Arteriographic demonstration of the release of coronary artery spasm by isosorbide dinitrate: a twenty-five-year retrospective.

It has been 25 years since my colleagues and I were first approached to apply the then newly emerging technique of coronary arteriography to the study of the effects of the new vasodilator isosorbide dinitrate (ISDN) on coronary arteries in vivo. Through a combination of careful patient assessment and serendipity, we were able to visualize the prompt release of coronary artery spasm by ISDN. Ensuing years have seen dramatic advances both in angiographic techniques and in the knowledge of ISDN efficacy. This review will briefly summarize the early work with ISDN and detail how the improvements in cineangiography have fostered better understanding of the actions of ISDN.

Acute myocardial infarction treated with intracoronary streptokinase: a report of the Society for Cardiac Angiography.

The Society for Cardiac Angiography maintains a registry of intracoronary streptokinase therapy (IC-SK) in patients with acute myocardial infarction. Between July 1981 and August 1984, 1,029 patients were entered into the registry. The baseline and clinical characteristics of patients were determined, the early results of therapy were evaluated, and baseline characteristics of those in whom reperfusion was achieved were compared with those in whom it was not. Multivariate discriminant analysis was used to identify the predictors of reperfusion and hospital mortality. The overall rate of reperfusion was 71.2%. Reperfusion was positively associated with hypotension, absence of cardiogenic shock and early treatment. The hospital mortality rate for all patients was 8.2% and was higher for women and the elderly. The hospital mortality was significantly lower among patients in whom reperfusion was achieved compared with those in whom it was not (5.5% vs 14.7%, p less than 0.0001) and for several high-risk subgroups. Thus, coronary artery reperfusion induced by IC-SK significantly reduces hospital mortality in high-risk patients with acute myocardial infarction. High-risk patients in whom reperfusion fails with IC-SK therapy should be considered for early coronary angioplasty or coronary artery bypass surgery.

Coronary reperfusion and Bezold-Jarisch reflex (bradycardia and hypotension).

This study reports the occurrence of bradycardia and hypotension (Bezold-Jarisch reflex) induced by myocardial reperfusion. Among 92 patients undergoing interventional catheterization for intracoronary thrombolysis in an early phase of acute myocardial infarction, left anterior descending, right coronary, and left circumflex (LC) arteries were identified as the "infarct vessel" in 44, 41, and 7 cases, respectively. The Bezold-Jarisch reflex occurred in 15 of 23 patients (65%) after right coronary recanalization and in 1 of 34 patients after left anterior descending recanalization. The reflex also was observed in 4 (22%) of 18 patients with nonoccluded or nonrecanalized right coronary arteries. The average time from onset of symptoms to right recanalization was significantly shorter (p less than 0.01) among patients in whom the reflex did not develop. Atropine, postural changes, or temporary pacing, or all 3, were generally sufficient to control symptoms. The findings of this study are substantially parallel to those reported by others and confirm that reperfusion of the inferoposterior myocardium is capable of stimulating a cardioinhibitory reflex. Follow-up data available in 15 patients with occluded and recanalized right coronary arteries indicate that the occurrence of the Bezold-Jarisch reflex after reperfusion is not a reliable predictor of myocardial salvage.

A comparative study of cephapirin, cephalothin, and methicillin in cardiovascular surgery.

An open, randomized study involving 217 patients undergoing elective cardiovascular surgery was undertaken to compare the effectiveness of cephapirin, cephalothin, and methicillin in preventing postoperative infections. One of the three antibiotics was assigned randomly to each patient and administered beginning 2 h before operation and continuing every 6 h for 5 days. There was no significant difference between the three study groups with respect to the incidence of infection (p = 0.9913). In both the cephalothin and methicillin groups, seven patients developed adverse reactions as compared with two patients in the cephapirin group. However, the difference was not statistically significant (p = 0.0788). The results from the investigation indicate that cephapirin, cephalothin, and methicillin are equally effective as prophylactic antibiotics when used perioperatively for cardiovascular surgery.

The use of injectable nitroglycerin in the cardiac catheterization laboratory. Nitroglycerin in cardiac catheterization.

At our institution, injectable nitroglycerin (TNG) has been employed during cardiac catheterization since 1976. Initially, it was primarily used in patients undergoing a provocative test for coronary spasm with ergonovine maleate. After the initial favorable experience, the use of injectable TNG became routine.

Mortality related to cardiac catheterization and angiography.

During a 14-month period, 75 deaths occurring in relation to 53,581 cardiac catheterizations were consecutively and prospectively reported to the Registry Committee of the Society for Cardiac Angiography. Three of the patients died several days after their catheterization from an unrelated cause and are excluded from this analysis. There were 21 patients (group I) who arrived at the laboratory in extremis and whose deaths were expected irrespective of the catheterization. Most of these patients suffered from recent myocardial infarctions and cardiogenic shock, or had complex congenital malformations. In 35 patients (group II), a cardiovascular complication occurring during the catheterization resulted in death. In 16 patients (group III) catheterization seemed uneventful, but death occurred suddenly 10 min to 10 h after the procedure. Of these 16 patients, eight had left main coronary artery obstruction greater than or equal to 90%, five had three-vessel disease all with 90% obstructions, one had 2-vessel disease both with 90% obstructions, and who had critical aortic stenosis. The 51 unexpected deaths (groups II and III) were considered to be causally related to the procedure, a mortality rate of 0.10%. Subsets with an increased mortality rate (M), were patients with: a) left main disease greater than 50% (M = 0.94%); b) ejection fraction less than 30% (M = 0.54%); c) NYHA class III or IV (m = 0.24%); d) age over 60 years (M = 0.23%); or e) three-vessel disease (M = 0.13%). In conclusion, catheterization related mortality occurs mostly in patients with far advanced cardiac disease. Nearly 1/3 of the unexpected deaths occurred suddenly after a seemingly uneventful procedure. Close monitoring after catheterization of patients with similar characteristics (left main disease greater than or equal to 90%, or three-vessel disease all greater than or equal to 90%) might disclose avenues for reducing mortality occurring after catheterization.

Relationship of age and biomedical risk factors to progression of coronary artery disease.

The relationship between age, biomedical risk factors and the progression of occlusive disease of the coronary arteries was studied in 176 patients (age range, 27-66 years) who had undergone at least two cine angiograms. The biomedical risk factors of interest were serum concentrations of cholesterol and triglycerides, smoking, hypertension, diabetes mellitus, family history of coronary disease, electrocardiographic abnormalities, obesity, and age. The findings did not reveal any significant differences in mean lipid levels between patients showing progression of disease and those who did not. However, the distribution of serum cholesterol values indicated more hypercholesterolemic patients among the disease-progression group, and more patients with ideal cholesterol levels among the no-progression group. The other biomedical variables did not appear to be related to the progression of coronary disease. Among the older patients, hypercholesterolemia and diabetes mellitus were related to disease progression. Among the younger patients, smoking was related to progression.

Bypass graft for coronary arterial stenosis following radiation therapy.

A 48-year-old man developed symptoms of progressive angina pectoris leading to myocardial infarction 12 years after two large doses of radiation for treatment of superior vena caval syndrome. Angiographic studies showed an isolated critical stenosis in the left anterior descending coronary artery, for which a successful surgical procedure for saphenous vein bypass graft was was performed. Coronary arterial stenosis following radiation therapy has been reported rarely, but this case supports the thesis that such lesion can be treated surgically.

[Indications and contraindications for surgery in coronary insufficiency]. / Indicazioni e controindicationi alla chirurgia dell'insufficienza coronarica

The indications to aortocoronary by-pass technique have during the last two years developed thanks to surgical, emodinamic and clinical exsperiences. The mortality of patients in whom surgery is limited electively to the intervention of aorto-coronary by-pass is at present around 4%. The principal indications to surgery are: a) existence of more than one coronary artery disease; b) a good diameter of the by-passing artery (more than 1 mm) corresponding to the site of the by-pass graft; c) a left ventricular telediastolic pressure lower than 20 mm of Hg; d) left ventricular function with ejection fraction not lesser than 0,40; e) absence of any associated severe and irreversible damages. The comparative data obtained recently from coronary patients medically and surgically treated would show at 4 years a survival rate higher than in those who underwent aorto-coronary by-pass.