ABSTRACT
The glycoprotein (GP) IIb-IIIa inhibitor eptifibatide (INTEGRILIN, COR Therapeutics, Inc., South San Francisco, California, and Key Pharmaceuticals, Inc., Kenilworth, New Jersey) is a novel and highly potent antithrombotic agent indicated for the management of patients with non-ST-segment elevation acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention. The approval of eptifibatide for non-ST-segment elevation ACS was based on the positive results of the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. With enrollment of almost 11,000 patients, not only is the PURSUIT trial the largest trial of a GP IIb-IIIa inhibitor to date, but it is also the largest clinical study ever conducted in patients with non-ST-segment elevation ACS. The key feature of the PURSUIT trial is that patient management closely resembled standard clinical practice, because decisions about the use and timing of invasive cardiac procedures were made by the individual physicians rather than being prespecified in the study protocol. Eptifibatide therapy was associated with a significant reduction in the incidence of the primary endpoint--a composite of death or myocardial infarction at 30 days (14.2 vs. 15.7% in the placebo group; p = 0.042). Of importance is the fact that the beneficial effect of eptifibatide was independent of the management strategy pursued during study drug infusion (invasive or conservative), and it was achieved with few major safety concerns. These findings demonstrate that the use of eptifibatide should be considered for all patients presenting with signs and symptoms of intermediate- to high-risk non-ST-segment elevation ACS.
Subject(s)
Angina, Unstable/drug therapy , Myocardial Infarction/drug therapy , Peptides/therapeutic use , Platelet Aggregation Inhibitors/therapeutic use , Platelet Glycoprotein GPIIb-IIIa Complex/antagonists & inhibitors , Angina, Unstable/mortality , Angina, Unstable/physiopathology , Eptifibatide , Female , Heart/drug effects , Heart Conduction System/physiopathology , Humans , Male , Middle Aged , Multicenter Studies as Topic , Myocardial Infarction/mortality , Myocardial Infarction/physiopathology , Peptides/pharmacology , Platelet Aggregation Inhibitors/pharmacology , Randomized Controlled Trials as Topic , Research Design , Survival Analysis , Syndrome , Treatment OutcomeABSTRACT
The use of abciximab after full-dose failed thrombolytics within 15 hours of acute myocardial infarction significantly increases the risk of major bleeding complications.
Subject(s)
Angioplasty, Balloon, Coronary , Antibodies, Monoclonal/adverse effects , Hemorrhage/epidemiology , Immunoglobulin Fab Fragments/adverse effects , Platelet Aggregation Inhibitors/adverse effects , Thrombolytic Therapy , Abciximab , Aged , Female , Hemorrhage/etiology , Humans , Incidence , Male , Middle Aged , Myocardial Infarction/drug therapy , Myocardial Infarction/therapy , Retrospective StudiesABSTRACT
Left internal mammary arteries (LIMA) are used routinely as grafts to the left anterior descending coronary artery (LAD) in selected patients undergoing coronary artery bypass graft (CABG) surgery because of better long-term patency rates. Pathology other than fibrointimal hyperplasia, accelerated atherosclerosis, or thrombus can sometimes cause obstructive lesions in such grafts. This report illustrates a kink in a LIMA graft to the LAD causing an obstructive lesion shortly after surgery and describes the subsequent management of this lesion with intracoronary stents.
Subject(s)
Graft Occlusion, Vascular/therapy , Internal Mammary-Coronary Artery Anastomosis , Stents , Adult , Angioplasty, Balloon, Coronary , Humans , Male , Prosthesis DesignABSTRACT
Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past--they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The post-operative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre- and intraoperative aspects of peri-CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short- and long-term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.
Subject(s)
Coronary Artery Bypass/adverse effects , Myocardial Ischemia/etiology , Adrenergic beta-Antagonists/therapeutic use , Analgesics/therapeutic use , Angioplasty, Balloon, Coronary , Calcium Channel Blockers/therapeutic use , Cardiac Catheterization , Coronary Disease/surgery , Coronary Vasospasm/complications , Female , Graft Occlusion, Vascular/complications , Humans , Male , Mammary Arteries , Myocardial Ischemia/diagnosis , Myocardial Ischemia/therapy , Platelet Aggregation Inhibitors/therapeutic use , Reoperation , Saphenous VeinABSTRACT
The influence of gender on the procedural outcome of directional coronary atherectomy (DCA) is controversial. This study of 373 consecutive patients (418 lesions) undergoing DCA demonstrates that the procedural success rate of DCA is significantly lower in women compared with men (72.7 vs. 82.9%, p = 0.011). Women have significantly smaller coronary arteries than men (2.5 mm vs. 2.7 mm, p = 0.028) and were older than men (66 vs. 61 years, p = 0.0001). Multivariate analysis identifies small coronary vessel size rather than female gender per se as an independent predictor of poor procedural outcome. Procedural success rates in women with coronary vessel size > or = 2.5 mm is significantly higher (92.2%) than in women with coronary vessel size < 2.5 mm (73.1%), and parallels that in men with vessel size > or = 2.5 mm (89.3%). Inability to engage the ostium of the coronary artery adequately with the guiding catheter and to cross the lesion with the atherectomy device is significantly more common in women compared with men. Major ischemic complication rates are similar in women and men (8.5 vs. 8.7%). Groin complications are significantly more common in women compared with men (13.5 vs. 2.9%). We conclude that procedural success rates in women may be improved by careful patient selection, with particular attention to small vessel size. DCA is best performed in vessels > 2.5 mm in diameter.
Subject(s)
Atherectomy, Coronary/methods , Coronary Artery Disease/surgery , Aged , Female , Humans , Male , Middle Aged , Prognosis , Regression Analysis , Sex FactorsABSTRACT
The role of routine selective angiography of the internal mammary artery prior to myocardial revascularization is controversial. We report a patient with coronary artery disease and peripheral vascular disease in whom the left internal mammary artery supplied blood flow to the left external iliac artery via a collateral network. Thus, selective angiography of the internal mammary artery did play a major role in the proper management of this patient who required coronary bypass surgery. A major potential postoperative complication of left lower extremity ischemia may have been prevented.
Subject(s)
Coronary Disease/complications , Coronary Disease/surgery , Iliac Artery/diagnostic imaging , Mammary Arteries/diagnostic imaging , Myocardial Revascularization , Peripheral Vascular Diseases/complications , Aged , Cardiac Catheterization , Collateral Circulation , Coronary Angiography , Coronary Artery Bypass , Coronary Disease/diagnostic imaging , Humans , Male , Preoperative CareABSTRACT
The influence of age on the clinical and angiographic outcome of directional coronary atherectomy is evaluated. Results demonstrate that DCA can be performed successfully in the vast majority (78.7-90%) of patients in all age groups. However, there is a non-statistical trend toward decreased success rates in the elderly (P > .05). Major ischemic complications and groin complications tend to be more common in the elderly (P > .05). Blood transfusions are required significantly more often in the elderly (P < .05). Directional coronary atherectomy is a useful method of coronary artery revascularization in all age groups, including the elderly.
Subject(s)
Atherectomy, Coronary , Coronary Disease/surgery , Postoperative Complications/diagnostic imaging , Aged , Angina, Unstable/diagnostic imaging , Angina, Unstable/surgery , Cineangiography , Coronary Aneurysm/diagnostic imaging , Coronary Angiography , Coronary Disease/diagnostic imaging , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnostic imaging , Myocardial Ischemia/diagnostic imaging , Retrospective Studies , Treatment OutcomeABSTRACT
The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography.
Subject(s)
Coronary Artery Disease/diagnostic imaging , Ultrasonography, Interventional , Coronary Angiography , Female , Humans , Middle AgedABSTRACT
Percutaneous transluminal coronary angioplasty (PTCA) of heavily calcified rigid coronary arteries has decreased success and increased complication rates. Three cases are presented describing a new technique for the dilatation of severely calcified coronary arteries that were not dilatable by conventional angioplasty methods. This technique involves the use of a balloon dilatation catheter system parallel to a guide wire.
Subject(s)
Angioplasty, Balloon, Coronary/instrumentation , Calcinosis/therapy , Coronary Disease/therapy , Aged , Angioplasty, Balloon, Coronary/methods , Calcinosis/diagnostic imaging , Cineangiography , Coronary Angiography , Coronary Disease/diagnostic imaging , Female , Graft Occlusion, Vascular/therapy , Humans , MaleABSTRACT
Marked bulging of the interventricular septum toward the left ventricle has been described as a reliable index of right ventricular systolic hypertension. We report a patient with Eisenmenger syndrome who has systolic aneurysmal protrusion of the interventricular septum into the left ventricular outflow tract. To our knowledge, this is the first report of systolic indentation of the left ventricular outflow tractin a patient with right ventricular pressure/volume overload.
Subject(s)
Echocardiography , Eisenmenger Complex/physiopathology , Systole , Ventricular Outflow Obstruction/etiology , Adult , Blood Pressure , Cardiac Volume , Female , Hemodynamics , Humans , Myocardial Contraction , Ventricular Function, LeftABSTRACT
Congenital coronary artery fistulas are important coronary artery anomalies. Bilateral coronary artery fistulas are very rare and coronary artery to left ventricular communications are even more infrequent. This report describes a patient with bilateral right and left coronary artery fistulas draining into a common channel and emptying into the left ventricular cavity.
Subject(s)
Coronary Vessel Anomalies , Fistula/congenital , Heart Ventricles/abnormalities , Aged , Coronary Angiography , Coronary Vessel Anomalies/diagnostic imaging , Fistula/diagnostic imaging , Heart Ventricles/diagnostic imaging , Humans , MaleABSTRACT
A 38-yr-old woman presented with abdominal pain, hematochezia, and fever of 7 days' duration. Computerized tomographic scanning revealed a mass 6 cm in diameter adherent to the sigmoid colon. At surgery, the mass was determined to be an endometrioma with an associated tubo-ovarian abscess eroding the sigmoid colonic wall. This case, illustrating colonic perforation, represents a rare complication of intestinal endometriosis and, to our knowledge, represents the first reported case of colonic perforation secondary to endometriosis not associated with pregnancy. The clinical manifestations of intestinal endometriosis leading to perforation are reviewed.
Subject(s)
Colon, Sigmoid , Colonic Neoplasms/complications , Endometriosis/complications , Intestinal Perforation/etiology , Adult , Colon, Sigmoid/pathology , Colonic Neoplasms/pathology , Endometriosis/pathology , Female , Humans , Pregnancy , Pregnancy ComplicationsABSTRACT
A patient of Middle-Eastern descent developed Kaposi's sarcoma of the skin and lymph nodes after renal transplantation while receiving medical immunosuppression, including the use of cyclosporine. The clinical presentation of this patient resembled that of the HTLV-III-associated Kaposi's sarcoma. The tumors totally regressed seven weeks after cessation of immunotherapy. This case, along with other recently reported cases of Kaposi's sarcoma in postrenal transplant patients receiving cyclosporine, illustrates a rare complication of current immunosuppressive therapy.
Subject(s)
Cyclosporins/adverse effects , Kidney Transplantation , Sarcoma, Kaposi/etiology , Skin Neoplasms/etiology , Adult , Female , Humans , Immunosuppression Therapy/adverse effects , Lymph Nodes/pathology , Sarcoma, Kaposi/pathology , Skin Neoplasms/pathologyABSTRACT
Interruption of the (I)n strand of (I)n.(C)n by unpaired bases [(U)] yielded mismatched analogues, (Ix,U)n.(C)n which were still effective as inducers of interferon, provided the I:U ratio (x) was equal or greater than 10. In highly sensitive interferon-induction systems such as primary rabbit kidney cells and human skin fibroblasts superinduced with cycloheximide and actinomycin D, (I10,U)n.(C)n and (I50,U)n.(C)n proved nearly as active as (I)n.(C)n. By virtue of their increased susceptibility to degradation by nucleases, (Ix,U)n.(C)n complexes with 10 less than or equal to x less than or equal to 50 may be expected not to persist as long in biological fluids as (I)n.(C)n, hence to induce fewer side effects.