Improved clinical effectiveness with a collagen vascular hemostasis device for shortened immobilization time following diagnostic angiography and percutaneous transluminal coronary angioplasty

This study prospectively compared immobilization time followed by use of a vascular hemostasis device (VasoSeal) versus manual compression to achieve hemostasis at the arterial puncture after angiography and percutaneous transluminal coronary angioplasty (PTCA). The trial shows that use of a vascular hemostasis device results in earlier mobilization, even in highly anticoagulated PTCA patients compared with manual compression, with no statistically significant complications.     

Abciximab in primary coronary angioplasty for acute myocardial infarction improves short- and medium-term outcomes

OBJECTIVES: The purpose of this study was to compare the outcome of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (MI) when performed with or without the platelet glycoprotein IIb/IIIa antibody, abciximab. BACKGROUND: Abciximab improves the outcome of angioplasty but the effect of abciximab in primary angioplasty has not been investigated. METHODS: Data were collected from a computerized database. Follow-up was by telephone or review of outpatient or hospital readmission records. RESULTS: A total of 182 consecutive patients were included; 103 received abciximab and 79 did not. The procedural success rate was 95% in the two groups. At 30-day follow-up, the composite event rate of unstable angina, reinfarction, target vessel revascularization and death from all causes was 13.5% in the group of patients who did not receive abciximab, 4% (p < 0.05) in the abciximab group and 2.4% (p < 0.05) in the subgroup of patients (n = 87) who completed the 12-h abciximab infusion. At the end of follow-up (mean 7+/-4 months), the composite event rate was 32.4%, 17% (p < 0.05) and 13.1% (p < 0.01) in these three categories respectively. Abciximab bolus followed by a 12-h infusion was an independent predictor of event-free survival, in a Cox proportional hazards model (relative risk 0.49; 95% confidence interval 0.24 to 0.99; p < 0.05). CONCLUSIONS: Abciximab given at the time of primary angioplasty may improve the short- and medium-term outcome of patients with acute MI, especially when a 12-h infusion is completed.     

Psychosocial interventions for patients with coronary artery disease: a meta-analysis

BACKGROUND: Narrative review strategies and meta-analyses have shown that drug treatment and exercise rehabilitation regimens can reduce psychological distress and postmyocardial infarction mortality and recurrence. OBJECTIVE: To question whether the addition of psychosocial interventions improves the outcome of a standard rehabilitation regimen for patients with coronary artery disease. METHODS: We performed a statistical meta-analysis of 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation from documented coronary artery disease. Anxiety, depression, biological risk factors, mortality, and recurrence of cardiac events were the clinical end points that were studied. Mortality data were available from 12 studies, and recurrence data were available from 10 of the 23 studies. RESULTS: The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects. The psychosocially treated patients showed greater reductions in psychological distress, systolic blood pressure, heart rate, and cholesterol level (with effect size differences of -0.34 [corrected], -0.24, -0.38, and -1.54, respectively). Patients who did not receive psychosocial treatment showed greater mortality and cardiac recurrence rates during the first 2 years of follow-up with log-adjusted odds ratios of 1.70 for mortality (95% confidence interval [CI], 1.09 to 2.64) and 1.84 for recurrence (CI, 1.12 to 2.99). CONCLUSIONS: The addition of psychosocial treatments to standard cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress, and some biological risk factors. The benefits were clearly evident during the first 2 years and were weaker thereafter. At the clinical level, it is recommended to include routinely psychosocial treatment components in cardiac rehabilitation. The findings also suggest an urgent need to identify the specific, most effective types of psychosocial interventions via controlled research.     

Severe thrombocytopenia associated with Abciximab therapy--apropos a clinical case

The authors present the case of a 52-year-old male patient with severe coronary artery disease, submitted to percutaneous transluminal coronary angioplasty on a type C right coronary artery lesion. The use of a platelet glycoprotein receptor IIb-IIIa inhibitor, Abciximab, led to severe thrombocytopenia, treated only with platelet concentrate transfusions and with complete recovery. We also review the principal characteristics of the drug, its main indications and side effects. Severe thrombocytopenia has rarely been described in the literature.     

Coronary angioscopy: initial experience during coronary interventions

BACKGROUND AND OBJECTIVE: Percutaneous coronary angioscopy (CAG) provides in vivo visual information about the luminal aspect of the vessel. In this report we describe our initial experience with CAG during coronary angioplasty (PTCA). METHODS: Fifty-five patients (age 60 +/- 9 years), 8 female, were included. Most patients, 42 (76%) were treated for unstable angina. RESULTS: In 49 patients (89%) CAG was performed prior to PTCA, and in all cases the intraluminal material responsible of the stenosis was recognized. This included plaque associated to thrombus in 29 patients (59%), isolated plaque in 15 (31%) and isolated thrombus in 5 (10%). Of these plaques, 25 (57%) were yellow, 14 (32%) were yellow and white and 5 (11%) were white. Of the 34 thrombi, 23 (68%) were mural and 11 (32%) protruding. CAG post-PTCA was performed in 43 patients (78%). CAG visualized residual plaque in 41 patients (95%) and residual thrombus in 34 (79%). In addition, CAG recognized dissections in 30 patients (70%). CAG was more sensitive than angiography for the detection of thrombus (pre-PTCA 34 [69%] vs 11 [22%]; p < 0.05, and post-PTCA 34 [79%] vs 5 [12%]; p < 0.05]) and coronary dissections (post-PTCA 30 [70%] vs 19 [44%]; p < 0.05). CAG before intervention caused angina in 39 patients (80%), ventricular fibrillation (successfully managed with DC cardioversion) in 1, and AV block in another patient. The angiographic result deteriorated in 4 patients (9%) immediately after the CAG performed following PTCA. A repeat balloon PTCA was required in these patients. CONCLUSIONS: CAG provides unique information on coronary lumen surface that complements angiographic data. As compared with angiography, CAG is more sensitive in the detection of intracoronary thrombi and dissections. Further studies are required to determine whether the additional information provided by CAG may be used, to select coronary interventions according to specific lesion characteristics, to optimize dilation results and, eventually, to improve the clinical outcome of these patients.     

Management of unstable coronary syndromes in patients with previous coronary artery bypass grafts following coronary angiography

A recent survey of psychiatric research indicates religion has been given little attention, and when it has been considered, the measures have been simplistic. The present study was designed to describe the religious needs and resources of psychiatric inpatients. With the use of a multidimensional conception of religion and two established instruments, 51 adult psychiatric inpatients were surveyed about their religious needs and resources. For comparison, 50 general medical/surgical patients, matched for age and gender, were also surveyed. Eighty-eight percent of the psychiatric patients reported three or more current religious needs. Although there were no differences in religious needs between the two patient groups, there were significant differences in religious resources. Psychiatric patients had lower spiritual well-being scores and were less likely to have talked with their clergy. Religion is important for the psychiatric patients, but they may need assistance to find resources to address their religious needs.     

Biobehavioral outcomes following psychological interventions for cancer patients.

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Altered hemostasis in male rats following administration of the ACAT inhibitor SKF-99085

We have previously found that high-frequency stimulation of the medial amygdala (MeA) induces long-term potentiation (LTP) of the population spike in the perforant path-dentate granule cell synapses of anesthetized rats. In the present study, we investigated the influence of MeA stimulation on the relationship between the population excitatory postsynaptic potential (pEPSP) and population spike in the dentate gyrus. High-frequency stimulation of the MeA produced a leftward shift of the E-S curve, in which population spike amplitude was plotted against pEPSP slope at various stimulus intensities. MeA-induced population spike LTP was also observed under blockade of GABAergic inhibition with picrotoxin. These results suggests that MeA stimulation leads to a long-lasting change in the internal firing characteristics of the dentate granule cells.     

Nitroglycerin treatment following experimental coronary occlusion

The effect of sublingual (0.2 mg.) nitroglycerin (TNG) was studied in anesthetized dogs before and after coronary occlusion. Coronary artery occlusion was accomplished by embolization of the circumflex branch of the left coronary artery. TNG was administered before embolization and again at one minute, one, two, and six hours after embolization. TNG treatment did not significantly increase the number of arrhythmias or deaths compared to untreated animals with coronary occlusion. Hemodynamic and blood biochemical parameters were measured 5 to 15 minutes after TNG treatment. At this time of measurement, blood pressures (AO, LV, LA, PA, RV, RA), cardiac output, pulmonary and systemic resistances, and left ventricle work were not significantly different in the TNG-treated group compared to the animals with coronary occlusion but no TNG treatment. In the first five minutes after TNG administration, aortic pressure is reduced. Blood samples withdrawn five minutes after TNG treatment are not significantly different from the untreated animals in PO2, PCO2, pH, glucose, lactate, pyruvate, free fatty acids, LDH, CPK, and SGOT. It is concluded that TNG is not detrimental to animals with acute coronary occlusion and that TNG has a transient, short-duration effect.     

Fluid therapy with Ringer's solution versus Haemaccel following coronary artery bypass surgery

BACKGROUND: Crystalloid and colloid infusion can be used in volume therapy following heart surgery. In this prospective, randomised study we compared Ringer's solution (group R) to Haemaccel (group H) following coronary artery bypass grafting. METHODS: A stringent protocol for adjusting the infusion rate was used. Haemodynamic parameters and pulmonary function were evaluated as well as chest tube drainage. The double-indicator dilution method was used to measure total blood volume index (TBVI), intrathoracic blood volume index (ITB-VI) and extravascular lung water index (EVLWI). RESULTS: Haemodynamic stability was achieved in both groups throughout the study period, as judged from mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, and cardiac index. However, the total volume infused was significantly higher in group R. TBVI and ITBV were higher in group H, although only significant at 8 h for TBVI. Pulmonary function was similar in both groups. There was no significant difference in EVLWI, pulmonary shunt fraction, and time on mechanical ventilation. Likewise, chest tube drainage was not significantly different in both groups. CONCLUSION: We conclude that volume therapy with Haemaccel following heart surgery requires less volume and achieves better filling of the circulation compared to Ringer's solution.     

Prolonged heparin after uncomplicated coronary interventions: a prospective, randomized trial

BACKGROUND: Both ischemic and direct vascular injury (angioplasty) result in the elaboration of proinflammatory substances, including tumor necrosis factor alpha (TNF), which may regulate vascular smooth muscle cell (VSMC) proliferation and promote vessel stenosis. Interleukin-10 (IL-10) is a pleiotropic cytokine with potent antiinflammatory effects in many cells lines. We hypothesized that IL-10 could be used therapeutically to influence vascular remodeling by inhibiting TNF-induced VSMC proliferation. The purposes of this study were (1) to determine whether human myocardium produces endogenous TNF in response to ischemia-reperfusion, (2) to examine the effect of TNF on human arterial smooth muscle proliferation, and (3) to explore the potential therapeutic effect of IL-10 on unstimulated and TNF-stimulated VSMC proliferation. MATERIALS AND METHODS: Right atrial muscle was obtained from patients undergoing elective cardiac surgery. Atrial muscle was subjected to simulated ischemia and reperfusion in vitro and TNF was measured by immunoassay. Human aortic VSMCs were isolated and cultured. Proliferation assays were performed to determine the effect of TNF and IL-10 on VSMC growth. RESULTS: Ischemia-reperfusion resulted in an increase in atrial myocellular TNF (94.5 +/- 15.8 pg/g wet tissue versus control 12.9 +/- 4.4 pg/g wet tissue, P < 0.002). Compared with control, TNF stimulated concentration-dependent VSMC proliferation (P < 0.005). IL-10 alone did not influence VSMC growth. However, following TNF stimulation, IL-10 inhibited VSMC growth at a dose as low as 0.1 pg/ml (P < 0.005). CONCLUSIONS: Ischemia-reperfusion insult results in increased endogenous myocardial TNF accumulation. TNF stimulates VSMC growth which is abrogated by physiologically relevant levels of IL-10. This antiinflammatory cytokine may prove to be an effective therapeutic agent in regulating vessel wall remodeling following both ischemic and direct cardiovascular injury.     

Circulatory changes in patients with coronary artery disease following thiamylal-succinylcholine and tracheal intubation

After introductory remarks concerning the Posner-Schlossman-syndrome (syndrome of glaucomatocyclitic crises) a case is reviewed. The concurrence with Addison's disease in this patient gives rise to speculations as to possible connections between the two conditions, but the conclusion is that the simultaneous occurrence of the two diseases at present must be regarded as coincidental.     

Pathophysiology of restenosis following percutaneous transluminal coronary angioplasty

Symptomatic restenosis occurs in approximately 30-40% of patients after percutaneous transluminal coronary angioplasty (PTCA). Despite intensive research, the primary pathophysiological mediators have not been defined, and pharmacological therapy has not been effective in preventing restenosis. Restenosis is a multifactorial and sequential process, which is initiated by mechanical injury of the vessel wall, and involves neointima formation caused by the local proliferation of smooth muscle cells and production of an extracellular matrix, followed by vascular remodelling. Numerous mediators are involved in these processes, e.g., protooncogenes, growth factors, cytokines and nitric oxide. This review discusses the pathobiological mechanisms underlying coronary restenosis, and outlines the prospects for future therapy.     

Secondary ulcer perforation after endoscopic hemostasis with fibrin glue

Emergency treatment of bleeding ulcer of the duodenum is endoscopy and endoscopic blood-staunching. In high-risk patients with Forrest Ia lesions or ulcers with visible vessel (Forrest IIa) endoscopic follow-up or early elective operation is required. Fibrin sealing can improve the results of endoscopic injection therapy for bleeding ulcer. Nevertheless, severe complications such as secondary perforation of the fibrin clot or recurrent bleeding can occur. Identification of high-risk patients and complications requires close monitoring and attention. A case of a secondary perforation of a bleeding ulcer of the duodenum after fibrin sealing is reported.     

Influence of hemosorption on hemostasis in patients with sepsis

The changes in the system of hemostasis were studied in 36 patients with sepsis managed with sorptive detoxication. The starting status of the system of hemostasis in patients with favorable outcome of the disease can be considered as the 2d stage of the disseminated intravascular coagulation (DIC), and in patients with the unfavorable outcome--as the 3d (hypocoagulative) stage. The sorptive detoxication provides the treatment of the DIC syndrome in favorable outcome, as well as further progression of the process in unfavorable outcome of sepsis. Conservative treatment provides stabilization of the hemostatic system and gives opportunity to perform delayed hemosorption with a positive clinical result.     

Post-traumatic ventricular septal defect following coronary bypass surgery

A 60-year-old patient underwent triple coronary artery bypass grafting following an inferoseptal myocardial infarction and early onset of exertional angina. Four years later he was involved in a car accident during which he sustained an abdominal and thoracic trauma. Approximately 1 month after discharge, a ventricular septal defect was diagnosed by two-dimensional Doppler echocardiography with patency of all grafts at coronary angiography. Closure of the septal defect was successfully accomplished through a right atrial approach. Rupture of the ventricular septum following blunt chest trauma in a patient with previous myocardial revascularization has not been previously reported.     

Care of the patient and management of complications after percutaneous coronary artery interventions

Certain aspects of patient management are common with conventional balloon angioplasty and newer coronary artery interventions. These aspects include the evaluation of chest pain or treatment of acute vessel closure shortly after the intervention, management of the vascular access site (especially if complications occur), prevention and treatment of contrast-induced renal dysfunction, and the use of anticoagulant or antiplatelet agents after the procedure. However, some aspects of management vary among techniques. Several different drug therapies are indicated after these procedures, but pharmacologic therapy for restenosis has been largely unsuccessful. Placement of an intracoronary stent decreases the frequency of restenosis and subsequent revascularization procedures, and functional testing may be of value in some patients after coronary artery interventions. It is important for the specialist in internal medicine to have a firm working knowledge of the various aspects of care that are required because their role in management is increasing.