Estrogen replacement therapy after coronary angioplasty in women.

OBJECTIVES: The purpose of this study was to assess the effects of estrogen replacement therapy on long-term outcome, including restenosis, myocardial infarction, stroke and death after a first percutaneous transluminal coronary angioplasty (PTCA) procedure, in postmenopausal women. BACKGROUND: Observational and epidemiologic studies, basic laboratory research and clinical trials consistently suggest that estrogen replacement therapy is associated with beneficial cardiovascular effects in women. These cardioprotective actions may be particularly relevant to women with coronary artery disease, such as those who have undergone PTCA. METHODS: This was a retrospective study that included 337 women who underwent elective PTCA between 1982 and 1994. The treatment group consisted of 137 consecutive women receiving long-term estrogen therapy at the time of elective PTCA and during follow-up. The control group comprised 200 women who were computer-matched with the estrogen group. The mean follow-up period was 65 +/- 35 months. RESULTS: Actuarial survival was superior in the estrogen group; the 7-year survival rate was 93% for the estrogen group versus 75% for the control group (p = 0.001). The cardiovascular event rate (death, nonfatal myocardial infarction or nonfatal stroke) was significantly lower in the estrogen group at 7 years (12% vs. 35% in the control group, p = 0.001). The need for subsequent revascularization during follow-up was similar in the two groups. Multivariable analysis identified diabetes, estrogen therapy (adjusted risk ratio 0.38, 95% confidence interval 0.19 to 0.79) and left ventricular ejection fraction < 40% as independent correlates of cardiovascular death or myocardial infarction during follow-up. CONCLUSIONS: Estrogen replacement therapy was associated with an improved long-term outcome after PTCA in postmenopausal women.

Screening cerebrovascular patients for silent myocardial ischemia with stress testing and ambulatory left ventricular function monitor.

Patients with symptomatic cerebrovascular disease suffer a high mortality from myocardial ischemia, which may occur during rest or following the conclusion of exercise. In a pilot study, we screened 11 patients with transient cerebral ischemic attack or stroke for silent myocardial ischemia using bicycle ergometer stress testing with electrocardiographic (EKG) monitoring and ambulatory left ventricular function monitoring (VEST). Three of 11 patients had nondiagnostic exercise EKGs due to failure to achieve their target heart rates during exercise but had positive VEST tests during and after exercise. One patient was falsely positive. VEST may be useful in combination with stress EKG for the detection of silent myocardial ischemia in cerebrovascular patients, but further assessment of the sensitivity and specificity in this patient population needs to be accomplished.

Supraventricular tachyarrhythmias. Characteristics and care.

Physicians often see patients with supraventricular tachycardia of some kind. How does the primary care physician distinguish between a benign, bothersome condition and a life-threatening emergency? What is the proper treatment for various manifestations? Drs Lawhorn and Emmot describe these arrhythmias and their mechanisms and discuss both acute and long-term treatment options.