Coronary Artery Disease in Patients Aged 35 or less - A Different Beast?

AIM: To assess the extent and severity of coronary artery disease (CAD) in 200 consecutive patients aged 35 years or less undergoing diagnostic coronary angiography. PATIENTS AND METHODS: Findings in these 200 patients (≤ 35 years of age) were analyzed to find the extent and severity of CAD. The mean age was 31.69 (±3.76) years. Majority were males (94%) and from the Arab ethnicity (70.5%). RESULT: Smoking (71%) and history of premature CAD (27%) were the most frequent risk factors (RF). History of previous ST elevation myocardial infarction (MI) was present in 68%. Anterior wall MI was the most frequent location (63.3%). The majority (54.3%) had moderate or large size MI. Ejection fraction (EF) less than 50% was noted in 30.3%. Left main or triple vessel CAD was seen in 15%. One- and two-vessel CAD was seen in 32.5% and 19% patients, respectively. Coronary angiogram was completely normal in 23.5%. The majority (54.5%) were treated conservatively and the rest (45.5%) needed percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The mean number of stents used was 1.3 ± 0.67 and the mean length of stents used was 20.3 ± 12.6 mm. CONCLUSION: The extent and severity of CAD was very significant in this subgroup of very young (≤35 years) Asian patients. Smoking was the main risk factor and half of the patients needed either PCI or CABG.

Effect of methimazole-induced hypothyroidism on histological characteristics of parotid gland of albino rat.

BACKGROUND: The current study was carried out to investigate the effect of hypothyroidism on the histological structure of parotid salivary gland of the rat. METHODS: Twenty male albino rats, weighing between 130-150 grams, were used which were divided into two groups: control group (A) and an experimental group (B), each containing 10 animals. Group B was rendered hypothyroid by giving methimazole (MMI) as 0.02% solution in drinking water daily for 3 weeks. On day 22nd parotid and thyroid glands were removed, weighed and processed for light microscopy. Salivary gland was fixed in Bouin's solution, H&E and Toluidine blue stains were used for histological examination. Serum T3, T4 and TSH levels were determined by enzyme immunoassay. RESULTS: In group A, serum concentration of T3, T4 and TSH was 12.58 +/- 3.05 etag/ml, 4.72 +/- 1.20 microg/dl, and 0.25 +/- 0.24 microIU/ml respectively, where as in group B it was 2.14 +/- 1.83 etag/ml, 1.04 +/- 0.44 microg/dl and 1.44 +/- 0.20 microIU/ml respectively. When differences between T3, T4 and TSH of the groups were compared, the p-value was < 0.000, < 0.000, and < 0.000 respectively. Mean thyroid weight significantly increased in group B (44.1 0 +/- 1.66 mg) when compared to that in group A (33.70 +/- 1.56 mg). These findings established the occurrence of hypothyroid state in the experimental group. There was a statistically significant reduction in the parotid gland weight in the animals of the experimental group (38.30 +/- 1.15 mg) when compared to the control group (39.60 +/- 0.84 mg), (p < 0.01). With light microscopy, group A showed a normal structure of parotid salivary gland, whereas multiple histological changes were observed in parotrid gland of the experimental group. Number of mast cells in parotid gland was also significantly higher (p < 0.017) in group B (3.70 +/- 1.11/mm2) than in group A (2.25 +/- 1.34/mm2). CONCLUSION: The level of T3, T4 decreased and that of TSH increased in the experimental group when compared with control group; there were also changes in the histological structure of the parotid salivary gland.

Coronary artery disease among diabetic and non-diabetic patients with end stage renal disease.

Cardiovascular disease is the major cause of death among patients with end stage renal disease and accounts for about half the deaths among the dialysis population. Several researchers have reported a high prevalence of coronary artery disease among diabetic patients with renal failure and coronary arteriography is often considered an integral part of the pre-transplant evaluation of diabetic patients with end stage renal disease. However, very few reports have addressed the question of coronary disease in non-diabetic patients, and the pattern and prevalence of coronary artery disease in non-diabetic patients with end stage renal disease are not well defined. We evaluated the clinical and coronary angiographic findings in 158 consecutive patients (84 diabetic and 74 non-diabetic) with end stage renal disease. The coronary arteries were divided into 16 segments and each segment was analyzed for the presence of coronary disease, which was defined as the presence of > or = 50% luminal diameter stenosis. Diabetic patients had more adverse risk factors for coronary artery disease, yet there was no significant difference in the prevalence of coronary artery disease between the diabetic and non-diabetic patients (67% vs. 55%, p = 0.15), or in the number of affected coronary artery segments (2.0 vs. 1.4, p = 0.05). Triple vessel coronary artery disease was however, significantly more common among the diabetic subjects (27% vs. 12%, p = 0.005). Non-diabetic patients with end stage renal disease also have a high prevalence of coronary artery disease and may merit as careful investigation of their coronary status as their diabetic counterparts.

Life-saving balloon mitral valvuloplasty in patient with cardiogenic shock after cardiac arrest.

Balloon mitral valvuloplasty is the procedure of choice in a selected group of patients with significant mitral stenosis and suitable valve morphology. Experience in patients with cardiogenic shock is very limited. We report the case of a dying patient in cardiogenic shock, with pulmonary edema and severe hepatic damage after cardiac arrest caused by mitral restenosis. The patient was successfully treated by emergency balloon mitral valvuloplasty with a good result and complete recovery.

A randomized study of the safety and efficacy of reused angioplasty balloon catheters.

BACKGROUND: To lower costs, many centers around the world utilize previously used, resterilized balloon catheters to perform coronary angioplasty There are no controlled trials regarding their safety and efficacy. METHODS AND RESULTS: We performed the first randomized, double-blind, controlled, single-center clinical trial comparing the safety (clinical success) and efficacy (angiographic success) of reused versus new coronary angioplasty balloon catheters. A total of 377 procedures were included, 178 in the reused catheter arm and 199 in the new catheter arm. There were no significant differences in clinical or lesion characteristics among the two arms. The incidence of first balloon failure in the reused catheter arm was similar to that of the new catheter arm (12 cases [7%] v. 10 cases [5%], respectively). The angiographic success rate was also similar-176 cases (98.9%) in the reused catheter arm and 196 cases (98.5%) in the new catheter arm. The number of balloon catheters used per lesion, amount of contrast, and procedural and fluoroscopy time were similar in the two arms. At 30 days, the incidence of major adverse cardiac events was similar in both arms, 8 cases (4.5%) in the reused catheter arm and 10 cases (5%) in the new catheter arm. The incidence of fever was also similar. CONCLUSIONS: When performing coronary angioplasty, reused catheters are as effective (similar angiographic success) and safe (similar clinical success) as new catheters.

Staged revascularization in critically ill patients with coronary artery disease.

BACKGROUND: Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity. HYPOTHESIS: The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock. METHODS: We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock. RESULTS: Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management. CONCLUSIONS: Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.

Transmyocardial laser revascularization: is the enthusiasm justified?

BACKGROUND: Transmyocardial laser revascularization (TMLR) is advocated to offer relief of incapacitating angina for patients whose coronary vessels are poor targets for coronary artery bypass graft surgery (CABG) or balloon angioplasty and stenting. In spite of significant mortality and morbidity, the preliminary reports from centers performing the procedure were quite enthusiastic for a period of about 1 year following the procedure. HYPOTHESIS: The study aimed to determine mortality, morbidity, and long-term results of TMLR. METHODS: The study included 19 individuals with incapacitating angina not suitable for CABG or percutaneous balloon angioplasty. Patients were followed up clinically for death, myocardial infarction, heart failure, arrhythmia, and repeated hospital admissions for unstable angina or other conditions. Stress testing with radionuclide tracers was done following surgery in patients who were not unstable. RESULTS: Of 19 patients, 8 experienced significant morbidity. There was one hospital death. Four died within 17 months. Relief from angina of two classes or more was present in 15 of 18 patients (83.3%) for a variable time period. Mean time for anginal relief was 8.0 months (range 1-30 months). At last follow-up, only two patients with a hybrid procedure (both CABG and TMLR in the same sitting) had mild angina for 17 and 29 months, respectively. All others with a mean follow-up period of 21.2 months (range 6-53 months) developed unstable angina or had a large area of ischemia on stress radionuclide studies. Despite a high incidence of significant angina in patients after TMLR, hospitalization was reduced from an average of 42.6 days pre procedure in the year before to 21 days during the follow-up period post procedure. CONCLUSION: Transmyocardial laser revascularization is associated with significant relief of angina pectoris in the majority of patients with severe diffuse coronary artery disease; however, this relief is short-lived in most. When mortality and morbidity are factored in, TMLR cannot be enthusiastically recommended.

Predictors of coronary disease in patients with end stage renal disease.

Patients with end stage renal disease have a high prevalence of cardiovascular disease and coronary arteriography is often routinely performed prior to kidney transplantation. However, the value of the conventional risk factors and non-invasive markers of coronary artery disease (CAD) in triaging patients for coronary arteriography has not been fully examined. 116 patients with end stage renal disease were evaluated. Coronary arteriography was performed in all patients either for a suspicion of CAD or as part of a routine pre-transplant evaluation. Lesions causing > or = 50% luminal diameter stenosis in any of the three major coronary artery systems were considered significant. The mean age was 53.3 +/- 9.3 years. Significant CAD was present in 69 patients (60%). Increasing age, family history of premature ischemic heart disease, the presence of angina, abnormal Q waves on the ECG or abnormal ST segment depression and the presence of coronary calcification were significant markers of coronary artery disease. However male gender, diabetes mellitus and obesity did not correlate with coronary disease. Even though hypertension, hypercholesterolemia and smoking were also not useful predictors these could have been modified by the renal failure. In conclusion increasing age, a family history of premature ischemic heart disease and some non-invasive markers were useful predictors of coronary disease.

Abolition of exercise induced positive U-wave after coronary angioplasty: clinical implication.

OBJECTIVE: We prospectively studied the course of exercise induced positive U-wave before and after percutaneous transluminal coronary angioplasty (angioplasty). BACKGROUND: Negative U-wave in ECG is known to be associated with the myocardial ischemia in the territory of the left anterior descending artery. Positive U-wave needs further evaluation to prove its diagnostic value in localization of coronary artery disease. METHOD: Twenty patients demonstrated exercise induced positive U-wave from a cohort of 730 patients referred because of chest pain. Exercise was carried to > or =90% of target heart rate. They underwent angiography and subsequent angioplasty for stenosis of 70% or greater. The exercise test was repeated post angioplasty. Careful screening for clinical endpoints and presence of ST segment depression and positive U-wave was done during exercise and the first 3 min of the recovery phase. RESULTS: Fifteen patients had isolated exercise induced U-wave and five had additional ST segment depression of > or =1 mm. Significant stenosis (>70% diameter reduction) of the circumflex artery was seen in 11 (55%) and of the right coronary artery in 9 (45%) patients. Coronary artery stenosis was reduced from 90+/-2% to 13+/-1% (mean+/-S.D.) P<0.001. On repeat of the exercise test U-wave and ST depression disappeared in all 20 individuals. Effort tolerance was improved after angioplasty for a mean duration of 3 min and 38 s, P<0.001. CONCLUSION: Exercise induced positive U-wave is an infrequent but specific marker of significant single coronary (circumflex or right) artery stenosis. It may lend itself to the detection of restenosis.