The promise of selective aldosterone receptor antagonists for the treatment of hypertension and congestive heart failure.

Inappropriate elevations in plasma aldosterone levels have multiple actions that play an important role in the pathophysiology of hypertension and heart failure. Patients with hypertensive cardiovascular disease are at increased risk for coronary artery disease, myocardial infarction, congestive heart failure, and sudden cardiac death. Despite long-term treatment with an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker, aldosterone levels usually remain high in these patients. The effectiveness of low-dose spironolactone raises the possibility that a nonselective aldosterone antagonist can block the deleterious effects of aldosterone on the cardiovascular system. However, side effects limit the use of this drug in many patients. The advent of selective aldosterone antagonists, which have a lower affinity for androgen and progesterone receptors, should minimize these side effects, leading to better compliance.

Drip and ship: a new strategy for the treatment of acute coronary syndromes.

Glycoprotein (GP) IIb/IIIa inhibitors block the final common pathway of platelet aggregation by preventing fibrinogen from binding to the GP IIb/IIIa platelet receptor. In patients with unstable angina (UA) or a non-Q wave myocardial infarction (NQWMI), including those with UA refractory to medical therapy, these agents decrease the risk of death, myocardial infarction (MI), and recurrent ischemia. Most patients with acute coronary syndromes are managed in hospitals without on-site angioplasty capabilities and often require transfer for an interventional procedure. We propose that GP IIb/IIIa inhibitors can be safely initiated at the referring hospital. We studied 20 patients with UA/NQWMI in whom therapy with a GP IIb/IIIa inhibitor, in addition to standard medical therapy, was initiated prior to transfer for an urgent percutaneous coronary intervention (PCI) ("drip and ship"). The primary end point was a composite of death, MI, and recurrent ischemia at 30 days. Twelve patients were treated with abciximab, 5 patients were treated with tirofiban, and 3 patients initially treated with tirofiban were converted to abciximab. Procedural success occurred in 33 out of 36 (92%) lesions and 18 out of 20 (90%) patients. At 30 days, 4 out of 20 (20%) patients had recurrent ischemia. The PTCA sites were widely patent in the 3 patients who underwent repeat angiography. The fourth patient had an unsuccessful PCI and was referred for coronary artery bypass surgery. There were no MIs or deaths. Patients who require transfer for an urgent PCI can be managed safely and efficaciously by initiating a GP IIb/IIIa inhibitor, in addition to standard medical therapy, prior to transfer.

Vasoseal after intra-aortic balloon pump removal: a pilot study.

Vascular complications after removal of an intra-aortic balloon pump (IABP) have been reported to occur in up to 15% of patients. Vasoseal, a vascular hemostasis device (VHD), has been shown to be safe and effective in rapidly achieving hemostasis after a cardiac catheterization or percutaneous coronary intervention. We propose that similar results can be obtained with the VHD when removing an IABP. However, it is necessary to first gain first the experience of deploying the VHD without insertion of a guidewire. We studied 10 patients in whom Vasoseal was utilized after an IABP was removed. The primary endpoint was a composite of major or minor bleeding, infection, and any vascular complication at 7 days. The time to achieve hemostasis was also assessed. There was not a single episode of bleeding, infection, or vascular injury at 7 days. The time to hemostasis ranged between 8 and 17 min (mean, 12.9 min). This VHD can be utilized safely and efficaciously when removing an IABP.

Ventricular septal defect and left ventricular aneurysm: late occurrence as complications of an acute myocardial infarction.

Mechanical complications of acute myocardial infarction (AMI) such as a ventricular septal defect (VSD) usually occur within the first week. In the thrombolytic era, the incidence of a VSD has not increased, but has been reported to occur earlier than previously described. We report an unusual case of an elderly Caucasian female with an acute anterior wall myocardial infarction treated with thrombolytic therapy. Her AMI was complicated by pulmonary edema secondary to a VSD and a left ventricular aneurysm five weeks later. Prompt diagnosis, immediate surgical closure of the VSD, and aneurysmectomy resulted in her complete recovery.

Rescue PTCA complicated by pulmonary artery rupture after tPA and abciximab.

Since the introduction of pulmonary artery catheterization for hemodynamic monitoring, several complications associated with its use have been described. Pulmonary artery rupture is an infrequent complication of flow-directed pulmonary artery catheters. We report a case of pulmonary artery rupture complicating rescue PTCA in the presence of systemic platelet inhibition with abciximab (Reopro), anticoagulation, and thrombolytic therapy. With the increasing use of these medications in patients undergoing acute coronary interventions, particularly those patients requiring hemodynamic monitoring, this uncommon but potentially fatal complication may be seen more frequently.