Lipid management program: results of applying national guidelines in a private practice.

In our large single-specialty cardiology practice, we implemented a lipid management program based on the recommendations of the Expert Panel of the National Cholesterol Education Program and the Helsinki Heart Study. This program used allied health professionals and customized computer software to deliver efficient, comprehensive care to the 1214 patients enrolled in the program after 33 months. Data are reported for the 543 patients enrolled for more than 1 year. Cholesterol data were analyzed for all patients whose initial triglyceride values were less than 400 mg/dL. For this group of patients, the mean cholesterol level decreased from 242.7 to 217.4 mg/dL, triglycerides fell from 170.0 to 144.7 mg/dL, HDL cholesterol increased from 41.6 to 42.9 mg/dL, and LDL cholesterol fell from 167.2 to 145.7 mg/dL. Using guidelines modified from the National Cholesterol Education Program, a significant number of patients were able to achieve desirable LDL and HDL goals. Modified national guidelines can be used effectively in a private practice setting.

Plasma DNA in the diagnosis of pulmonary embolism.

To assess the diagnostic value of measuring free plasma deoxyribonucleic acid (DNA) in patients suspected of having pulmonary embolism, we prospectively assayed the plasma of 40 consecutive patients who underwent pulmonary angiography for the presence of free plasma DNA. Fifteen of them had angiographic evidence of pulmonary embolism. Of these 15 only two (13%) had a positive result in the test for free double-stranded plasma DNA. We concluded that measuring free double-stranded plasma DNA is of no value in the diagnosis of pulmonary embolism.

Pericardial fluid gas analysis in hemorrhagic pericardial tamponade.

Nine patients with hemorrhagic pericardial tamponade were studied to determine the localizing value of gas analysis of pericardial fluid in therapeutic pericardiocentesis. The aspirate and the central venous blood was analyzed simultaneously for partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and hematocrit at the time of pericardiocentesis. In all 9 patients the difference in hematocrit between the pericardial fluid and the central venous blood was not significant. The PCO2 of pericardial fluid was significantly higher than that of central venous blood (p less than 0.025). The PO2 of pericardial fluid was consistently and significantly lower than that of central venous blood (p less than 0.005). We conclude that in patients with hemorrhagic pericardial tamponade, the simultaneous measurement of PO2 and PCO2 of central venous blood and pericardial fluid is a useful rapid bedside method to confirm the site of aspiration during pericardiocentesis. The PO2 determination is statistically the best discriminator between the two fluids in this setting.

Prophylactic use of intra-aortic ballon pump in aortocoronary bypass for patients with left main coronary artery disease.

Aortocoronary bypass surgery in patients with left main coronary artery disease is reported to have an operative mortality of between 1.4 and 39%. It is generally accepted that the operative mortality in this group of patients is considerably greater than in routine bypass candidates, presumably due to the large amount of myocardium threatened by a single lesion. In an effort to preserve threatened left ventricular myocardium, intra-aortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty per cent of these patients had New York Heart Association Class IV angina, 25% had Class III, and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina. Operative patients requiring left ventricular aneurysmectomy and/or valve replacement, were excluded. No operative deaths have been encountered in 20 consecutive patients managed in this manner. One patient displayed signs of myocardial infarction in the postoperative period. Correctable peripheral vascular ischemic complications of pump insertion were encountered in three patients. Preliminary results from this ongoing study support the hypothesis that prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized routinely in aortocoronary bypass surgery for left main coronary artery disease.

Aortocoronary bypass surgery: Correlation of angiographic symptomatic and functional improvement at 1 year.

Angiographic changes in the coronary circulation were evaluated in 60 patients 1 year after aortocoronary bypass surgery, and their relation to the postoperative clinical status was examined. Of 124 grafts implanted, 26 were closed, 7 stenotic and 91 (74 percent) patent at 1 year. Progression of occlusive disease occurred in 21 of 57 (37 percent) nongrafted and 78 of 123 (63 percent) grafted vessels. On the basis of location and severity of progression, significant lesions bypassed and patency of grafts, postoperative coronary perfusion was considered optimal in 16 patients (Group I), better in 24 (Group III). Complete freedom from chest pain or lessening of pain (improvement by two New York Heart Association functional classes) occurred in 88 and 79 percent of patients in Group III. Positive preoperative treadmill stress tests became negative after surgery in five of six patients in Group I, five of eight in Grojp II and three of eight in Group III. This study demonstrates that when progression of disease, graft patency and extent of revasculariztion are considered in combination, the postoperative angiographic status of the coronary circulation correlates well with clinical improvement at 1 year. These findings support the hypothesis that improved blood supply to ischemic myocardium is a major factor contributing to relief of angina pectoris after saphenous vein bypass surgery.

Blood concentration profiles of acetaminophen following oral administration of fatty acid esters of acetaminophen with pancreatic lipase to dogs.

Fatty acid esters of acetaminophen were administered orally to dogs, and blood concentrations of acetaminophen were determined at various time intervals. Blood concentrations of acetaminophen following oral administration of a short chain ester, p-acetamidophenyl acetate, were not significantly different from those found using acetaminophen. Blood concentrations of acetaminophen following oral administration of intermediate hydrocarbon chain-length compounds were less than those of the control at 1 and 3 hr postdosing. There appears to be a direct relationship between the in vitro hydrolysis rates and the blood concentration in vivo. Concomitant oral administration of acetaminophen derivatives, pancreatic lipase, and calcium salts resulted in an increase in the blood levels of acetaminophen as compared to administration of the esters alone. Calcium carbonate was included as a source of calcium ion to activate the lipase involved in the hydrolysis of the fatty acid esters. A combination of p-acetamidophenyl acetate, p-acetamidophenyl dodecanoate, pancreatic lipase, and calcium carbonate was shown to achieve a prolonged release of acetaminophen. p-Acetamidopheny acetate was thought to provide the initial release of acetaminophen; p-acetamidophenyl dodecanoate, being hydrolyzed more slowly, provided the prolonged release, which maintained therapeutic blood concentrations for 13 hr following a single dose of the combination in dogs.

Hydrolysis of fatty acid esters of acetaminophen in buffered pancreatic lipase systmes I.

A series of fatty acid esters of acetaminophen were prepared beginning with acetate, the propionate, and all even-numbered fatty acids and going through the octadecanoate. The enzymatic hydrolysis of all derivatives was studied in vitro with varying amounts of lipase assed to the hydrolysis mixtures. Under the conditions of the in vitro hydrolysis, it was observed that all derivatives were hydrolyzed more readily in an aqueous medium at pH 7.8. A positive relationship was seen between the hydrolysis rates and the concentration of lipase at this pH. There was a negative relationship between the chain length of the acyl moiety and the corresponding hydrolysis rates. The short chain esters were hydrolyzed at rates many times more rapid than the long chain esters. The intermediate chain-lenght ester, p-acetamidophenyl decanoate, p-acetamidophenyl laurate, and p-acetamidophenyl myristate, were hydrolyzed at intermedediate time periods extending over 12 hr, approaching completion at 97.5, 87.5, and 80.5%, respectively, when 18 Wilson units of lipase was used in each milliliter of hydrolysis mixture. The longer chain esters, p-acetamidophenyl palmitate and p-acetamidophenyl stearate, were hydrolyzed to the extent of 16 and 8%, respectively, over 12 hr under the same in vitro conditions.