Clinical trials of coronary revascularization for chronic stable angina: medical treatment versus coronary revascularization.

For patients with chronic stable angina, several randomized trials have been performed comparing medical management with surgery, medical management with angioplasty, and angioplasty with surgery. Data from the medical versus revascularization trials (either surgery or angioplasty) support the following contentions: For patients with multivessel disease, particularly involving the proximal left anterior descending coronary artery, survival is superior to surgical treatment. Symptom relief with either type of revascularization is superior to medical management. The subsequent rate of myocardial infarction is not affected by the initial treatment strategy, whether medical, angioplasty, or surgery. In individual patients the potential benefits of any revascularization strategy must be weighed against its initial risks. Further study is needed, particularly with multifaceted pharmacologic therapy and with updated angioplasty techniques, to evaluate relative survival benefits in these patients. The studies supporting these conclusions are highlighted in this paper.

The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial.

BACKGROUND: Smoking prevalence rates among women are declining at a slower rate than among men. OBJECTIVE: To determine if exercise, a healthful alternative to smoking, enhances the achievement and maintenance of smoking cessation. METHODS: Two hundred eighty-one healthy, sedentary female smokers were randomly assigned to either a cognitive-behavioral smoking cessation program with vigorous exercise (exercise) or to the same program with equal staff contact time (control). Subjects participated in a 12-session, group-based smoking cessation program. Additionally, exercise subjects were required to attend 3 supervised exercise sessions per week and control subjects were required to participate in 3 supervised health education lectures per week. Abstinence from smoking was based on self-report, was verified by saliva cotinine level, and was measured at 1 week after quit day (week 5), end of treatment (week 12), and 3 and 12 months later (20 and 60 weeks after quit day, respectively). RESULTS: Compared with control subjects (n = 147), exercise subjects (n = 134) achieved significantly higher levels of continuous abstinence at the end of treatment (19.4% vs 10.2%, P = .03) and 3 months (16.4% vs 8.2%, P=.03) and 12 months (11.9% vs 5.4%, P=.05) following treatment. Exercise subjects had significantly increased functional capacity (estimated VO2 peak, 25+/-6 to 28+/-6, P<.01) and had gained less weight by the end of treatment (3.05 vs 5.40 kg, P = .03). CONCLUSIONS: Vigorous exercise facilitates short- and longer-term smoking cessation in women when combined with a cognitive-behavioral smoking cessation program. Vigorous exercise improves exercise capacity and delays weight gain following smoking cessation.

Effect of smoking cessation on exercise performance in female smokers participating in exercise training.

We evaluated in a randomized prospective trial the possible effect of smoking cessation on exercise performance in middle-aged female smokers who underwent vigorous exercise training as an adjunct to a cognitive-behavioral smoking cessation treatment program. A total of 109 subjects met the criteria for this substudy; of these, 51 were in the contact control (nonexercising) group and 58 were in the exercise training group. Both groups had a graded maximal exercise stress test performed on a bicycle ergometer before and after 12 weeks of treatment. All subjects participated in a 12-session, group-based, cognitive-behavioral treatment program for nicotine dependence. Subjects in the contact condition participated in 3 supervised health education lectures per week but did not engage in regular exercise. Subjects in the exercise group trained 3 times a week, averaging 83% of maximum heart rate achieved on their baseline exercise test. On the 12-week exercise stress test, the exercise group did significantly better than control in all aspects of exercise performance. Those who quit showed a further increase in their exercise test duration (p <0.001) and had a greater increase in calculated peak oxygen consumption expressed as fat-free weight (p = 0.031). In conclusion, women who undergo a vigorous exercise training program and quit smoking demonstrate improved exercise performance over those who continue to smoke.

Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine.

Despite increasing use of percutaneous transluminal coronary angioplasty (PTCA) to treat stenotic coronary artery disease, there are relatively few prospective studies evaluating its long-term effectiveness. We prospectively randomized 212 stable patients with provocable myocardial ischemia and single-vessel subocclusive coronary disease to receive primary therapy with either PTCA or medical therapy. This report presents the clinical follow-up of these patients at a mean, after randomization, of 2.4 years for interview and 3.0 years for exercise testing. Of the 212 patients originally randomized, 175 received an extended follow-up interview, and 132 underwent exercise testing; 62% of patients in the PTCA group were angina free compared with 47% of patients in the medical group (p <0.05). Furthermore, exercise duration as measured by treadmill testing was prolonged by 1.33 minutes over baseline in the PTCA group, whereas it decreased by 0.28 minutes in the medical group (p <0.04). Although the angina-free time on the treadmill was not different (p=0.50), fewer patients in the medical group developed angina on the treadmill at 3 years than those in the PTCA group (p=0.04). By 36 months, excluding the initial randomized PTCA, use of PTCA and use of coronary artery bypass surgery were not different in the 2 treatment groups. These data indicate that some of the early benefits derived from PTCA in patients with single-vessel coronary artery disease are sustained, making it an attractive therapeutic option for these patients.

Evaluation of exercise thallium scintigraphy versus exercise electrocardiography in predicting survival outcomes and morbid cardiac events in patients with single- and double-vessel disease. Findings from the Angioplasty Compared to Medicine (ACME) Study.

OBJECTIVES: We sought to evaluate the prognostic ability of cardiac exercise stress tests in predicting cardiac mortality and morbidity in a low risk group of patients with established coronary artery disease (CAD). BACKGROUND: Although previous studies have demonstrated the superior value of stress nuclear cardiac scintigraphy in the prognosis of patients with CAD, none of these studies have focused on patients with a proven angiographic low risk profile (i.e., single- and double-vessel CAD). METHODS: Three hundred twenty-eight patients with documented single- and double-vessel disease were treated by random assignment to percutaneous transluminal coronary angioplasty or medical therapy in the Angioplasty Compared to Medicine (ACME) trial. Six months after randomization, maximal symptom-limited exercise tests were performed with electrocardiography (n = 300) and thallium scintigraphy (n = 270). Patients were followed up for a minimum of 5 years thereafter. RESULTS: A reversible thallium perfusion deficit documented after 6 months of either therapy was associated with an adverse mortality outcome (18% mortality rate with a reversible thallium perfusion defect and 8% mortality rate with no reversible thallium perfusion deficit, p = 0.02). Moreover, an important mortality gradient was demonstrated in relation to the number of reperfusing defects (0 = 7%, 1 to 2 = 15%, >3 = 20%, p = 0.04). Exercise electrocardiography did not predict this mortality outcome. CONCLUSIONS: A reversible thallium perfusion deficit demonstrated 6 months after medical therapy or coronary angioplasty is a valuable prognostic marker in patients with angiographically documented single- and double-vessel disease and is superior to exercise electrocardiography in this regard.

Emergency department use of aspirin in patients with possible acute myocardial infarction.

BACKGROUND: Efforts have been made to improve the suboptimal use of aspirin after hospitalization. OBJECTIVE: To assess the frequency and timing of aspirin administration in emergency department patients with possible myocardial infarction. DESIGN: Retrospective record review. SETTING: Emergency departments of four hospitals affiliated with the same university. PATIENTS: All patients who were admitted to the four hospitals in 1994 for evaluation and treatment of suspected acute myocardial infarction. MEASUREMENTS: The frequency and timing of aspirin administration and the definitive diagnosis established before discharge from the hospital. RESULTS: Aspirin was not given to 253 of 463 emergency department patients (55%) who had a definitive diagnosis of acute myocardial infarction. Seventy-eight percent of patients who did receive aspirin received it more than 30 minutes after arrival in the emergency department. CONCLUSION: Aspirin therapy is underutilized as the first intervention in patients who are admitted with suspected myocardial infarction.

Rationale, design, and baseline data for Commit to Quit: an exercise efficacy trial for smoking cessation among women.

BACKGROUND: The Commit to Quit trial was designed to address the methodological problems of prior studies that have examined the contribution of exercise to smoking cessation. METHODS: This paper provides an overview of the study design and describes the sample of women who participated in this trial (N = 281). Interrelationships among eating, exercise, and smoking behavior are examined. RESULTS: Subjects randomized into the study compared with the sample of women who completed the initial assessment but were not randomized were more likely to be white, to have at least a high school education, and to smoke fewer cigarettes per day. Overall, the most frequent ineligibility criteria were health-related issues and scheduling conflicts. On average, participants in this study smoked more cigarettes per day than national samples of women smokers. Significant interrelationships include the positive association of motivational readiness for quitting smoking and enhanced levels of dietary restraint and the positive association of motivational readiness for exercise adoption and high levels of weight concern. CONCLUSIONS: This study represents the first adequately powered randomized controlled clinical trial comparing the relative efficacy of a cognitive-behavioral smoking cessation treatment plus vigorous exercise with the same treatment plus contact control.

Effects of left ventricular systolic function on left ventricular diastolic filling patterns in severe mitral regurgitation.

Significant mitral regurgitation (MR) may alter the normal pattern of Doppler detected left ventricular (LV) filling by causing a prominent early filling (E) wave velocity. The manner and extent to which the typical filling pattern of uncomplicated MR is affected by concomitant impaired LV systolic function has not been characterized. Twenty patients with severe LV systolic dysfunction (2-dimensional echocardiographic estimation of ejection fraction < or = 30%) and 21 age- and sex-matched case controls with normal systolic function (ejection fraction > or = 55%) were selected. In addition, 20 subjects with normal LV systolic function and no MR were analyzed as a reference group. Maximal E-wave velocity was increased and highest among MR patients with preserved LV systolic function (124 +/- 37 cm/s) than among those with LV systolic dysfunction (101 +/- 25 cm/s; p <0.05) and normal controls (74 +/- 18 cm/s; p <0.001). Concurrently, A-wave velocity was lowest in patients with systolic dysfunction and MR (47 +/- 23 cm/s; p <0.001) than in patients with normal systolic function and MR (79 +/- 33 cm/s) and normal controls (74 +/- 20 cm/s). Deceleration time of the E wave was longest among those with normal systolic function and MR (203 +/- 41 ms) than among those with systolic dysfunction and MR (152 +/- 35 ms; p <0.001) and normal controls (167 +/- 53 ms; p <0.05). Thus, systolic LV dysfunction in patients with severe MR, compared to patients with MR and normal LV systolic function, is associated with important changes in diastolic inflow velocities, including reduction of the maximal A-wave velocity to a greater extent than the E wave, resulting in an increased E/A ratio and shortening of deceleration time of the E wave.

Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME InvestigatorS.

OBJECTIVES: This study sought to assess outcomes of men with double-vessel coronary artery disease randomly assigned to treatment by percutaneous transluminal coronary angioplasty (PTCA) or medical therapy, compared with previously reported outcomes for men with single-vessel disease. BACKGROUND: We previously reported that PTCA provides better symptom relief and treadmill performance than medical therapy for men with stable angina pectoris due to single-vessel disease. Whether this advantage applies to patients with double-vessel disease is unknown. METHODS: Male patients (n = 328) with stable angina pectoris and ischemia on treadmill testing were randomly assigned to PTCA or medical therapy; 101 patients had double-vessel disease, and 227 had single-vessel disease. Symptoms, treadmill performance, quality of life score, coronary stenosis and myocardial perfusion were compared at baseline and at 6 months. Patients were followed up for up to 6 years and underwent additional treadmill testing 2 to 3 years after randomization. RESULTS: PTCA-treated and medically treated patients with double-vessel disease experienced comparable improvement in exercise duration (+1.2 vs. +1.3 min, respectively, p = 0.89), freedom from angina (53% and 36%, respectively, p = 0.09) and improvement of overall quality of life score (+1.3 vs. +4.4, respectively, p = 0.32) at 6 months compared with baseline. This contrasts with greater advantages favoring PTCA by these criteria in patients with single-vessel disease (p = 0.0001 to 0.02). Trends present at 6 months persisted at late follow-up. Patients undergoing double-vessel dilation had less complete initial revascularization (45% vs. 83%) and greater average stenosis of worst lesions at 6 months (74% vs. 56%). Likewise, patients with double-vessel disease showed less improved myocardial perfusion imaging (59% vs. 75%). CONCLUSIONS: PTCA is beneficial in male patients with double-vessel disease; however, we cannot demonstrate the same advantage over medical therapy seen in similar patients with single-vessel disease. Less complete revascularization and greater restenosis for patients having multiple dilations would account for these findings. Alternatively, a type 2 error might be operative. Technical advances since completion of this trial might improve these outcomes. These findings warrant further investigation in a larger trial.

Is computer interpretation of the exercise electrocardiogram a reasonable surrogate for visual reading? Veterans Affairs ACME Investigators.

BACKGROUND: Interpretation of exercise tests as positive or negative is primarily based upon exercise-induced ST segment changes. Consistently accurate measurements are difficult to obtain during exercise. HYPOTHESIS: This study compared on-line computer-generated electrocardiographic (ECG) analysis with visual interpretation. The goals were to document the extent of agreement, establish reasons for disagreements, characterize ST-segment depression (extent, onset, duration), and determine the sensitivity and ability to localize coronary artery disease for each method. METHODS: Comparisons were made in 120 patients at eight Veterans Affairs Medical Centers. An exercise test was considered positive if > 1.0 mm horizontal or downsloping ST-segment depression was detected 0.08 s after the J point during exercise or recovery. The ST-segment depression had to be present on at least two successive ECG recordings 15 s apart. Computer interpretation was based on median averaged beats. RESULTS: There was an 88% agreement of visual and computer interpretations [106/120 (both positive, n = 62; both negative, n = 44)]. The disagreements involved visual negative, computer positive in 10 cases and visual positive, computer negative in 4 cases. Correlation was excellent between methods for characterization of ST-segment depression (p < 0.0001). Sensitivity for detecting and the ability to localize coronary artery disease (> or = 70% stenosis) were similar for both methods. CONCLUSION: This computer algorithm using median averaged beats is a reasonable surrogate for visual interpretation of the exercise ECG, making it a valuable source of confirmation of physician readings in large research trials and in clinical settings.

Pathogenesis and prognostic significance of conduction abnormalities after coronary bypass surgery.

Of 200 men who underwent isolated coronary bypass graft surgery, 40 (20%) developed new postoperative, persistent conduction abnormalities. The pathogenesis of conduction abnormalities was examined by relating their presence to that of significant proximal left coronary disease before surgery, and to various intraoperative factors that included indices of myocardial preservation and revascularization. Proximal left coronary disease was observed in 92 (46%) of 200 patients, of whom 27 (29%) developed conduction abnormalities. In contrast, of the 108 patients without proximal left coronary disease, only 13 (12%) developed persistent conduction abnormalities (P < 0.01). Intraoperative factors appeared to have little or no role in the development of such abnormalities. It is concluded that the development of persistent postoperative conduction abnormalities is related more to proximal left coronary disease than to intraoperative factors and that such abnormalities do not progress during long-term follow-up (average 53 months).

'Abnormal' diastolic Doppler patterns in patients over age 65 with severe left ventricular systolic dysfunction.

OBJECTIVE: The purpose of this study was to determine whether Doppler diastolic filling patterns of the left ventricle are altered in patients over age 65 with poor left ventricular function, compared to patients with normal left ventricular systolic function. BACKGROUND: In elderly, healthy subjects, the mitral valve Doppler inflow pattern exhibits an increase in atrial contribution to left ventricular filling. Myocardial disease, which results in stiffness, may also cause an increase in A wave velocity. METHODS: Twenty-seven patients over age 65, with left ventricular systolic dysfunction, were age and sex-matched with 19 patients with normal left ventricular systolic function. Patients with significant mitral or aortic valvular disease were excluded. Maximal early inflow velocity, maximal atrial inflow velocity, heart rate, acceleration time and deceleration time were calculated. RESULTS: Comparing the group with normal left ventricular systolic function, the group with decreased left ventricular systolic function had pseudonormalization of the maximal early flow/atrial flow velocity ratio (1.7 +/- 1.3 vs. 0.9 +/- 0.3; P = 0.003), E wave velocity was similar (82 +/- 28 vs. 70 +/- 24 cm/s; P = n.s.), and A wave velocity was diminished (66 +/- 30 vs. 84 +/- 20 cm/s; P = 0.02). The acceleration time was similar for the groups (53 +/- 17 vs. 46 +/- 21 ms), but the deceleration time was shorter in patients with left ventricular systolic dysfunction (122 +/- 33 vs. 192 +/- 80 ms; P < 0.001). CONCLUSION: Such differences may relate to increased left atrial pressure, increased left ventricular diastolic pressure and/or decreased atrial systolic function. These findings are important when interpreting left ventricular filling indices by Doppler echocardiography in elderly patients.

The role of noninvasive testing in evaluating patients for coronary artery disease.

Risk stratification of patients with coronary artery disease using noninvasive imaging techniques has become increasingly more important in the cost-conscious delivery of patient care. This is evidenced by significant developments involving both nuclear cardiology and echocardiography for the assessment of viability, silent myocardial ischemia and prognosis, as well as the emergence of new techniques, in particular the use of positron emission tomography isotopes with single photon emission computed tomography cameras and low-dose dobutamine echocardiography in the detection of viability. New developments regarding screening for and the clinical importance of silent myocardial ischemia as well as new developments regarding classification of radionuclide perfusion defects and stress echocardiograms that portend a poor prognosis are also reviewed. Finally, new techniques and stress agents have been development that add to the choices available to the clinician for the optimal assessment of the patient being considered for revascularization.

Long-term effects of multiple pregnancies on cardiac dimensions and systolic and diastolic function.

OBJECTIVE: This study evaluated whether the recurring volume loading and hormonal changes in multiple pregnancies might have some cumulative effect on heart size and function. STUDY DESIGN: Echocardiograms were performed on 20 healthy women with at least 4 (mean 5.2) term pregnancies; 20 healthy, age-matched, nulliparous women served as controls. RESULTS: There were no significant differences in chamber dimension, systolic or diastolic function, valvular incompetence, or heart rate between the groups. There was a small, but significant, prolongation in deceleration time of the E wave in the multiparous women. CONCLUSION: These findings show that the human heart is generally able to repeatedly adapt to multiple episodes of volume overload in pregnancy without lasting detrimental structural or functional changes.

A comparison of quality of life scores in patients with angina pectoris after angioplasty compared with after medical therapy. Outcomes of a randomized clinical trial. Veterans Affairs Study of Angioplasty Compared to Medical Therapy Investigators.

BACKGROUND: Evaluations of therapy for the treatment of angina have traditionally consisted of a combination of objective measures, such as exercise tolerance, and subjective markers, such as angina attack rate. Recently, the need to assess "how patients feel"--their quality of life (QOL)--has been regarded with increasing importance. Standard instruments are available to assess QOL and its change after therapeutic intervention. Although QOL instruments have been used to assess the efficacy of percutaneous transluminal coronary angioplasty (PTCA), they have not been used previously to compare the impact of PTCA with that of medical therapy in patients with angina pectoris. We report on the changes in self-assessed QOL among patients randomly assigned to treatment by PTCA or medical therapy and relate these measurements to changes in exercise performance and coronary angiograms. METHODS AND RESULTS: Patients with stable angina, a positive exercise tolerance test, and at least 70% stenosis (index lesion) in the proximal two thirds of one major coronary artery were randomly assigned to receive PTCA or medical therapy. Six months after randomization, each patient underwent repeat exercise testing and coronary angiography. Before randomization and at the 6-month visit, patients completed a self-administered QOL questionnaire that measured physical functioning and psychological well-being. We compared the changes in QOL with changes between the baseline and 6-month exercise tests, stratified by terciles (decrease in duration, 0- to 2-minute increase, and > 2-minute improvement). We also stratified patients by whether there was more or less than 2 SD change (18.8%) in diameter stenosis of the index lesion (initial minus follow-up angiogram), and we related these to changes in QOL measures. One hundred eighty-two patients with one-vessel disease completed baseline and 6-month questionnaires. At baseline, there were no differences in any QOL measurements between treatment groups. At the 6-month follow-up visit, there was greater improvement in both physical functioning and psychological well-being scores for patients receiving PTCA (+7.36 +/- 15.6, PTCA; +1.98 +/- 14.7, medical therapy; P < .02). Improvement in QOL variables was noted only in patients demonstrating an increase in exercise performance. Also, patients assigned to either treatment whose angiograms demonstrated more than 18.8% improvement in index lesion percent stenosis experienced a significant increase in their QOL scores. CONCLUSIONS: This was the first study of the relative changes in QOL measures assessed with the use of previously validated and standardized instruments in patients randomly assigned to treatment with PTCA or medical therapy. Patients assigned to PTCA demonstrated a significantly greater improvement in both physical and psychological measures. This improvement was noted in patients whose exercise performance improved and whose angiograms demonstrated an improvement in lesion severity.

Pitfalls in the diagnosis and management of papillary muscle rupture: a study of four cases and review of the literature.

Four cases of papillary muscle rupture occurring in the setting of acute myocardial infarction are presented, which illustrate the following points: the diagnosis may not be apparent at presentation, a mitral regurgitant murmur may be absent, transesophageal echocardiography may establish the diagnosis when transthoracic echocardiography does not, and appropriate surgical correction can lead to excellent functional recovery.