Efficacy of a one-catheter concept for transradial coronary angiography.

INTRODUCTION: Transradial coronary angiography (TRC) can be performed with a one-catheter approach for the right and left coronary ostium (R/LCO). We investigated the performance of a special diagnostic catheter widely used for the one-catheter-approach, the Tiger (Tiger II, TerumoTM). METHODS: In a dual center registry we analyzed 1412 TRC-procedures exclusively performed by experienced TRC-operators. We compared the performance of the Tiger with Judkins catheters by retrospectively judging ostial catheter stability during contrast injection, and by measuring contrast use, fluoroscopy time (FT) and complication rate. RESULTS: Poor or failed ostial engagement was found in 40.5% in the Tiger group, compared to 46.6% with the use of Judkins catheters (p<0.183). Ostial instability of the Tiger was found more often during engagement of the LCO than the RCO (34.4% vs. 10.8%, p<0.001), whereas it was similar in the LCO and RCO for Judkins catheters (27.4% vs. 26.7%, p = 0.840). TRC-procedures performed with Tiger catheters were associated with less contrast volume (63.48 ± 29.83mL vs. 82.51 ± 56.58mL, p<0.004) and shorter FT than with Judkins catheters. (198.27 ± 194.8sec vs. 326.85 ± 329.70sec). Forearm hematomas occurred less often with the Tiger (1.2% vs. 6.6%, p< 0.02). CONCLUSION: The Tiger employed as a single catheter in TRC is an effective tool to achieve lower contrast volume and fluoroscopy time at a low complication rate. Unstable engagement affects predominantly the left coronary artery, but its overall frequency is similar for both, the Tiger and Judkins catheters.

Impact of Center Experience on Patient Radiation Exposure During Transradial Coronary Angiography and Percutaneous Intervention: A Patient-Level, International, Collaborative, Multi-Center Analysis.

BACKGROUND: The adoption of the transradial (TR) approach over the traditional transfemoral (TF) approach has been hampered by concerns of increased radiation exposure-a subject of considerable debate within the field. We performed a patient-level, multi-center analysis to definitively address the impact of TR access on radiation exposure. METHODS AND RESULTS: Overall, 10 centers were included from 6 countries-Canada (2 centers), United Kingdom (2), Germany (2), Sweden (2), Hungary (1), and The Netherlands (1). We compared the radiation exposure of TR versus TF access using measured dose-area product (DAP). To account for local variations in equipment and exposure, standardized TR:TF DAP ratios were constructed per center with procedures separated by coronary angiography (CA) and percutaneous coronary intervention (PCI). Among 57 326 procedures, we demonstrated increased radiation exposure with the TR versus TF approach, particularly in the CA cohort across all centers (weighted-average ratios: CA, 1.15; PCI, 1.05). However, this was mitigated by increasing TR experience in the PCI cohort across all centers (r=-0.8; P=0.005). Over time, as a center transitioned to increasing TR experience (r=0.9; P=0.001), a concomitant decrease in radiation exposure occurred (r=-0.8; P=0.006). Ultimately, when a center's balance of TR to TF procedures approaches 50%, the resultant radiation exposure was equivalent. CONCLUSIONS: The TR approach is associated with a modest increase in patient radiation exposure. However, this increase is eliminated when the TR and TF approaches are used with equal frequency-a guiding principle for centers adopting the TR approach.

Anxiety is associated with a reduction in both mortality and major adverse cardiovascular events five years after coronary stenting.

OBJECTIVE: Previous studies in post-myocardial infarction patients with heart failure have documented that high anxiety levels are associated with increased mortality. In this prospective study, we determined the impact of anxiety on long-term event risk in stable coronary heart disease (CHD) patients treated with percutaneous coronary interventions (PCIs). METHODS: A total of 470 patients referred for PCI completed the Hospital Anxiety and Depression Scale (HADS) before undergoing stent implantation. Over a five-year follow-up period, data on survival, occurrence of major adverse cardiovascular events (MACEs) and repeat revascularization were obtained from n = 462 participants (98.3%). RESULTS: All-cause mortality rates differed significantly across the four quartiles of the HADS anxiety subscale, the lowest number of deaths (1.9%) being seen in patients with the highest HADS-A quartile (scores ≥ 10) as compared to those in the three lower quartiles (11.8%, odds ratio = 0.14, 95%-confidence interval (95% CI): 0.03-0.60, p = 0.002). Cox regression models adjusted for a variety of potential somatic and procedural confounders confirmed the results from the univariate analyses (hazard ratio (HR) = 0.21, 95% CI: 0.05-0.91, p = 0.037). There were also fewer MACEs in anxious patients as compared to non-anxious subjects (HR = 0.34, 95% CI: 0.14-0.80, p = 0.014). In contrast, anxious patients had a higher rate of repeat revascularization (26.4% versus 16.6%, p = 0.033). CONCLUSIONS: In CHD patients undergoing elective PCI, higher anxiety levels are positively associated with survival and reduce the risk for MACE during the first five years after index PCI. The beneficial effects of anxiety on cardiovascular mortality and morbidity suggest that a differentiated approach to diagnosing and treating anxiety in CHD patients is warranted.

Type D personality is unrelated to major adverse cardiovascular events in patients with coronary artery disease treated by intracoronary stenting.

BACKGROUND: Previous research in cardiac patients suggested that type D personality, defined as a combination of negative affectivity (NA) and social inhibition (SI), was associated with adverse outcome. PURPOSE: The objective of this prospective study was to examine the independent prognostic value of type D in patients with coronary artery disease (CAD). METHODS: A total of 465 patients completed the Type D Scale (DS14) questionnaire before undergoing stent implantation and were followed up for 5 years. RESULTS: In a Cox regression model adjusted for selected confounders, we found a trend towards NA for the prediction of nonfatal major adverse cardiovascular event (MACE, hazard ratio (HR) = 1.07, 95 % confidence intervals (CIs) = 0.99-1.14, p = 0.074), while, in contrast, SI was a significant and independent predictor of better outcome (HR = 0.92, 95 % CI = 0.86-0.99, p = 0.027). CONCLUSIONS: In a cohort of CAD patients, the type D pattern was not linked to adverse outcome, whereas SI was negatively associated with MACE.

Transient impact of baseline depression on mortality in patients with stable coronary heart disease during long-term follow-up.

OBJECTIVE: The objective of this prospective study was to determine the impact of depressive symptoms on long-term survival in coronary heart disease (CHD) patients treated with intracoronary stenting. METHODS: Four hundred and seventy patients completed the Hospital Anxiety and Depression Scale (HADS) before undergoing stent implantation and were followed over a 5-year period. Survival data were collected from n = 462 participants (98.3 %). A cut-off ≥8 on the HADS depression subscale was used to indicate probable clinical levels of depression. RESULTS: All-cause mortality rates differed significantly between depressed and non-depressed patients at 2-year follow-up, as 6 out of 98 subjects with elevated HADS-D scores (6.1 %), but only 8 out of 364 (2.2 %) patients with normal HADS-D scores had died [odds ratio = 2.9, 95 % confidence interval (95 % CI) = 1.0-8.6, p = 0.044]. In a Cox regression model adjusted for sociodemographic and clinical parameters, positive HADS-D scores [hazard ratio (HR) = 4.3, 95 % CI = 1.2-15.4, p = 0.025], body-mass index (HR = 0.8, 95 % CI = 0.7-1.0, p = 0.040) and stent length (HR = 1.1, 95 % CI = 1.0-1.1, p = 0.042) independently predicted 2-year survival. From the third to the fifth year after index PCI, the frequency of deaths in the depressed patients' group did not significantly differ from that observed in non-depressed patients (5.5 % versus 7.0 %, p = 0.607), and the predictive role of baseline HADS-D scores for survival was lost. CONCLUSION: In CHD patients, self-rated depressive symptoms at baseline were negatively linked to survival at 2-year follow-up, but failed to predict mortality 3 years later. Thus, in contrast to other well-established risk factors, the prognostic value of depression for predicting adverse outcome may be temporarily limited. The mechanisms behind this transient effect need further study.

Reduction of operator radiation dose by a pelvic lead shield during cardiac catheterization by radial access: comparison with femoral access.

OBJECTIVES: This study sought to determine the efficacy of patient pelvic lead shielding for the reduction of operator radiation exposure during cardiac catheterization via the radial access in comparison with the femoral access. BACKGROUND: Cardiac catheterization via the radial access is associated with significantly increased radiation dose to the patient and the operator. Improvements in radiation protection are needed to minimize this drawback. Pelvic lead shielding has the potential to reduce operator radiation dose. METHODS: We randomly assigned 210 patients undergoing elective coronary angiography by the same operator to a radial and femoral access with and without pelvic lead shielding of the patient. Operator radiation dose was measured by a radiation dosimeter attached to the outside breast pocket of the lead apron. RESULTS: For radial access, operator dose decreased from 20.9 ± 13.8 µSv to 9.0 ± 5.4 µSv, p < 0.0001 with pelvic lead shielding. For femoral access, it decreased from 15.3 ± 10.4 µSv to 2.9 ± 2.7 µSv, p < 0.0001. Pelvic lead shielding significantly decreased the dose-area product-normalized operator dose (operator dose divided by the dose-area product) by the same amount for radial and femoral access (0.94 ± 0.28 to 0.39 ± 0.19 µSv × Gy(-1) × cm(-2) and 0.70 ± 0.26 to 0.16 ± 0.13 µSv × Gy(-1) × cm(-2), respectively). CONCLUSIONS: Pelvic lead shielding is highly effective in reducing operator radiation exposure for radial as well as femoral procedures. However, despite its use, radial access remains associated with a higher operator radiation dose.

Depressive symptoms predict recurrence of atrial fibrillation after cardioversion.

OBJECTIVE: The aim of this study was to evaluate whether depressive symptoms and the type-D personality are predictive of early recurrence of atrial fibrillation (or atrial flutter; AF) after successful electrical cardioversion (CV). BACKGROUND: Depressive symptoms are associated with an adverse prognosis in patients with coronary artery disease, congestive heart failure, and ventricular arrhythmias. Anger and hostility have been shown to be predictive of development of AF. However, little is known about the effects of depression on AF. METHODS: Fifty-four patients with persistent AF completed the Hospital Anxiety and Depression Scale (HADS) and the Type D Scale (DS-14) prior to elective electrical CV. Patients with a successful CV were followed for 2 months. RESULTS: During the follow-up period, 27 patients (50%) had recurrence of the arrhythmia. Depressive mood (HADS depression scale >7) was the only significant nonsomatic predictor of recurrence, which was observed in 85% of depressed versus 39% of nondepressed patients [odds ratio=8.6; 95% confidence interval (CI)=1.7-44.0, P=.004]. HADS anxiety scores and the presence of the type-D personality pattern were not associated with recurrence of AF. On multivariate Cox regression analysis, including variables with a prevalence >10% of the total study population and a univariate discriminative effect yielding a P value of <.2, a HADS depression score >7 was found to be the only independently predictive variable of arrhythmia recurrence (hazard ratio=2.7; 95% CI=1.05-7.2; P=.046). CONCLUSIONS: Our results indicate that depressive mood is a major risk factor for recurrence of AF after electrical CV. Heightened adrenergic tone and a proinflammatory state are possible mechanisms responsible for the observed association. Identification of depression may be of value prior to the decision to perform electrical CV.

Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach.

Controversial data have been published on the amount of radiation exposure during radial coronary procedures. We hypothesized that in the current era, high-volume operators with optimal technique would not be exposed to higher radiation doses during radial procedures. A total of 297 patients undergoing cardiac catheterization (195 elective diagnostic coronary angiograms and 102 elective coronary interventions) were prospectively assigned in a random fashion to the radial access (RA) or femoral access (FA). All procedures were performed by the same operator with vast experience in radial procedures and standard measures for radiation protection were used. Operator radiation exposure was measured with an electronic radiation dosimeter attached to the breast pocket of the operator on the outside of the lead apron and estimates of the ambient dose equivalent were derived. For coronary angiograms, fluoroscopy time (2.8 +/- 2.1 vs. 1.7 +/- 1.4 min; P < 0.001) and dose-area product (15.1 +/- 8.4 vs. 13.1 +/- 8.5 Gy x cm(2); P < 0.05) were increased by 18% and 15%, respectively, for RA vs. FA. Operator radiation exposure was 100% higher for the RA compared to the FA (64 +/- 55 vs. 32 +/- 39 microSv; P < 0.001). For coronary interventions, fluoroscopy time (11.4 +/- 8.4 vs. 10.4 +/- 6.8 min; P = NS) and dose-area product (46.3 +/- 28.7 vs. 51.0 +/- 29.4 Gy x cm(2); P = NS) for RA and FA were not statistically different. However, operator radiation exposure was increased by 51% for the RA compared to the FA (166 +/- 188 vs. 110 +/- 115 microSv; P < 0.05). This study demonstrates that the radial approach is burdened with a 100% increase in operator radiation exposure during diagnostic coronary catheterization procedures and a 50% increase during coronary interventions, provided that no special devices for radiation protection are used. Measurements of radiation dose, such as fluoroscopy time and dose-area product, substantially underestimate the disproportionate rise in radiation exposure. Special precautions are warranted to improve radiation protection during invasive coronary procedures via the radial approach.

Woldemar Mobitz and His 1924 classification of second-degree atrioventricular block.

Woldemar Mobitz, an early 20th century German internist, analyzed arrhythmias by graphing the relationship of changing atrial rates and premature beats to AV conduction. Through an astute mathematical approach, he was able to classify second-degree atrioventricular block into 2 types, subsequently referred to as Mobitz type I (Wenckebach) and Mobitz type II (Hay). Type I AV block was most often due to digitalis and was reversible. There were no associated pathological findings. Type II AV block frequently progressed to complete AV block and was associated with seizures, death, and pathological findings.

Folate therapy and in-stent restenosis after coronary stenting.

BACKGROUND: Vitamin therapy to lower homocysteine levels has recently been recommended for the prevention of restenosis after coronary angioplasty. We tested the effect of a combination of folic acid, vitamin B6, and vitamin B12 (referred to as folate therapy) on the risk of angiographic restenosis after coronary-stent placement in a double-blind, multicenter trial. METHODS: A total of 636 patients who had undergone successful coronary stenting were randomly assigned to receive 1 mg of folic acid, 5 mg of vitamin B6, and 1 mg of vitamin B12 intravenously, followed by daily oral doses of 1.2 mg of folic acid, 48 mg of vitamin B6, and 60 microg of vitamin B12 for six months, or to receive placebo. The angiographic end points (minimal luminal diameter, late loss, and restenosis rate) were assessed at six months by means of quantitative coronary angiography. RESULTS: At follow-up, the mean (+/-SD) minimal luminal diameter was significantly smaller in the folate group than in the placebo group (1.59+/-0.62 mm vs. 1.74+/-0.64 mm, P=0.008), and the extent of late luminal loss was greater (0.90+/-0.55 mm vs. 0.76+/-0.58 mm, P=0.004). The restenosis rate was higher in the folate group than in the placebo group (34.5 percent vs. 26.5 percent, P=0.05), and a higher percentage of patients in the folate group required repeated target-vessel revascularization (15.8 percent vs. 10.6 percent, P=0.05). Folate therapy had adverse effects on the risk of restenosis in all subgroups except for women, patients with diabetes, and patients with markedly elevated homocysteine levels (15 micromol per liter or more) at baseline. CONCLUSIONS: Contrary to previous findings, the administration of folate, vitamin B6, and vitamin B12 after coronary stenting may increase the risk of in-stent restenosis and the need for target-vessel revascularization.