Exercise stress testing and risk factor assessment among offspring of cardiac patients

As we learn more about the origins of coronary artery disease, research has begun to focus on its prevention. The purpose of this study was to determine if exercise stress testing of the offspring of our cardiac rehabilitation patients would be a useful adjunct to their general cardiac risk factor assessment. In addition, we sought to quantitate the number of cardiac risk factors they might have already accumulated. We determined the lifestyle and lipid profiles of 22 young, healthy subjects. Subjects underwent maximal multistage exercise stress tests. Eighty-six percent of subjects had two or more major risk factors for CAD, and 73% had contributory risk factors. Seventy-three percent of subjects also demonstrated hypercholesterolemia. Exercise testing did not induce ischemic changes on electrocardiography of any subject. Our research revealed that these offspring demonstrate an alarming number of coronary artery disease risk factors, even though exercise stress tests were negative.     

Effect of percutaneous transluminal coronary angioplasty on exercise in patients with and without previous myocardial infarction

Improvement in exercise capacity is an important clinical effect of percutaneous transluminal coronary angioplasty (PTCA), and was assessed in patients with and without previous myocardial infarction (MI) undergoing PTCA. We prospectively followed patients with exercise testing before and 2 weeks after angioplasty in 415 patients, 170 (41%) of whom had a previous MI. A third exercise test was performed 20 +/- 2 weeks after PTCA in 403 patients. From left ventricular angiography obtained before PTCA, regional dyskinesia was classified into anterior or posterior locations. Both patients with and without previous MI had a significant increase in exercise capacity from before to 2 and 20 weeks after PTCA (previous MI: 31.9% and 29.3%; no MI: 50.7% and 38.2%; p <0.0001 [analysis of variance]). In patients with MI and anterior dyskinesia, in whom lesions on the left anterior descending artery were dilated or posterior dyskinesia in whom lesions on the right coronary artery were dilated, exercise capacity increased significantly from before to 2 and 20 weeks after PTCA (left anterior descending artery: 53.1% and 39.7%, p <0.0001; right coronary artery: 16.9% and 27.6%, p = 0.01 [analysis of variance]). Multivariate regression analysis revealed that male sex, no previous MI, and dilation of left anterior descending artery were significantly associated with increased exercise capacity after angioplasty adjusted for age and smoking habits, whereas left ventricular ejection fraction and end-diastolic pressure were not associated with increased exercise capacity.     

One-year outcomes of diabetic versus nondiabetic patients with non-Q-wave acute myocardial infarction treated with percutaneous transluminal coronary angioplasty

Risk factors and outcomes associated with non-Q-wave myocardial infarction (MI) in diabetics and nondiabetics were analyzed for 376 consecutive patients, 77 with diabetes (20%) and 299 nondiabetics (80%), who had non-Q-wave MI and had percutaneous transluminal coronary angioplasty (PTCA) performed before discharge from hospital during the period from January 1992 to February 1996. Diabetics were slightly older (64 +/- 10 years vs 61 +/- 12 years, p <0.053), had more prior coronary artery bypass grafting (CABG) surgery (27% vs 12%, p <0.001), and hypertension (77% vs 49%, p <0.001). There was no significant difference in unstable angina, saphenous vein graft PTCA, single versus multiple vessel disease, or history of MI. PTCA success rates for diabetics versus nondiabetics were similar (96% vs 97%, p = NS). In-hospital complications such CABG, recurrent MI, repeat PTCA, stroke, and death were not statistically significant between the 2 groups. At 1-year follow-up, survival in diabetics (92%) was similar to nondiabetics (94%, p = NS), although event-free survival (PTCA, CABG, MI, death) was worse in diabetics (55% vs 67% for nondiabetics, p <0.05). Although diabetic patients with non-Q-wave MI represent a cohort with more risk factors for poor outcome, aggressive in-hospital revascularization with PTCA results in an excellent short-term outcome as well as 1-year survival similar to the nondiabetic patients. However, total events at 1-year follow-up are more common in the diabetic patients, suggesting that more aggressive screening and therapy in follow-up may be warranted, and that a diabetic with non-Q-wave MI will require increased utilization of cardiovascular resources in the first year after the event.     

Physical activity after cardiac rehabilitation: Evidence that different types of self-efficacy are important in maintainers and relapsers.

Objective: To test whether maintenance self-efficacy predicts physical activity among individuals who maintain an active lifestyle and whether recovery self-efficacy predicts physical activity among those who relapse to a less active lifestyle. Study Design and Participants: In a longitudinal study, data were collected from 114 participants 4-10 days after a myocardial infarction (MI), 2 weeks after rehabilitation (2 months after MI), and 8 months after MI. Results: In a subgroup of participants who maintained regular activity at 8 months after MI, maintenance self-efficacy predicted physical activity. Among participants who had relapsed by 8 months after MI, recovery self-efficacy predicted physical activity. Conclusions: Those who conduct interventions among cardiac rehabilitation patients should aim to increase recovery self-efficacy among those patients who are at risk for relapse and to increase maintenance self-efficacy among those patients who are likely to maintain their level of physical activity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

It Takes Two to Tango: Personal and Organizational Resilience as Predictors of Strain and Cardiovascular Disease Risk in a Work Sample.

In a cross-sectional sample of 428 employees, the job demand-control-support and effort-reward imbalance job stress models were amalgamated and expanded to include modifiable risk factors and noncontrollable genetic factors related to cardiovascular disease (CVD) risk. With structural equation modeling, the constructs of lack of job resilience, lack of personal resilience, and job demand were used to examine how employer and employee factors related to psychosomatic strain and risk indicators of CVD. Negative perception of job demand predicted perception of lack of job resilience but not lack of personal resilience. Lack of job and personal resilience predicted strain. Women reported greater strain than men. CVD risk was predicted by strain, age, sex, and family history. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

PTCA for acute coronary syndrome

The use of intravenous thrombolytic therapy have revolutionized the medical management of acute MI, prolonging survival and preserving LV function. Yet, despite these important beneficial effects, many deficiencies exist, such as the fewer lytic eligible patients, the low rate of complete reperfusion and high incidence of recurrent Ischemia and intracranial hemorrhage. To improve on these deficiencies, several PTCA strategies for acute MI have emerged, including primary PTCA, rescue PTCA, immediate PTCA, and delayed PTCA. If skilled intervention-list and cath lab team are available, the optimal reperfusion strategy is primary PTCA. If a cath lab is not available and the patient is eligible for thrombolysis, intravenous thrombolytic therapy should be administered. Nevertheless, PTCA still has significant limitations, including complex lesion morphology and restenosis. Preliminary experience support the feasibility and safety of coronary stenting in the setting of acute MI. A randomized trial using the heparin-coated Palmaz-Schatz stent for primary stenting in MI is ongoing. Until a randomized trial data are available, we recommend stenting for provisional stenting.     

Erwin Payr, Hans von Haberer, Ernst Jeger--a set of 3 stars in the universe of vascular surgery]

BACKGROUND: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited. HYPOTHESIS: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty. METHODS: A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise > 5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow-up. RESULTS: During a mean follow-up of 30 +/- 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction < 40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction > or = 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise > 5 units below the resting value, angina pectoris or ST-segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI. CONCLUSION: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.     

Changes in hemostasis in ischemic heart disease

The relationship between changes in blood coagulation, the occurrence and severity of risk factors of ischemic heart disease and the clinical condition of the patient was investigated. The at risk group of patients 42.2% had more than 3 pathological parameters. Intravascular blood coagulation was not activated in any of the patients. In patients with acute myocardial infarction (MI), 62.2% had more than 3 pathological parameters on the first day of MI development. Demonstrable activation of intravascular blood coagulation was found in 28.2% of these patients. On day 5 of MI, activation of intravascular blood coagulation was recorded in 57.7% of the patients treated by classical approach and in 15.4-30.8% of the patients on thrombolytic treatment. In the at risk group, primary hemostasis and the fibrinolytic system were more affected, in patients with MI the whole hemostatic mechanism was involved. On day 5 of MI, in patients with classical therapy pathological laboratory findings still persisted or were even more deteriorated, particularly increases in fibrinogen level. At that time, in patients on thrombolytic therapy no substantial changes of initial values were recorded. No correlation was found to exist between changes in hemostasis and the risk profile or between changes in hemostasis and the clinical severity of MI. The obtained results justify the administration of antithrombotic substances, especially in patients with unstable angina pectoris. On observing time constraints, administration of thrombolytics is justified in MI. (Fig. 9, Ref. 25.)     

The stress connection. Women and coronary heart disease

Assessment and treatment of the stressors associated with major medical illness such as CHD without regard to gender overlooks women's issues in some extremely fundamental ways. To ensure that rehabilitation formats are relevant for women, more qualitative studies are needed so that women can give voice to the story of an MI recovery from a feminine perspective. It is vital to understand the psychologic contribution to the development and treatment of CHD both as described by women in their own words and as evaluated by distinctly feminine constructs. Assessment of psychosocial factors should be an essential component of a CHD diagnostic evaluation. Although little can be done about a genetic predisposition to CHD, education and personal support can help women make needed lifestyle changes to forestall further cardiac damage and to improve a woman's level of functioning. The capacity to take charge of one's life and social support are strong counterpoints to negative psychosocial symptoms of CHD. There is a strong need to make rehabilitation programs for women with CHD contextually congruent. Strategies to involve women in cardiac rehabilitation must take into account a woman's needs, providing both age-appropriate physical exercise and psychologic social support for women at times convenient to their schedules. Women must be given permission to let go of normally performed duties after a major cardiac event and to seek out what is meaningful. Group formats that offer women essential social support, an opportunity to verbally process the meaning of a life-threatening diagnosis, an opportunity to share their experiences with other women, and the ability to reconstruct a new sense of self based on feminine constructs may be as important for women as other lifestyle structural components in effective rehabilitation programs. Society must reclassify the CHD disease process as one that equally affects women. Research studies with women as primary subjects and key informants can provide needed direction in the identification of psychosocial risk factors and appropriate treatments to reduce alarming morbidity and mortality of CHD in women. More data are needed about the psychosocial mechanisms that aggravate and mediate physiologic responses in CHD in women.     

Early diagnosis of dementia: neuroimaging

BACKGROUND [corrected] AND PURPOSE: We reviewed Stroke Clinic data to determine the extent of risk factor modification achieved in patients with cerebrovascular disease over 2 years. METHODS: Visits to the Stroke Clinic of a tertiary medical center from July 1, 1994, through June 30, 1996, were reviewed. Obesity, smoking, hypertension, hyperlipidemia, hyperglycemia, and lifestyle changes were noted in patients with >/=2 visits (n=61) and measures (number varied) of these parameters. RESULTS: Fifty-six patients (92%) had primary care physicians. In the 49 patients with >/=2 weight measurements, 33 (67%) were moderately or severely overweight by weight-height correlation. Forty-four patients (90%) remained in the same weight category. Of the 60 patients with available blood pressure data, 50 (83%) were hypertensive. At their last visits, 43 of the 50 (86%) were receiving medications, and 22 of the 43 treated (51%) were controlled. Serum glucose remained elevated in 14 of 47 patients (30%) and in 11 of 16 diabetic patients (69%). Thirty-six of 47 patients (55%) had elevated lipid measurements. None of the 21 smokers quit during the study period. Few patients modified dietary and exercise practices. Of 61 patients, 29 (48%) sustained vascular events during the study, with 17 of these 29 patients (59%) having strokes or transient ischemic attacks. CONCLUSIONS: Although most patients were asked to quit smoking, received advice regarding diet and exercise, and were medicated for hypertension, elevated glucose, and cholesterol levels, their risk factor profiles showed little improvement during the 2-year period. More effective methods of controlling stroke risk factors are needed.     

The relationship of daily stress and health-related behaviors to adolescents' cholesterol levels

It has been well established that some of the major risk factors for coronary heart disease are related to lifestyle, that is, behaviors that are potentially modifiable. Although studies have identified psychosocial stress as a factor associated with elevated cholesterol levels in adults, this relationship has not been thoroughly examined in adolescents. The present study investigated the relationship between daily life events and total cholesterol levels among 104 high school students. The contributions of health-related behaviors, such as dietary patterns, physical activity, smoking, and television viewing, were also examined. Hierarchical multiple regression analyses showed that scores on a scale of daily life events explained a significant portion of the variance in cholesterol measurements. However, when the sample was stratified by gender, this effect remained significant for adolescent females but not males. Overall, females reported a greater degree of negative health behaviors than did males. Implications of these findings are discussed.     

Effect of spinal cord injury on the heart and cardiovascular fitness

The use of various FES protocols to encourage increases in physical activity and to augment physical fitness and reduce heart disease risk is a relatively new, but growing field of investigation. The evidence so far supports its use in improving potential health benefits for patients with SCI. Such benefits may include more efficient and safer cardiac function; greater stimulus for metabolic, cardiovascular, and pulmonary training adaptations; and greater stimulus for skeletal muscle training adaptations. In addition, the availability of relatively inexpensive commercial FES units to elicit muscular contractions, the ease of use of gel-less, reusable electrodes, and the increasing popularity of home and commercial upper body exercise equipment mean that such benefits are likely to be more accessible to the SCI population through increased convenience and decreased cost. The US Department of Health and Human Services has identified those with SCI as a "special population" whose health problems are accentuated, and so need to be specifically addressed. FES presents "a clear opportunity.... For health promotion and disease prevention efforts to improve the health prospects and functional independence of people with disabilities." As a corollary to this, the Centers for Disease Control and Prevention have recommended the development of techniques to prevent or ameliorate secondary disabilities in persons with a SCI. Patients with SCI have an increased susceptibility to cardiac morbidity and mortality in the acute and early stages of their injury. Most of these patients make an excellent adaptation except when confronted with infection or hypoxia. SCI by itself does not promote atherosclerosis; however, in association with multiple secondary conditions related to SCI, along with advancing age, patients with SCI are predisposed to relatively greater risk of heart disease. The epidemiologic significance of this is reflected in demographic studies that indicate an increasing number of SCI patients becoming aged. Currently 71,000 (40%) of the total 179,000 patients with SCI living in the United States are older than 40 years, and 45,000 have injuries sustained more than 20 years earlier. In addition, new injuries in the older population are increasing (currently 11% of all injuries), and some of these new patients with SCI already have pre-existing cardiac disease. Studies have demonstrated that improved lifestyle, physical activity, lipid management, and dietary restrictions can affect major risk factors for coronary artery disease. Therefore an aggressive cardiac prevention program is appropriate for patients with SCI as part of their rehabilitation. At a given submaximal workload, arm exercise is performed at a greater physiologic cost than is leg exercise. At maximal effort, however, physiologic responses are generally greater in leg exercise than arm exercise. Arm exercise is less efficient and less effective than lower body exercise in developing and maintaining both central and peripheral aspects of cardiovascular fitness. The situation is further compounded in SCI because of poor venous return as a result of lower-limb blood pooling, as a result of lack of sympathetic tone, and a diminished or absent venous "muscle pump" in the legs. This latter mechanism perhaps contributes the greatest diminution in the potential for aerobic performance in the SCI population. Obtaining a cardiopulmonary training effect in individuals with SCI is quite possible. Current studies indicate decreases in submaximal HR, respiratory quotient, minute ventilation, and oxygen uptake, with increases in maximal power output, oxygen uptake, minute ventilation, and lactic acid. Individuals with SCI have been shown to benefit from lower limb functional electrical stimulation (FES)-induced exercise. Studies have consistently reported increases in lower limb strength and cycle endurance performance with these protocols, as well as improvements in metabolic and     

Primary culture and transfection of epithelial cells of human small intestine

OBJECTIVE: To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair. DESIGN: Case series. SETTING: University and Veterans' Administration medical centers. PATIENTS: One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction. INTERVENTIONS: Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed. MAIN OUTCOME MEASURES: Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death. RESULTS: Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P = .001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P = .03) Overall survival by lifetable analysis was 87.9% and 69.7% at 3 and 5 years, respectively. CONCLUSION: Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.     

Prediction of death and myocardial infarction by screening with exercise-thallium testing after coronary-artery-bypass grafting

BACKGROUND: The role of myocardial-perfusion imaging in calculating risk in symptom-free patients who have had coronary-artery-bypass grafting (CABG) is unclear. Practice guidelines have argued against routine screening of these patients. We sought to find out the independent and incremental prognostic value of exercise thallium-201 single-photon-emission computed tomography (SPECT) for prediction of death and non-fatal myocardial infarction (MI) in these patients. METHODS: Analyses were based on 873 symptom-free patients undergoing symptom-limited exercise thallium-201 SPECT between September, 1990, and December, 1993. All had undergone CABG and none had recurrent angina or other major intercurrent coronary events. Exercise and thallium-perfusion variables were analysed to determine their prognostic importance during 3 years of follow-up. FINDINGS: Myocardial-perfusion defects were noted in 508 (58%) patients. There were 57 deaths and 72 patients had major events (death or non-fatal MI). Patients with thallium-perfusion defects were more likely to die (9% vs 3%, p=0.0004) or suffer a major event (11% vs 4%, p=0.0002). Reversible defects were also predictive of death (12% vs 5%, p=0.002) and major events (13% vs 7%, p=0.004). The exercise variable with the strongest predictive power was an impaired (< or = 6 METs [measure of oxygen consumption equal to 3.5 mL/kg/min]) exercise capacity; poor exercise capacity was predictive of death (18% vs 4%, p<0.0001) and death or non-fatal MI (19% vs 5%, p<.00001). After adjusting for baseline clinical variables, surgical variables, time elapsed since CABG, and standard cardiovascular risk factors, thallium-perfusion defects remained predictive of death (adjusted relative risk 2.78, 95% CI 1.44-5.39) and major events (2.63, 1.49-4.66). Similarly, impaired exercise remained strongly predictive of death (4.16, 2.38-7.29) and major events (3.61, 2.22-5.87) after adjusting for confounders. INTERPRETATION: In this group of patients who were symptom-free after CABG, thallium-perfusion defects and impaired exercise capacity were strong and independent predictors of subsequent death or non-fatal MI. Recommendations against routine screening exercise myocardial-perfusion studies in this setting should be reconsidered.     

Characteristics of West Virginians having myocardial infarction

BACKGROUND: Prevalence of risk factors in patients having myocardial infarction (MI) have been reported in large US and international studies, but little is known about the prevalence of risk factors in West Virginians having MI. METHODS: Risk factors for MI were identified by ICD-9 codes. Logistic regression analysis was used to compute odds ratios and 95% confidence intervals. RESULTS: In this cohort (n = 727), 72% of men less than 65 years old were current smokers. Women were older and had a lower frequency of smoking and a higher frequency of diabetes mellitus and obesity than men. Women less than 65 years old had significantly more hypertension than men. CONCLUSIONS: In West Virginia, women who have MI are more likely to be nonsmoking diabetics with hypertension.     

Clinical events in coronary patients who report low distress: Adverse effect of repressive coping.

Objective: Coronary artery disease (CAD) patients who report low distress are considered to be at low psychological risk for clinical events. However, patients with a repressive coping style may fail to detect and report signals of emotional distress. The authors hypothesized that repressive CAD patients are at risk for clinical events, despite low self-rated distress. Design: This was a prospective 5- to 10-year follow-up study, with a mean follow-up of 6.6 years. At baseline, 731 CAD patients filled out Trait-Anxiety (distress), Marlowe-Crowne (defensiveness), and Type D scales; 159 patients were classified as "repressive," 360 as "nonrepressive," and 212 as "Type D." Main Outcome Measures: The primary endpoint was a composite of total mortality or myocardial infarction (MI); the secondary endpoint was cardiac mortality/MI. Results: No patients were lost to follow-up; 91 patients had a clinical event (including 35 cardiac death and 32 MI). Repressive patients reported low levels of anxiety, anger and depression at baseline, but were at increased risk for death/MI (21/159 = 13%) compared with nonrepressive patients (22/360 = 6%), p = .009. Poor systolic function, poor exercise tolerance, 3-vessel disease, index MI and Type-D personality--but not depression, anxiety or anger--also independently predicted clinical events. After controlling for these variables, repressive patients still had a twofold increased risk of death/MI, OR = 2.17, 95% CI = 1.10-4.08, p = .025). These findings were replicated for cardiac mortality/MI. Conclusion: CAD patients who use a repressive coping style are at increased risk for clinical events, despite their claims of low emotional distress. This phenomenon may cause an underestimation of the effect of stress on the heart. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Randomised Intervention Treatment of Angina

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) are both effective intervention strategies for patients with coronary heart disease. We report comparative long-term clinical and health-service cost findings for these interventions in the first Randomised Intervention Treatment of Angina (RITA-1) trial. METHODS: 1011 patients with coronary heart disease (45% single-vessel, 55% multivessel) were randomly assigned initial treatment strategies of PTCA or CABG. Information on clinical events, subsequent intervention, symptomatic status, exercise testing, and use of health-care resources is available for a median 6.5 years of follow-up. Analyses were by intention to treat. FINDINGS: The predefined primary endpoint of death or nonfatal myocardial infarction occurred in 87 (17%) PTCA-group patients and 80 (16%) CABG-group patients (p=0.64). Similarly, there was no significant treatment difference in deaths alone (39 PTCA, 45 CABG), of which 46% were cardiac related. In both groups, the risk of cardiac death or myocardial infarction was more than five times higher in the first year than in subsequent years of follow-up. 26% of patients assigned PTCA subsequently also had CABG, and a further 19% required additional nonrandomised PTCA. Most of these reinterventions occurred within a year of randomisation, and from 3 years onwards the reintervention rate averaged 4% per year. In the CABG group the reintervention rate averaged 2% per year. The prevalence of angina was consistently higher in the PTCA group, with an absolute average 10% excess compared with the CABG group (p<0.001). Total health-service costs over 5 years showed no significant difference between initial strategies of PTCA and CABG (mean difference pounds sterling 426 [95% Cl -pounds sterling 383 to pounds sterling 1235]; p=0.30). The clinical and cost comparisons showed similar patterns for patients with single-vessel and multivessel disease. INTERPRETATION: Initial strategies of PTCA and CABG led to similar long-term results in terms of survival and avoidance of myocardial infarction and to similar long-term health-care costs. Choice of approach, therefore, rests on weighing the more invasive nature of CABG against the greater risk of recurrent angina and reintervention over many years after PTCA.     

A common prothrombin variant (20210 G to A) increases the risk of myocardial infarction in young women

Using specimens from a population-based case control study among women ages 18 to 44 years in western Washington, we assessed the relationship between carriership of a genetic clotting factor II variant (20210 G-->A) and myocardial infarction (MI). The factor II variant was previously shown to be present in 1% to 2% of the population, to increase the levels of factor II, and to be associated with venous thrombotic disease. Personal interviews and blood samples were obtained from 79 women with a first myocardial infarction and 381 control women identified through random-digit telephone dialing. Polymerase chain reaction (PCR) method was used to determine the factor II genotypes. The factor II 20210 G to A transition was present more often in women with MI (5.1%) than among control women (1.6%). The age-adjusted odds ratio for MI was 4.0 (95% confidence interval 1.1 to 15.1). The relative risk was high when another major cardiovascular risk factor was also present, such as smoking (odds ratio 43.3, 95% confidence interval 6.7 to 281), and the risk seemed limited to those with other risk factors. These results, in which the effect of major coronary risk factors is enhanced fourfold to sixfold by the prothrombin variant, are similar to those previously reported for another genetic clotting abnormality, factor V Leiden. We conclude that factor II 20210 G to A increases the risk of myocardial infarction in young women, especially in the women with other major risk factors for coronary heart disease.     

Percutaneous transluminal coronary angioplasty reverses vasoconstriction of stenotic coronary arteries in hypertensive patients

BACKGROUND: Endothelial dysfunction of coronary arteries with impaired vasodilation has been reported in patients with arterial hypertension. However, the effect of dynamic exercise on coronary vasomotion of a stenotic vessel segment before and after PTCA has not yet been evaluated in these patients. METHODS AND RESULTS:Coronary vasomotion of a normal and a stenotic vessel segment was studied in 39 patients with coronary artery disease during supine bicycle exercise before and 9+/-3 months after PTCA. Luminal area changes were determined by biplane quantitative coronary arteriography. There were 21 normotensive and 18 hypertensive patients who did not differ with regard to clinical characteristics. Percent area stenosis decreased after PTCA from 90% to 39% (P<0.001) in normotensive and from 86% to 33% (P<0.001) in hypertensive patients. Exercise-induced vasomotion of the normal vessel segment was significantly different between normotensives and hypertensives before (+19% versus +1%, P<0.01) and after (+16% versus +3%, P<0.01) PTCA. In contrast, stenotic vessel segments showed vasoconstriction in both normotensive and hypertensive patients (Deltaexercise, -11% versus - 20%, P=NS), which was reversed after PTCA (+3% versus +2%, P=NS). CONCLUSIONS: Normal coronary arteries show reduced vasodilation during exercise in hypertensive patients that may be explained by the presence of endothelial dysfunction. Stenotic vessels demonstrate paradoxical vasoconstriction during exercise in both normotensive and hypertensive patients. PTCA reverses vasoconstriction by elimination of the flow-limiting stenosis and prevention of coronary stenosis narrowing during exercise in normotensive and hypertensive patients.     

Immunocytochemical detection of advanced glycated end products in rat renal tissue as a function of age and diabetes

Lifestyle practices and the health promoting environment of hospital nurses This paper examined the lifestyle practices of hospital nurses and the impact of specific interventions in the hospital environment. The perception of nurse as health promoter and as carer of AIDS patients was also examined. A self-administered questionnaire was used to collect data at two different time periods. The sample represented 729 nurses (at pre- and post-time periods), both qualified and student nurses. Qualified nurses reported the highest stress levels while student nurses reported more negative lifestyle practices such as smoking, alcohol consumption and drug use. A greater number of current smokers (29%) consumed alcohol and used drugs than non-smokers. The impact of intervention strategies around compliance with smoking policy and work-site walk routes reduced exposure to passive smoking at work for qualified nurses and increased exercise participation for both groups of nurses. Workplace was identified as the main source of stress which included relationships at work and demands of the job. Hospital nurses experiencing high work stress were more likely to use professional support and personal coping (discuss problems with friends/family, have a good cry and eat more) than others. Nurses believed in the importance of health promotion as part of their work; however, qualified nurses felt more confident and gave more health related information than student nurses. Student nurses perceived a lower risk of contacting AIDS through work and a higher concern/worry in caring for AIDS patients than qualified nurses.