Angiographic methods to assess human coronary angiogenesis

It is unclear how agents designed to promote angiogenesis in the human heart affect the arteriographic appearance of the collateral circulation. Possible changes in collateral vessels include new collateral vessels arising from epicardial arteries, new branches emanating from existing collateral vessels, wider or longer collateral vessels, and higher dye transit rates that result in improved recipient vessel filling. Given the multiple mechanisms by which these new agents may improve myocardial perfusion, a rigorous, systematic, and comprehensive analysis of coronary arteriograms is required to discern the true mechanism of benefit. The method of analysis must account for potential changes in collateral blood flow, number, branching pattern, and length as well as changes in recipient vessel filling. The ability to detect differences between intricate networks of vessels in an angiographic study is dependent on maintaining consistency in cinefilming as well as the core laboratory methods between time points. In this report, we describe the methodology our angiographic core laboratory has found to be most effective to evaluate these very complex angiograms and attempt to capture all the possible modalities of angiogenesis.     

Ethnicity, hypertension, coronary heart disease and renal diseases in South Africa

This paper reviews the impact of race and environment upon hypertension, coronary heart disease and renal diseases in South Africa. Inequalities of socioeconomic status, lifestyle, and access to South African health care have produced striking differences in the prevalence and complications of hypertension. Coronary heart disease is 'epidemic' in the white and Indian population and is still relatively uncommon in blacks. There are different histological patterns of glomerulonephritis among the racial groups, which may lead to end-stage renal disease. Hypertension is an important cause of end-stage renal disease in the black population whilst analgesic nephropathy is important in the white population. Efforts are now being made to comprehend these daunting realities and to minimize the inequalities.     

Comparison of modalities to diagnose coronary artery disease

The purpose of this review is to compare several modalities available for detection of coronary artery disease (CAD). We compare the clinical history, rest/exercise electrocardiogram (ECG), rest/stress left ventricular (LV) function by radionuclide or echocardiographic methods, myocardial perfusion imaging (MPI) by single photon emission computed tomography (SPECT) or positron emission tomography (PET), contrast coronary angiography, magnetic resonance imaging (MRI), spectroscopy (MRS) and angiography (MRA), and ultrafast cine computed tomography (UFCT) to assess LV function, myocardial perfusion, and coronary calcification. We compare the modalities by answering six questions: (1) Does the modality provide unique clinical information? (2) What is the observer error? (3) What are sensitivities and specificities to detect CAD? (4) What patient selection criteria should be applied for each modality? (5) What incremental benefit is obtained from one modality versus another modality? and (6) Where do the modalities fit in the overall scheme of diagnostic testing for CAD? PET MPI appears to be the best noninvasive test for CAD, followed by SPECT thallium-201 and then dobutamine echocardiography. MRA and UFCT may soon play a larger role because they visualize the arteries. Contrast coronary angiography remains the gold standard despite its limitations. Exercise ECG is the least accurate test. The choice of tests critically depends on patient selection--based on clinical history, age, gender, and risk factors to estimate the pretest, clinical probability of CAD.     

Cost-benefit analysis of walking to prevent coronary heart disease

OBJECTIVE: To quantify the cost-benefit relationship of walking to prevent coronary heart disease. DESIGN: Cost-benefit analysis. PARTICIPANTS: Hypothetical cohorts of sedentary men and women aged 35 to 74 years. MAIN OUTCOME MEASURES: Decision-analysis simulation was used to evaluate the cost-benefit relationship of walking, varying level of benefit from exercise, frequency of exercise to achieve benefit, participation rates, and costs of exercise and injury. RESULTS: At a relative risk of 1.9 for heart disease associated with sedentary behavior, $5.6 billion would be saved annually if 10% of adults began a regular walking program. A $4.3 billion savings is predicted if the entire sedentary population began walking regularly and the cost of the time an individual spends exercising is accounted for in those who dislike exercising. According to our baseline assumptions, walking is economically beneficial for men aged 35 to 64 years and for women aged 55 to 64 years. The threshold of relative risk at which economic benefit is found for walking in this population overall is estimated at 1.7, and under a volunteer model, most adults would benefit even at a relative risk of 1.15. CONCLUSIONS: There are significant sex and age differences in the economic benefits of walking to prevent heart disease. The value assigned to the time an individual spends exercising has a significant impact on the results. Overall, a substantial savings is predicted from encouraging sedentary individuals to participate in a regular walking program.     

Comparison of methods to determine the prevalence and nature of oral mucositis

PURPOSE: Chemotherapy-induced oral mucositis may cause considerable patient morbidity. Its prevalence has been reported as ranging from 30% to 39%, although a prevalence as high as 75% has been reported with 5-fluorouracil. This variation may be a function, in part, of the methods of measurement used across different studies. The first purpose of this study was to determine the prevalence of oral mucositis in a sample of 127 patients receiving specific chemotherapy. The second purpose was to compare different instruments and techniques for assessing oral mucositis. DESCRIPTION OF STUDY: A longitudinal design was used to collect data at four monthly chemotherapy cycles during drug nadir. The methods of measuring oral mucositis included interview (conducted monthly x 4); Eiler's Oral Assessment Guide (monthly x 4); Chemotherapy Knowledge Questionnaire and Behavior Checklist (both at the fourth month); Self-Care Behavior Log (ongoing over 4 months); and medical record review (collected at 4 months). RESULTS: The mucositis prevalence in this one sample ranged from 30% to 69% depending on the method of measurement. The use of multiple instruments and techniques captured a clinical picture of oral mucositis far more detailed than published reports--a picture not revealed with any one instrument or technique. The chart record severely underdocumented the prevalence of mucositis compared to the interview. This discrepancy could reflect under-reporting by the patients, inadequate history taking at provider visits, or perhaps the documentation of only the more severe mucositis or mouth problems in the medical record. CLINICAL IMPLICATIONS: Clinicians and researchers must choose their method of measurement carefully in relation to the purpose of assessment. For subjective tolerance of symptoms, the interview technique may be most useful. To test interventions, the use of a quantitative rating instrument is desirable. Intervention studies using multiple measures may require a combination of subjective and objective measures.     

Nutrition in prevention of coronary heart disease

Medical conditions often have an important causal role in urinary incontinence in the elderly. Aside from causing functional impairments, such diseases directly may involve the genitourinary system--particularly its neurologic control--resulting in specific lower urinary tract pathophysiology. Knowledge of the specific effects that medical conditions may have on the genitourinary system and continence can assist the urologic specialist in determining the often complex cause(s) of UI in older persons.     

Chronotherapy for coronary heart disease

Traditionally the therapy for coronary heart disease has been focused on the "how-to" problem. However, the clustering of cardiovascular events around the specific time of the day has been clarified. To solve the problems of the clustering would give us the clue to treat the coronary heart disease timely and in time. Therefore, the research has been stressed to solve "when-to" problem. The circadian variabilities in coronary heart disease has been clarified to be the function of the biologic time. Therefore, three problems were discussed in this paper. 1) The circadian variabilities in biology should be assessed based on the biologic zero hour rather than the mid-night of the mechanical clock. Our concept of the biologic zero hours has been proposed to answer this problem. 2) Daily health care with circadian order and harmony for the prevention of the coronary risk factors should be recommended as the prevention of the acute coronary risk factors as the trigger mechanism of the cardiovascular events. 3) The chronotherapy to chronic coronary risk factors such as hypertension was discussed, In hypertension the anti-hypertensive therapy should be customized individually adjusting the circadian variability of blood pressure with the proper selection of agents and time of the administration.     

Homocysteine and coronary heart disease. Is slight or moderate homocysteinemia related to increased risk of coronary heart disease?

Homocystinuria, a rare inherited disturbance of amino acid metabolism is associated with severe atherosclerosis and thromboembolism already in childhood. The incidence of the homozygous disease of cystathionine beta synthase is estimated to be 1:200,000, that of the heterozygous form 1:300. There are, however, numerous other causes of a mild to moderate homocysteinemia, for example, a deficiency of the cofactors vitamin B6, B12 and folic acid. The question as to whether a mild to moderate elevation of homocysteine in the plasma is also associated with an increased risk of CAD has been investigated in a number of studies in recent years. In summary, however, the presently available data do not provide a basis of proof that a mild to moderate homocysteinemia is an independent risk factor for CAD. Our present knowledge suggests that only when the family history is clearly positive does it appear reasonable to undertake a diagnostic search for possible homocysteinemia.     

Comparison of coronary angiographic findings in acute and chronic first presentation of ischemic heart disease

BACKGROUND: It is generally assumed that the clinical manifestations of ischemic heart disease occur randomly on the same underlying pathological process. Therefore, coronary angiographic findings should be similar whether the first presentation of ischemic heart disease is acute myocardial infarction or uncomplicated chronic stable angina. METHODS AND RESULTS: We studied 102 patients (men < or = 60 years old, women < or = 65 years old) presenting with either acute myocardial infarction as first manifestation of coronary artery disease with a concomitant coronary angiogram (55 patients; mean age, 50.2 years) or stable angina for at least 2 years with no history, ECG, or left ventriculographic evidence of any acute event and with an angiogram performed at least 2 years after initial symptoms (47 patients; mean age at symptom onset, 51.7 years). These angiograms were evaluated blindly for severity (number of vessels diseased, stenoses > or = 50%, occlusions), extent of disease (with an index derived by assigning a score of 0-3 per segment, depending on the proportion of lumen length irregularity and dividing the sum by the number of visualized segments), and pattern (discrete: three or fewer loci of disease never involving more than 50% of the length of any segment or diffuse: anything exceeding this). Patients with unheralded myocardial infarction had fewer vessels diseased, fewer stenoses and occlusion, and a lower extent index than those with uncomplicated stable angina (mean +/- SD of 1.3 +/- 0.8 versus 2.1 +/- 0.8, p < 0.001; 2.1 +/- 1.8 versus 3.9 +/- 1.8, p < 0.001; 0.6 +/- 0.6 versus 1.0 +/- 0.9, p < 0.02; and 0.6 +/- 0.5 versus 1.2 +/- 0.5, p < 0.001, respectively). A discrete pattern was present in 54.5% of patients with unheralded infarction and in only 8.5% of those with uncomplicated angina (p < 0.001). CONCLUSIONS: These very different angiographic findings suggest that unheralded acute myocardial infarction and uncomplicated chronic stable angina do not occur randomly on a common atherosclerotic background but rather that additional factors, such as a varying propensity to thrombosis, may predispose to one or the other of these two clinical syndromes.     

Secondary prevention of coronary heart disease

Despite the significant reduction in cardiovascular mortality during the past three decades, atherosclerotic coronary heart disease (CHD) remains the leading cause of death and disability in the United States. Randomized clinical trials in patients with CHD have provided convincing evidence that risk factor modification is beneficial in decreasing all-cause mortality and cardiovascular morbidity and mortality. Multifactorial coronary risk reduction provides the most substantial benefit. Coronary risk reduction is associated with a decrease in cardiovascular-related hospital admissions, a reduced need for myocardial revascularization procedures, and an improved quality of life for the patients so treated. Control of coronary risk factors is an integral component of the optimal care of the patient with CHD.     

Addressing coronary heart disease risk in women

Contrary to popular perceptions, coronary heart disease (CHD) is a serious and widespread problem in US women. Public education, preventive interventions, and better data on CHD risk and prevention in women are needed.     

Left coronary artery transit time in latent coronary heart disease

In a group of 104 cases with possible silent coronary heart disease, 36 had normal angiographic findings and 68 significant coronary artery disease. The transit time of the contrast medium in the left coronary artery was significantly shorter in cases with abnormalities of the artery than in non-afflicted cases. The extent of arterial disease seemed to influence the transit time inversely, whereas the location of the abnormalities did not influence the transit time.     

Renal stones and coronary heart disease

The relationship between risk factors for coronary heart disease (CHD) and renal stone disease has been studied in a population of more than 2000 middle-aged men. The only positive association found was a slight increase in diastolic BP among stone formers and a higher stone prevalence in untreated hypertensives. Furthermore, the prevalence of a history of renal stones in male survivors of myocardial infarction (MI) was similar to that found in the population study. An investigation of the vitamin D intake by means of a dietary questionnaire revealed no differences between stone formers, healthy controls and MI survivors. Contrary to other reports, the present study indicates that the risk factor profile for CHD in stone formers is similar to that in the general population.     

High-density lipoproteins and coronary heart disease

High-density lipoproteins (HDLs) play an important role in the process of reverse cholesterol transport, the pathway by which the cholesterol in extrahepatic tissues is transported through plasma to the liver for recycling or for excretion from the body in bile. The concentration of HDL cholesterol is a powerful inverse predictor of the development of coronary heart disease, leading to a widely held view that HDL protects against the development of atherosclerosis. The mechanism by which HDLs protect is unknown. To date, no studies have been designed specifically to test the proposition that increasing the concentration of HDL cholesterol translates into a reduction in coronary risk. Nevertheless, in a subgroup of the Helsinki Heart Study, it was found that a substantial proportion of the beneficial effect of gemfibrozil was explicable in terms of an increase in the concentration of HDL cholesterol.