appropriate.

False aneurysm of the mitral-aortic intervalvular fibrosa after uncomplicated aortic valve replacement.

False aneurysms of the mitral-aortic intervalvular fibrosa are rare and usually complicate aortic valve endocarditis. We report a case of a false aneurysm of the mitral-aortic intervalvular fibrosa after recent bioprosthetic aortic valve replacement in the absence of endocarditis.

Carga isquêmica total: definiçäo, mecanismos e implicaçöes terapêuticas / Total ischemic load: definition, action mechanism, therapeutic implications

O conceito de carga isquêmica total inclui todos os tipos de isquemia englobando tanto episódio silenciosos como sintomáticos. Presentemente, este conceito está causando uma reavaliaçäo dos objetivos terapêuticos atuais para pacientes com doença cardíaca coronariana. Embora o mecanismo da dor cardíaca ainda näo esteja esclarecido, temos algumas informaçöes acerca de outros mecanismos patofisiológicos que atuam neste distúrbio. Pensamos em isquemia como ocorrendo secundariamente a uma diminuiçäo de suprimento (isquemia primária), aumento de demanda (isquemia secundária), ou uma combinaçäo dos dois fatores (isquemia mista). Devido ao fato da menor freqüência cardíaca estar sendo associada a muitos episódios de isquemia durante as atividade diárias, sugerindo que a vasoconstricçäo está desempenhamdo um papel de desequilíbrio na relaçäo oferta/demanda, os antagonistas do cálcio parecem ser particularmente úteis no tratamento da vasoconstricçäo em pacientes anginosos