[Prehospital care of acute coronary syndrome by anaesthetists. Prospective comparison with the care standards of cardiologists]. / Prähospitale Versorgung des akuten Koronarsyndroms durch Anästhesisten. Prospektiver Vergleich mit dem Versorgungsstandard durch Kardiologen.

BACKGROUND: Prehospital treatment of acute coronary syndrome (ACS) by anaesthetists acting in physician staffed emergency medical service (EMS) was compared with that of the gold standard of cardiologists. METHODS: Prospectively 599 patients with assumed ACS were traced. Prehospital diagnosis and therapy were compared with re-evaluation of ECGs and diagnosis on hospital discharge. RESULTS: In the case of ST-segment elevating myocardial infarction (STEMI) anaesthetists diagnosed 84% of cases correctly and cardiologists in 94% (p=0.048). False positive diagnoses were given in 11% by anaesthetists versus 5% by cardiologists (p=0.31). Anaesthetists accompanied all patients with instable angina versus 94% by cardiologists (p=0.06). Anaesthetists achieved 82% of patients to be pain-free versus 73% of cardiologists (p=0.01). Mortality until discharge was identical for the two groups (8.2%). CONCLUSION: In prehospital management of ACS cardiologists showed higher diagnostic competence, whereas anaesthetists revealed a greater degree of therapeutic caution. Patient mortality was not influenced.

Beneficial effects of pravastatin (+/-colestyramine/niacin) initiated immediately after a coronary event (the randomized Lipid-Coronary Artery Disease [L-CAD] Study).

Secondary prevention of coronary heart disease by antilipidemic therapy beginning at > or =3 months after an acute coronary syndrome is well documented. The impact, however, of immediate initiation of antilipidemic therapy on coronary stenoses and clinical outcome in patients with acute coronary syndrome is unknown. In our study, patients were randomized, on average, 6 days after an acute myocardial infarction and/or percutaneous transluminal coronary angioplasty secondary to unstable angina, to pravastatin (combined, when necessary, with cholestyramine and/or nicotinic acid) to achieve low-density lipoprotein cholesterol levels of < or =130 mg/dl (group A, n = 70). In controls (group B, n = 56), antilipidemic therapy was determined by family physicians. Quantitative coronary angiography was performed at inclusion, and at 6- and 24-month follow-up. The combined clinical end points were total mortality, cardiovascular death, nonfatal myocardial infarction, need for coronary intervention, stroke, and new onset of peripheral vascular disease. Minimal lumen diameter in group A increased by 0.05 +/- 0.20 mm after 6 months and 0.13 +/- 0.29 mm after 24 months, whereas it decreased by 0.08 +/- 0.20 mm and 0.18 +/- 0.27 mm, respectively, in group B (p = 0.004 at 6 months and p <0.001 at 24 months). After 2 years, 29 patients of 56 patients in group B, but only 16 of 70 patients in group A, experienced a clinical end point (p = 0.005; odds ratio 0.28, confidence intervals 0.13 to 0.6). We conclude that pravastatin-based therapy initiated immediately after an acute coronary syndrome is well tolerated and safe, lessens coronary atherosclerosis, and has a pronounced clinical benefit.

[Short- and long-term effects of intensified versus conventional antilipidemic therapy in patients with coronary heart disease. Results from the Lipid-Coronary Artery Disease (L-CAD) Study]. / Kurz- und Langzeiteinfluss einer frühzeitigen Pravastatin-Kombinationstherapie im Vergleich zu konventioneller Behandlung auf Koronarstenosen und klinische Ereignisse bei Patienten mit Hypercholesterinämie und koronarer Herzerkrankung: Ergebnisse der Lipid-Coronary Artery Disease (L-CAD)-Studie.

In a prospective, randomized study of patients with acute manifestation of coronary heart disease and hypercholesterolemia (LDL cholesterol >/= 130

Effect on global and regional left ventricular functions by percutaneous transluminal coronary angioplasty in the chronic stage after myocardial infarction.

Data are reported on 145 consecutive patients with prior myocardial infarction who had successful percutaneous transluminal coronary angioplasty (PTCA) of the infarct-related artery (5 +/- 6 months after infarction), and left ventricular (LV) angiograms before PTCA and during follow-up (7 +/- 4 months). There was a significant long-term improvement in LV function, ejection fraction increased from 60 +/- 13% to 64 +/- 13% (p less than 0.001), and regional wall motion abnormalities decreased by 40%. Multivariate discriminant analysis identified reduced LV function and a high degree of stenosis before PTCA as predictors for improvement in LV function (ejection fraction less than 60%: ejection fraction from 48 +/- 9% to 57 +/- 14%, p less than 0.001; and stenosis greater than or equal to 90%: ejection fraction from 59 +/- 15% to 66 +/- 14%, p = 0.003). Restenosis greater than or equal to 90% in patients with initial stenosis less than 90% decreased ejection fraction from 59 +/- 16% to 51 +/- 14% (p less than 0.05). Other factors tested (treatment of infarction by thrombolysis, time between infarction and PTCA, and severity of angina pectoris) had no effect on long-term changes in LV function. It is concluded that successful elective PTCA of a high-grade stenosis in an infarct-related artery may improve LV ejection fraction and regional wall motion abnormalities, especially in patients with impaired LV function.

Influence of catheter technology and adjuvant medication on acute complications in percutaneous coronary angioplasty.

We report on the complication rates in 660 consecutive coronary angioplasties (725 lesions) performed using four procedures that differed with respect to catheter technology and adjuvant medication. After the PTCA regimen in our laboratory had been changed from conventional steerable systems to the monorail technique, we observed a significant increase in the incidence of transient vessel occlusions from 2.6% to 7.7%, of permanent occlusions from 3.6% to 8.8%, and of intracoronary thrombus-formation from 2.6% to 5.5%. This was associated with the frequent observation of thrombotic material on the partially Teflon-coated guidewires. Coronary perfusion with urokinase (1,670-6,670 U/min) lead to a further increase in the complication rates (10.4%/10.3%/6.5%). Our present percutaneous transluminal coronary angioplasty (PTCA)-regimen (monorail technique with P.E.T. balloons, fully silicon-coated guidewires, no urokinase) shows an incidence of 3.8% for intermittent and recurrent coronary occlusions and 1.9% for permanent occlusions. Urokinase did not prevent intracoronary thrombus formation with the monorail technique. Furthermore, we suspect that in the case of PTCA-induced regional intimal dissection, fibrinolysis can prevent reestablishment of intima adherence to the vessel wall. Because five procedural deaths were observed in the 212 patients treated with i.c. urokinase as opposed to three deaths in the 448 procedures without urokinase, we feel that i.c. urokinase in PTCA is a potentially harmful regimen. We suggest that the monorail technique should be performed with fully silicon-coated guidewires and without urokinase.

[Acute complications in coronary angioplasty: dependence on catheter material and adjuvant medication]. / Akutkomplikationen bei Koronarangioplastie: Abhängigkeit vom Kathetermaterial und adjuvanter Medikation.

We report on the complication rates in 660 consecutive coronary angioplasties (725 lesions) performed using four procedures that differed with respect to catheter technology and adjuvant medication. After the PTCA regimen in our laboratory had been changed from conventional steerable systems to the monorail-technique, we observed an increase in the incidence of intermittent and recurrent vessel occlusions from 2.6% to 7.7%, of permanent occlusions from 3.6% to 8.8%, and of intracoronary thrombus-formation from 2.6% to 5.5%. This was associated with the frequent observation of thrombotic material on the guide wires. Coronary perfusion with urokinase (1670-6670 U/min) lead to a further increase in the complication rates (10.4%/10.3%/6.5%). Our present PTCA-regimen (monorail-technique with PET balloons, silicon-coated guide wires, no urokinase) shows an incidence of 3.8% for intermittent and recurrent coronary occlusions, and of 1.9% for permanent occlusions. We suspect that in case of PTCA-induced regional intimal dissection, fibrinolysis prevents reestablishment of intima-adherence to the vessel wall. We conclude that i.c. urokinase in PTCA is a potentially harmful regimen and that the monorail-technique should be performed with silicon-coated guide wires.

Flocculation of sulfamerazine suspensions by a cationic polymer.

Flocculation by a cationic polymer of sulfamerazine suspensions containing a wetting agent was evaluated. Suspensions with sufficient surfactant concentrations to ensure complete wetting were deflocculated. When the anionic surfactant, dioctyl sodium sulfosuccinate, was used as a wetting agent, the suspensions were flocculated over a limited polymer concentration range. Flocculation was attributed to simultaneous interaction of a polymer molecule with more than one particle. At higher polymer concentrations, the particles were covered completely with polymer, leading to repulsion between the particles and deflocculation of the suspensions. The polymer concentration required for flocculation provided evidence for interaction between the anionic surfactant and the cationic polymer. Suspensions containing a nonionic surfactant also were flocculated using various polymer concentrations. When a surfactant mixture was employed in the suspensions, the peak sedimentation volume of flocculated systems and the concentration of polymer at the peak depended on the surfactant mixture composition.

B-mode nephrosonography in renal masses. Its use and some limitations.

One hundred B-mode nephrosonograms were reviewed, and 41 percent of these had a diagnosis proved by either arteriography, cyst puncture or tissue examination. There were 8 proved normal sonograms with one error, an upper pole renal cell carcinoma in a kidney badly distorted by chronic pyelonephritis and ureteral obstruction. Overlying ribs and anatomic distortion contributed to the misinterpretation. Sonic diagnosis of solid tumor was correct in all proved cases. Cysts were diagnosed in 23 patients; six were in error. Four were called cysts less than 3 cm. in diameter. If the lower limit of sonographic resolution is considered 3 cm., the accuracy for diagnosed simple cysts becomes 90 per cent.