Manpower in cardiology in Europe. The Cardiology Monospeciality Section of the UEMS.

This is the first systematic survey of cardiology manpower in Europe. Hitherto, there has been no published information on the number of cardiologists in the different European nations and whether it was growing or stable. Important differences in the number of cardiologists and trainees are observed, with the highest figures in Greece, Italy and France (more than 80/10(6)inhabitants) and the lowest in the Scandinavian nations, Austria, Germany and the U.K. (35 or less/10(6)inhabitants). This is partly due to different roles and the activities of the cardiologists in these countries as well as their capacity to undertake various cardiological procedures. Some comparisons with the U.S.A. and projections for the year 2000 are also made.

Syncope after effort.

A 29-year-old man developed recurrent syncope following exertion. Cardiac investigations revealed no evidence of structural heart disease, but during exercise testing, in the recovery phase, he sustained a bradycardia and then asystole for a prolonged period. Before cardiac massage could be instituted a tonic-clonic fit occurred, and this initiated a return to sinus rhythm. His symptoms were abolished following the implantation of a dual-chamber pacemaker.

Coronary angiography in the presence of peripheral vascular disease: femoral or brachial/radial approach?

Peripheral vascular disease is considered a relative contraindication to the femoral approach for coronary angiography, but no data exist comparing the femoral and brachial/radial routes under these circumstances. We examined the influence of vascular approach on outcome. Two hundred and ninety-seven patients, mean age 67.1 +/- 8.4 years, with clinical or radiographic evidence of aortofemoral peripheral arterial disease underwent diagnostic coronary angiography during a 3-year period at this cardiothoracic center. The approach was successful in 121 of 154 femoral cases (79%) compared with 130 of 143 brachial/radial cases (91%; P < 0.01). Of the 33 failed femoral cases, 15 were then approached from the other femoral artery, with success in 6 (40%), while 18 were approached from the arm, with success in all (100%; P < 0.01). Brachial/radial cases took significantly longer than femoral cases (51 +/- 19 vs. 42 +/- 22 mins; P < 0.01). In cases where the femoral pulse was considered normal, the femoral approach nonetheless failed in 19 of 95 (20%). Major vascular complications (e.g., pulseless limb, arterial dissection, hemorrhage, or false aneurysm) occurred in nine femoral cases vs. zero brachial/radial cases (P < 0.01). Patients with peripheral vascular disease who undergo coronary angiography from the femoral artery have a 1-in-5 risk of procedural failure, necessitating use of an alternative vascular approach, and a 1-in-20 risk of a major vascular complication. Normality of femoral arterial pulsation is not a good predictor of femoral success. Brachial/radial approaches take longer, but succeed more frequently and have a negligible major vascular complication rate. We believe that patients with peripheral vascular disease should undergo coronary angiography via brachial or radial approach. Cathet. Cardiovasc. Intervent. 49:32-37, 2000.

Coronary angiography from the radial artery--experience, complications and limitations.

AIMS: to assess the outcomes, complications and limitations of coronary angiography performed via percutaneous radial artery puncture. METHODS AND RESULTS: two hundred and fifty patients underwent diagnostic coronary angiography from the radial artery, 182 (72.8%) of whom had contraindications to the femoral approach, for example due to peripheral vascular disease (n=85), therapeutic anticoagulation (29), or failed femoral approach (17). Procedural success in this high-risk population was achieved in 231 patients (92.4%). Principle reasons for failure were unsuccessful radial access (5) and arterial spasm (5). Procedure duration (SD) for an operator's first 20 cases compared with cases thereafter (min) was 47.7 (16.7) vs. 41.5 (14.6), P=0.0004; fluoroscopy time (min) 9.7 (7.1) vs. 6.6 (5.1), P=0.0001 and procedural success 89.6% vs. 94.1%, P=ns. Complications included two deaths associated temporally with catheterisation, three cases of arterial dissection without ischaemic sequelae and one transient ischaemic attack. CONCLUSIONS: coronary angiography can be performed successfully from the radial artery, but this approach has limitations, which include the need to demonstrate dual palmar vascular supply, the prolonged learning phase, the procedural failure rate, patient discomfort and a demonstrable incidence of vascular and haemodynamic complications. We believe that radial coronary angiography should only be undertaken when there is a contraindication to the femoral approach.

Ventricular pacemaker upgrade: experience, complications and recommendations.

OBJECTIVE: To assess outcomes of pacemaker upgrade from single chamber ventricular to dual chamber. DESIGN: Retrospective analysis of patients undergoing the procedure. SETTING: Specialist cardiothoracic unit. PATIENTS: 44 patients (15 female, 29 male), mean (SD) age at upgrade 68.2 (12.9) years. INTERVENTIONS: Upgrade of single chamber ventricular to dual chamber pacemaker. MAIN OUTCOME MEASURES: Procedure duration and complications. RESULTS: Principal indications for upgrade were pacemaker syndrome (17), "opportunistic"--that is, at elective generator replacement (8), heart failure (7), non-specific breathlessness/fatigue (7), and neurally mediated syncope (3). Mean (SD) upgrade procedure duration (82.9 (32.6) minutes) significantly exceeded mean VVI implantation duration (42.9 (13.3) minutes) and mean DDD implantation duration (56.6 (22.7) minutes) (both p < 0.01). Complications included pneumothorax (1), ventricular arrhythmia requiring cardioversion (2), protracted procedure (10), atrial lead repositioning within six weeks (8), haematoma evacuation (1), superficial infection (1), and admission to hospital with chest pain (1); 20 patients (45%) suffered one or more complications including four of the eight who underwent opportunistic upgrade. CONCLUSIONS: Pacemaker upgrade takes longer and has a higher complication rate than either single or dual chamber pacemaker implantation. This suggests that the procedure should be performed by an experienced operator, and should be undertaken only if a firm indication exists. Patients with atrial activity should not be offered single chamber ventricular systems in the belief that the unit can be upgraded later if necessary at minimal risk.

Comparison of radial versus brachial approaches for diagnostic coronary angiography when the femoral approach is contraindicated.

One hundred patients with contraindications to the femoral approach were randomized to undergo diagnostic coronary angiography via percutaneous radial puncture or brachial artery cutdown. Procedure duration, fluoroscopy time, and total radiation dose were significantly less via the radial route, whereas procedural success, complication rates, and pain scores were comparable; we conclude that the radial technique should be the arm approach of choice for new trainees, although there will be occasions when radial access fails and a brachial approach is required.

Late complications following permanent pacemaker implantation or elective unit replacement.

OBJECTIVE: To determine the rate of late complications following first implantation or elective unit replacement of a permanent pacemaker system. DESIGN: Analysis of pacemaker data and complications prospectively acquired on a computerised database. Complications were studied over an 11 year period from January 1984 to December 1994. SETTING: Tertiary referral cardiothoracic centre. PATIENTS: Records of 2621 patients were analysed retrospectively. MAIN OUTCOME MEASURES: Complications requiring repeat procedures occurring more than six weeks after pacemaker implantation or elective unit replacement. RESULTS: The overall rate of late complications was significantly lower after first implantation of a permanent pacemaker (34 cases, complication rate 1.4%, 95% confidence interval 0.9% to 1.9%) than after elective unit replacement (16 cases, complication rate 6.5% (3.3% to 9.7%). There were 20 cases of erosion, 18 infections, five electrode problems, and seven miscellaneous problems. Complications were more common with inexperienced operators (18.9% (6.0% to 31.8%)) than with experienced operators (0.9% (0.3% to 1.5%). CONCLUSIONS: The incidence of late complications following pacemaker implantation is low and compares favourably with early complication rates. The majority are caused by erosion and infection. Patients who have undergone elective unit replacement are at particular risk.

Radial versus femoral approach for diagnostic coronary angiography in stable angina pectoris.

We compared coronary angiography of the radial artery using 6Fr catheters in 116 patients with that of the femoral artery in 100 case controls. We showed that transradial coronary angiography offers a useful alternative to the femoral route and can be performed without resorting to 5Fr catheters.

Both endothelium-dependent and endothelium-independent function is impaired in patients with angina pectoris and normal coronary angiograms.

BACKGROUND: The aim of this study was to investigate both endothelium-dependent and endothelium-independent vasodilatation in syndrome X patients. Recently selective impairment of endothelium-dependent function has been reported in a small number of syndrome X patients. However, other investigators have reported impaired endothelium-independent function. METHODS: We infused the endothelium-independent vasodilators papaverine and glyceryl trinitrate, and endothelium-dependent vasodilator acetylcholine in the left coronary artery of 35 patients with syndrome X and in 17 control subjects (atypical chest pain, negative exercise test, and normal coronary angiograms). Coronary blood flow was measured with an intracoronary Doppler catheter positioned in the proximal left anterior descending coronary artery, and the artery diameter was assessed using quantitative coronary angiography. RESULTS: The mean increase in coronary blood flow in response to a 12 mg dose of papaverine was significantly less in the syndrome X group (185 +/- 74% vs 411 +/- 59%, P < 0.001). The increase in coronary blood flow in response to acetylcholine, at doses of 1, 3, 10, and 30 micrograms.min-1, was also significantly lower in the syndrome X group (12 +/- 13 (P < 0.05), 41 +/- 33, 57 +/- 68, and 124 +/- 87% (P < 0.001)) as compared to the control group (76 +/- 49, 214 +/- 116, 355 +/- 115, and 361 +/- 74%). CONCLUSION: These findings demonstrate that both endothelium-dependent and endothelium-independent dilatation of the coronary microvasculature is impaired in syndrome X.

Changing from intensive anticoagulation to treatment with aspirin alone for coronary stents: the experience of one centre in the United Kingdom.

OBJECTIVE: To investigate whether an elective change in the anticoagulation protocol for patients with coronary stents affected clinical outcomes and length of hospital stay. DESIGN: Retrospective observational study of a consecutive series of patients treated with coronary stents over an 18 month period from April 1994 to October 1995. BACKGROUND: Intensive anticoagulation regimens are used in many UK centres to reduce the risk of coronary stent thrombosis. Recent data have called into question the necessity for full anticoagulation and favourable results have been reported with antiplatelet agents alone. The results from a tertiary referral centre were investigated during a period where an elective change in policy was made: an initial 70 patients were treated intensively with intravenous heparin and with warfarin and aspirin; subsequently 94 were treated with aspirin and deployment of a high pressure balloon only. METHODS: Review of case notes, angiograms, and a database of intervention procedures and telephone interview. Classic epidemiological techniques, as well as linear regression and logistic regression, were used to model the outcomes of major procedural complications and length of hospital stay. PATIENTS: 164 patients treated with 196 coronary stents. RESULTS: There were 22 (13.4%) major complications (coronary bypass grafting 11, subacute thrombosis 6, tamponade 2, myocardial infarction 1, death 2). With logistic regression, the risk of major complication was shown not to be affected by anticoagulation (relative risk (RR) 1.03; P = 0.97). Significant determinants of risk included acute vessel closure as an indication for stenting (RR = 80.6; P < 0.001) and sex (male: female RR = 0.19; P = 0.02). The median length of stay (LOS) was 5 days (1-45). Use of a linear regression model showed that anticoagulation added 4.5 days and a major complication added a further 4.5 days to a baseline length of stay of 3.2 days (R2 = 0.32; P < 0.001). CONCLUSION: This is a report of coronary stenting as part of usual clinical practice in one British tertiary referral centre. In this experience, treatment with aspirin alone is probably as safe as intensive anticoagulation, and has the benefit of reducing length of stay by more than 50% to 3.2 days in an uncomplicated case.