Incidence of coronary artery by-pass graft following percutaneous transluminal coronary angioplasty.

Two hundred fifty eight patients had percutaneous transluminal coronary angioplasty. Of those, 48 cases underwent surgical revascularization for unsuccessful angioplasty. Sex was not a risk factor. Timely surgical revascularization reversed acute ischemia and/or myocardial infarction or limited the size of the infarction in 32 of the 48 patients or 67%. Revascularization procedures were performed in six out of forty-eight patients who had previous aortocoronary by-pass surgery and attempted PTCA, none had any complications. Death occurred in one out of forty-eight patients, or 2%. Femoral-femoral by-pass devices, in addition to intra-aortic balloon devices, should be available in the cardiac catheterization laboratory. Patients with multi-vessel disease are at greater risk of angioplasty and surgery. Sixteen out of 23 patients (70%) who had emergency revascularization procedures had multi-vessel disease. In one patient with borderline renal function, emergency surgery after PTCA with a large amount of renograffin dye injected caused renal failure and led to permanent dialysis.

Hemodynamic and myocardial performance characteristics after verapamil use in congestive heart failure.

Because of its intrinsic negative inotropic effect, the administration of the recently introduced calcium antagonist, verapamil, is thought to be contraindicated in presence of congestive heart failure (CHF). Yet, as CHF is frequently associated with arrhythmias and angina pectoris, and verapamil possesses potent antiarrhythmic and antianginal properties that could be of great benefit to selected patients with CHF, this study was undertaken to determine whether verapamil can be given to such subjects safely. For this purpose, 14 patients with CHF were studied in the control (preverapamil) state with a combined hemodynamic-cineangiographic approach; the same interventions were repeated during intravenous verapamil administration (0.1 mg/kg bolus, followed by 0.005 mg/kg/min infusion). Verapamil markedly lowered mean aortic pressure (95 +/- 19 to 81 +/- 12 mm Hg, p less than 0.001) and systemic vascular resistance (1,953 +/- 873 to 1,417 +/- 454 dynes s cm-5, p less than 0.01). Simultaneously, indexes of left ventricular (LV) performance substantially improved: the ejection fraction increased from 29 +/- 13 to 37 +/- 17% (p less than 0.01), and mean velocity of circumferential fiber shortening increased from 0.45 +/- 0.18 to 0.64 +/- 0.28 circ/s (p less than 0.001). Cardiac index also increased (from 1.98 +/- 0.49 liters/m2/min before verapamil to 2.24 +/- 0.60 liters/m2/min after verapamil), although this improvement did not become statistically significant. No appreciable changes were noted in the heart rate, LV end-diastolic pressure, or mean pulmonary arterial or pulmonary capillary wedge pressure. Thus, the intrinsic negative inotropic activity of intravenous verapamil in therapeutic doses generally does not represent a serious drawback even in patients with CHF; its potent unloading vasodilatory properties more than compensate for any intrinsic decrease in LV contractility, and can thereby actually improve overall cardiac function.

Verapamil versus placebo in relieving stable angina pectoris.

Verapamil and placebo were compared in patients with stable, effort-induced angina. Single-blind dose titration (240, 360 and 480 mg/day) preceded a double-blind crossover. Among the 18 patients who completed graded exercise stress tests with reproducible pretreatment effort-limiting angina, exercise duration increased from 348 +/- 127 seconds (SD) before treatment to 494 +/- 182 seconds after verapamil (p less than 0.001), but did not change after placebo. Compared with placebo, verapamil reduced the weekly number of anginal episodes from 4.54 +/- 5.03 to 2.44 +/- 3.30 (p less than 0.05) and reduced nitroglycerin consumption from 3.46 +/- 5.30 to 1.55 +/- 2.89 tablets per week (p less than 0.05). Of 26 patients who completed the single-blind dose titration, 16 were improved (greater than 1 minute) at a dosage of 240 or 360 mg/day. No patient improved (greater than 1 minute) on 480 mg/day who had not already improved on a lower dose, but side effects requiring reduction in dosage occurred in seven patients receiving 480 mg of verapamil per day. Verapamil is an effective antianginal drug that appears most efficacious at a dose of 360 mg/day, but side effects are common at a dose of 480 mg/day.