Antiplatelet is superior to anticoagulant treatment after coronary stenting: fewer coronary and other events within 30 days after stenting.

Stent prosthesis is a high efficacious method with low complication rates. However, the ideal adjunctive therapy following stent implantation remains controversial. The authors compared the effectiveness and complication rates of aspirin-ticlopidine antiplatelet therapy vs. anticoagulant therapy with acenocoumarol within 30 days following stent prosthesis. They prospectively studied 404 patients following stent prosthesis while randomly receiving anticoagulant (Group A: 201 patients) vs. antiplatelet treatment (Group B: 203 patients). Groups A and B were similar in demographic data (age, gender), stent location, clinical presentation, indication of stenting, and type of implanted stent. Chi-square test, t test, and Wilcoxon test for two samples were used for statistical analysis of the results. Stent implantation was attempted in 434 cases. This was successful in 70/85 (82%) of the bailout, 122/135 (90%) of the suboptimal, and 212/214 (99%) of the elective cases. In 201 patients anticoagulant treatment with acenocoumarol was administered for 4 weeks (group A), while 203 received antiplatelet treatment with ticlopidine (group B). The need for reintervention was less and total cardiac events were fewer in group B than in group A: three (1.5%) and nine (4.4%) vs 18 (9%) and 29 (14.4%), p<0.0008 and p<0.006 respectively. Hemorrhagic complications and total noncardiac events were fewer in group B than in group A: six (3%) and six (3%) vs. 18 (9%) and 19 (9.5%), p<0.01 and p<0.007 respectively. The length of hospital stay was shorter in group B than in A, p<0.0001. In conclusion, in this study of intracoronary stenting the authors had a high success rate in 434 attempted cases. Antiplatelet therapy was accompanied by fewer cardiac and noncardiac 1 month events when compared with anticoagulant therapy, supporting its role as the adjunctive treatment of choice post-stenting for the time being.

Clinical characteristics and follow-up of patients with chest pain and normal coronary arteries.

The authors identified 160 men and women from all 3,700 patients with anginal pain between 1990 and 1994 who were subsequently found to have normal coronary arteries at diagnostic cardiac catheterization with follow-up to the present (mean follow-up 2.5 years). The group comprised 50 women and 110 men. Mean age was significantly greater in women (53.1 +/- 7.7 vs 47.2 +/- 9.2 years, p<0.001). Forty percent of the women but only 10% of the men had a positive exercise test. At follow-up, a larger proportion of patients continue to experience chest pain (95 patients, 59%) of whom 65 patients (41%) continue antianginal therapy. Furthermore one patient suffered a sudden cardiac death and two patients had a nonfatal myocardial infarction. Of patients referred with chest pain, women were more likely to have normal coronary arteries, compared with men. All patients have an excellent prognosis. A large proportion of women had a positive exercise test in the absence of coronary artery disease. On the other hand, morbidity remains high in these patients, despite the reassurance of a normal-appearing coronary arteriogram.

Dissection During Restenotic Lesion Balloon Angioplasty: Comparison with Initial Angioplasty.

The aim of this study was to assess the frequency and severity of dissection during repeat angioplasty for restenosis, to correlate the occurrence of this event with the lesion characteristics and the procedure-related factors and to examine if dissection during initial angioplasty predisposes to dissection during the repeat procedure. Sixty-nine significant lesions in native coronary arteries were treated with balloon angioplasty (A«PTCA) and retreated for restenosis with balloon angioplasty (B«PTCA). Dissection was detected less frequently during B«PTCA (7/69 vs. 18/69, p < 0.05). Anatomic variables did not differ significantly between A« and B«PTCA. Balloon to artery ratio (B/A ratio) was slightly but significantly higher during B«PTCA (1.03 +/- 0.13 vs. 0.97 +/- 0.14, p < 0.05) and duration of inflation was shorter (377 +/- 218 vs. 473 +/- 305 sec, p < 0.05). In 17 out of the 18 lesions which were dissected during A«PTCA, dissection did not occur during B«PTCA, despite the application of a higher B/A ratio (1.05 +/- 0.13 vs. 0.97 +/- 0.17, p < 0.05). Duration of inflation was shorter during B«PTCA (390 +/- 227 vs. 639 +/- 394 sec, p < 0.05). Six out of seven lesions which were dissected during B«PTCA had not been dissected during A«PTCA. In this subgroup, lesion characteristics did not differ between the two interventions and duration of inflation was shorter during B«PTCA (340 +/- 101 vs. 458 +/- 128, p < 0.05). CONCLUSIONS: Dissection occurred less frequently during restenotic lesion PTCA. Dissection during A«PTCA did not predispose to dissection during B«PTCA. These findings may be ascribed to the proliferative nature of the restenotic process.

The natural history of aneurysmal coronary artery disease.

OBJECTIVE: To assess the contribution of coronary artery ectasia, either isolated or in association with obstructive coronary artery disease, to morbidity and mortality from ischaemic heart disease. DESIGN: A retrospective study of patients undergoing coronary arteriography at a tertiary cardiac centre. PATIENTS AND METHODS: The epidemiological, clinical, arteriographic, and follow up characteristics of three groups of patients were examined: group A, 172 patients with coronary artery ectasia and coexisting significant coronary artery disease; group B, 31 patients with coronary artery ectasia only; group C, 165 patients with significant coronary artery disease but without ectasia, matched for sex and age with group A. RESULTS: Group A patients had a similar incidence of a previous myocardial infarction to group C patients (61.6% v 64.2%), exercise performance, severity of obstructive lesions (CASS score 2.19 v 2.14), and similar distribution of diseased vessels. At follow up of approximately two years they experienced a similar incidence of unstable angina (7.5% v 4.4%) and myocardial infarction plus cardiac death (4.9% v 6.1%). They underwent bypass surgery with similar frequency (39% v 42%) but there was a lower frequency of percutaneous transluminal coronary angioplasty (5.8% v 17%, P < 0.01). Patients with pure coronary ectasia (group B) had a lower incidence of a previous myocardial infarction (38.7%, 12/31, P < 0.05) than the two other groups. The infarct in all cases was related to an ectatic artery. Their exercise performance and ejection fraction (9 (SD 3) minutes and 56.5(9)%) were higher (P < 0.01) than group A (5 (2) minutes, 48.3(10)%) and group C (5.3 (2) minutes, 49.3(10)%). Group B had no myocardial infarctions, cardiac death, surgery, or intervention at follow up; 4.4% (5/115) developed unstable angina. The incidence of angina at study entry was similar in all three groups (38.7-49.7%). CONCLUSIONS: Coronary artery ectasia does not confer added risk in patients with coexisting obstructive coronary artery disease. Although there is a measurable incidence of previous myocardial infarction, patients with pure ectasia have a good prognosis. The wisdom of giving oral anticoagulants to such patients is questioned.

Hyperventilation test in syndrome X.

The hyperventilation (HV) test has been extensively used in different forms of coronary artery disease. The purpose of this work was to investigate the response to HV in patients with syndrome X and compare HV with exercise (EX) test. The authors studied 20 patients with syndrome X (angina, a positive EX test, and normal coronary angiogram) and 20 healthy subjects who underwent HV and EX tests. In 7 patients, all women, angina and electrocardiographic (ECG) changes occurred during HV but in none of the controls. Patients with syndrome X and controls had a similar rate-pressure product (RPP) at rest and achieved a similar RPP with HV. The RPP achieved with HV in patients with syndrome X without ECG changes was significantly lower, 121.8 +/-29.1(mean +/-SD), than what was achieved by those with changes, 167.9 +/-42.9, P < 0.01. In patients with an abnormal response to HV the RPP at which angina and ECG changes occurred was similar to that where similar changes were observed during EX. There was a significant correlation of the RPPs between the two tests, r=0.82, P < 0.02. In contrast, in patients in whom no angina or ECG changes occurred, the RPP they achieved with HV was significantly lower than the anginal threshold during EX 204 +/- 47.4, P < 0.0001. In conclusion, a significant proportion of patients with syndrome X, mainly women, who achieve a high RPP with HV, develop angina and ECG changes during overbreathing. The close relation between EX and HV RPPs where these changes occur suggests an increased myocardial oxygen demand as the most likely underlying mechanism for this behavior.

Percutaneous balloon pericardiotomy as a therapeutic alternative for cardiac tamponade and recurrent pericardial effusion.

A terminally ill patient with cardiac tamponade secondary to metastatic breast cancer was successfully treated by percutaneous balloon pericardiotomy. The procedure was performed through subxiphoid approach under local anaesthesia and its beneficial effect was maintained until the patient's death from her primary disease. A second, 86-year-old, debilitated patient and a third 52-year-old patient were managed likewise and both left hospital relieved from recurrent severe pericardial effusions. The later two patients have shown no signs of recurrence for fifteen and twelve months respectively.

Systolic segmental disappearance of internal mammary artery graft. Correlation with prolonged spasm of the graft.

Vasospasm of the saphenous vein and internal mammary grafts may develop spontaneously under several conditions. We present for the first time spasm of a left internal mammary artery bypass graft during coronary arteriography. A patient who underwent coronary artery bypass operation 4 years ago was recatheterized because he developed chest pain. Selective catheterization of the left internal mammary artery graft showed disappearance of its lumen at its distal part during systole, whereas the patient developed angina. These phenomena disappeared after intravenous nitroglycerin administration.

[Single coronary artery]. / Artère coronaire unique.

A single coronary artery is a rare abnormality of the coronary circulation (0.09% in the authors' experience), a fortuitous finding on coronary angiography. The authors report three new cases of this abnormality, including one with a ventricular septal defect and another with ischaemic heart disease. Exercise stress testing was positive in two patients.

Intracoronary Palmaz-Schatz stent placement after complicated angioplasty: medium term follow-up.

Acute or impending coronary artery occlusion during percutaneous coronary balloon angioplasty represents a serious and potentially life-threatening complication. We studied the clinical and angiographic outcome in 21 patients who underwent emergent intracoronary Palmaz-Schatz stent implantation (11 due to persistent residual stenosis and 10 due to flow-limiting dissection) during complicated balloon angioplasty and who were followed for a mean period of 7.9 +/- 5.7 months. Excluding one patient lost to follow-up, the event-free survival rate was 70%. Six (30%) patients developed adverse clinical events. One died and 3 required elective revascularization procedures. One subacute stent thrombosis was documented. Acute Q-wave myocardial infarction occurred in 2 patients. Among 9 patients studied angiographically 5.6 +/- 2.5 months after stent placement, 2 had developed restenosis (> 50% luminal narrowing). Eleven have remained essentially symptom free. For selected patients, emergent deployment of a Palmaz-Schatz coronary stent, following complicated balloon angioplasty, offers satisfactory long-term results, thus obviating the need for a high risk emergency bypass surgery.

Effect of successful coronary angioplasty on the signal-averaged electrocardiogram.

The effect of successful coronary artery angioplasty on the signal-averaged electrocardiogram (SAECG) was examined in 50 patients (41 men, 9 women, aged 55 +/- 8 years) with stable (26 patients) or unstable angina (24 patients) and good overall left ventricular function (ejection fraction = 55% +/- 8%). The SAECG was recorded before and within 24-48 hours after the angioplasty and was filtered at 40-250 Hz, with 250 beats averaged. The noise level averaged 0.57 +/- 0.15 microV before and 0.56 +/- 0.17 microV after the procedure. There was no overall significant difference between pre- and postangioplasty SAECGs. Subgroup analysis showed that 14 patients had a significant increase of the root mean square voltage of the last 40 msec of the filtered QRS that was independent of noise level changes, previous myocardial infarction, stable or unstable angina status, positive or negative baseline SAECG, or vessel being dilated. Eleven patients (22%) had late potentials at baseline, of whom four (36%) lost them after angioplasty, while one patient developed them after the procedure, all due to root mean square voltage changes. Thus, successful angioplasty exerted no significant overall effect on the SAECG, suggesting that the substrate of late potentials was not grossly altered by the procedure in our patients. However, there appear to be some patients, constituting approximately one third of this study population, who derive a favorable influence on the SAECG from angioplasty, a subgroup that needs to be further defined in future studies.