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.     

Risk factors and prevention of thromboembolic risk in laparoscopy

PURPOSE: To investigate if retinol and carotenoids are present in the subretinal space following rhegmatogenous retinal detachment. METHODS: Blood and subretinal fluid were collected from patients at the time of surgical repair of retinal detachment. After removal of cellular contents in a specimen by centrifugation, the supernatant fraction was analyzed by liquid chromatography using a silica column eluted by 16% dioxane in hexane. Retinol and carotenoids were identified in the chromatograms based on their retention time and absorption spectrum. RESULTS: The retinol concentrations (mean+/-SD) in the serum and subretinal fluid were 305+/-144 and 166+/-96 ng/ml respectively. The 450 nm chromatogram had 7 peaks with the characteristic absorption spectrum of carotenoids. Peak 1 and 7 coincided with the retention time of beta-carotene (1.8 min) and lutein (10.8 min) respectively. The concentrations of beta-carotene and lutein in serum were 161+/-63 and 142+/-98 ng/ml respectively. There was very little beta-carotene in subretinal fluid (4.7+/-2.4 ng/ml). Lutein was the major carotenoid peak in subretinal fluid (41.4+/-14.1 ng/ml). The minor carotenoid peaks of serum were not observed in subretinal fluid. CONCLUSION: There is a substantial amount of retinol and lutein in subretinal fluid. The high proportion of lutein and very low amount of beta-carotene in the subretinal fluid support the occurrence of a highly selection transport mechanism of lutein from the blood to the retina.     

Cardiac rehabilitation in acute coronary syndrome

Recently, there have been a great advancement in diagnosis and treatment of ACS, and therefore the modality of cardiac rehabilitation has also been greatly changed. In the era of primary intervention, the hospital stay after ACS has been grossly shortened even within several days. Since morphologies and functions of the diseased coronary arteries and the left ventricle are already correctly and precisely assessed before reaching CCU, the initiation and subsequent progression of cardiac rehabilitation can be performed with great ease. On the contrary to these benefits, however, the time for patients education after ACS is greatly limited. Lifestyle modifications that are thought to be well established key elements in modern preventative cardiology has to be accomplished after discharge from the hospital. These new trends in cardiac rehabilitation must be more efficacious than previous painstaking inhospital rehabilitation procedures and can be accepted widely as economically feasible and safe treatment modalities after ACS.     

Risk factors in dengue shock syndrome

Despite a growing body of evidence predominantly, but not exclusively, from Thailand suggesting that the risk of developing dengue shock syndrome (DSS) is greatest following an anamnestic dengue infection, particularly if the most recent infection was with dengue 2 virus, there continues to be debate about the justification for these claims. This report describes a five-year, prospective study in two townships (suburbs) in Yangon (Rangoon) Myanmar (Burma) in which attempts were made to confirm the data from an earlier prospective study in Thailand and to address some of the criticism of earlier studies. This investigation found the incidence of anamnestic dengue infections in DSS patients to be significantly higher than in the community from which they were drawn and a significantly higher risk of developing DSS following an anamnestic infection (particularly with dengue 2 virus) than following a primary infection with any serotype.     

Risk factors and prevention of vascular complications in polycythemia vera

Two experiments investigated long-term verbal memory performance in groups of 20-year-old heavy (HSDs) and light social drinkers (LSDs), in the presence and absence of a pharmacological challenge (lorazepam 2 mg). In Experiment 1 (n = 13), a verbal learning task was presented visually and it was found that lorazepam significantly impaired delayed verbal recall performance in both groups. Experiment 2 (n = 14) assessed the effect of presenting the verbal learning task in the auditory compared to the visual modality. Both groups' performance on the delayed trials of the visually presented task was reduced in the lorazepam treatment. However, in the auditory presented task, lorazepam reduced 30-min delayed recall performance in the HSDs but not in the LSDs. The differential effect of lorazepam on HSDs compared to LSDs on delayed recall performance when material is presented in the auditory modality may suggest that frequent heavy social drinking results in changes in CNS functioning.     

Complications after treatment of acute coronary syndrome

The rupture of the unstable plaque and the thrombus formation caused the occlusion of the coronary artery and followed myocardial ischemia and/or myocardial necrosis, then resulted in clinical worse outcome. The reopen of the occluded artery is the most important things for the treatment of acute coronary syndrome, and there are usually two established ways to open the occluded artery. Thrombolysis and angioplasty are already established ways to reopen, however has some complications, that is, failure to reopen, reocclusion, and bleeding. Angioscopic observations reveal the mechanism underlying these complications and suggest that platelet rich white thrombus formation continues until a month after the onset and unstable yellow plaques exist until 18 months after the onset. The most problems for the treatment in today are the unaware of the mechanism of the occlusion. If the thrombus is the major mechanism for the occlusion, thrombolytic therapy must be chosen. If the plaque is the major occlusive mechanism, the angioplasty must be chosen. To reveal the mechanisms underlying the coronary artery occlusion, we will have to use the angioscope instead of coronary angiography. After we will be able to clarify the occlusive mechanism by angioscope, we will reduce the dosage of thrombolytic agents and resulted in the decrement of bleeding complications and reopen the coronary artery effectively without complications.     

Risk factors in the pathogenesis of coronary artery disease

In men, plaque rupture is strongly correlated with total cholesterol, and smoking is a predictor of acute thrombosis. In women younger than 50, plaque erosion correlates with smoking, whereas in women older than 50, thrombosis is secondary to plaque rupture and correlates with total cholesterol.     

Emergent coronary artery bypass grafting in patients with acute coronary syndrome

The incidence of emergent CABG in patients with acute coronary syndrome has been decreasing, because thrombolytic therapy and/or catheter intervention have proved to be done faster and more efficient. The present indication of CABG is mostly limited to patients with left main trunk lesion or severe triple vessel disease, whose PTCA is failed with persistent chest pain or unstable hemodynamic condition. The factors associated with an increased hospital mortality are ejection fraction < 30%, age > 70 years, presence of cardiogenic shock, and cardiac index < 1.5. The interval between operation and AMI is not a significant risk factor. The prognosis of the operative survivors is relatively good. The use of the internal thoracic artery graft does not influence on the early outcome as far as the preoperative hemodynamic condition is stable. To get better surgical results, improvements in intraoperative myocardial protection and in postoperative cardiac support are imperative.     

ACE inhibitors use in patients with acute coronary syndrome

Angiotensin converting enzyme (ACE) inhibitors (ACE-I) reduce the incidence of re-infarction in patients with myocardial infarction (MI), and the DD genotype for the ACE gene is an independent risk factor of MI. These findings suggest involvement of ACE in the natural history of coronary plaques and in the pathogenesis of acute coronary syndrome (ACS). ACE-I potentially prevent coronary plaque rupture by suppressing angiotensin II-induced vasoconstriction and sympathetic nerve activity. Actions of ACE-I on risk factors, including insulin resistance, may retard the progression of atheromatous changes in the coronary artery. Furthermore, ACE-I attenuate contractile dysfunction due to myocardial stunning and hibernation, while it augments anti-infarct tolerance of the myocytes afforded by preconditioning. These actions on the myocardium may also be beneficial in ACS. Although favorable effects of ACE-I on the mortality rate of MI patients has been established, the benefit of chronic therapy with ACE-I for patients who have coronary artery disease without MI remains to be clarified.     

Treatment with beta-blockers in patients with acute coronary syndrome

BACKGROUND: Immunosuppressive treatment with cyclosporin A (CsA) improves the survival of renal allografts, but is associated with renal vasoconstriction and hypertension. Previous reports suggest that the calcium-channel blockers nifedipine and amlodipine may improve graft function in CsA-treated patients. We have compared the effects of amlodipine (5-10 mg once daily) and nifedipine retard (10-40 mg twice daily) on renal function and blood pressure in renal transplant recipients treated with CsA. METHODS: This was a multicentre, two-way, crossover study in 27 evaluable hypertensive patients with renal insufficiency following renal transplantation, who were maintained on a stable dose of CsA. Patients received either amlodipine (5-10 mg once daily) or nifedipine retard (10-40 mg twice daily) for 8 weeks, and were then crossed over to the other treatment for a further 8 weeks. RESULTS: Trends were seen during amlodipine treatment towards larger improvements, in serum creatinine (by 8% of baseline on amlodipine vs 4% on nifedipine), lithium clearance (13% vs 2%), and glomerular filtration rate 11% vs 7%). Effective renal plasma flow was increased by 11% of baseline on nifedipine vs 9% on amlodipine. There were no significant differences between treatments. Amlodipine and nifedipine lowered systolic blood pressure to a similar extent (21 mmHg vs 15 mmHg respectively, P=0.25), but amlodipine was more effective than nifedipine in lowering diastolic blood pressure (13 mmHg vs 8 mmHg, P=0.006). Both treatments were well tolerated. CONCLUSION: Once-daily amlodipine is at least as effective as twice-daily nifedipine retard in controlling blood pressure and does not adversely affect graft function in hypertensive renal allograft recipients.     

Risk factors for new coronary events in older African-American men and women

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).     

Risk factors for acute renal failure in trauma patients

OBJECTIVE: To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma. DESIGN: Prospective observational study. SETTING: A general intensive care unit (ICU) of a university hospital. PATIENTS: A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months. RESULTS: Forty-eight (31%) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p < 0.001), higher mortality (p < 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS > 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) > 10000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score < 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure > 6 cm H2O, rhabdomyolysis with CPK > 10000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF. CONCLUSIONS: The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.     

Risk factors associated with acute dental pain in children

We have previously shown that high altitude pulmonary edema-susceptible subjects (HAPE-S) have an accentuated pulmonary vascular response to hypoxia. In this study, we investigated the relationship between plasma endothelin-1 (ET-1) levels and the acute hypoxic pulmonary vascular response in HAPE-S and control subjects. In six HAPE-S and seven healthy subjects, we evaluated acceleration time/right ventricular ejection time (AcT/RVET) using Doppler echocardiography, and measured plasma ET-1 levels by radioimmunoassay (RIA) before and after 5 minutes of breathing 10% oxygen. The HAPE-S showed a significantly increased pulmonary vascular response to hypoxia compared with healthy subjects. However, no statistically significant changes of plasma ET-1 levels were observed before and after hypoxia in both groups. We conclude that the increased pulmonary vascular response to acute hypoxia in HAPE-S may not be related to ET-1 release.     

Coagulation/fibrinolytic system and platelet in acute coronary syndrome]

Coagulation/fibrinolytic system and platelet function play roles not only in the onset of acute coronary syndrome (ACS) but also in the development of atherosclerosis, which is a major underlying condition of ACS. In this paper we reviewed the involvement of coagulation/fibrinolytic system and platelet in coronary atherosclerosis and ACS. It is well known that hyperchoresterolemia and diabetes mellitus (DM) are the important risk factor for coronary atherosclerosis and ACS. Both oxidized LDL and advanced glycation endproduct (AGE) activate endothelial cells with down-regulating thrombomodulin and tissue plasminogen activator(t-PA) expression. Moreover the oxidized LDL and AGE up-regulate the expression of tissue factor, and t-PA inhibitor, PAI-1. Thus Ox-LDL and AGE impair the endothelial antithrombotic function and result ACS. These may explain the pathomechanism of coronary sclerosis and ACS. In the atherosclerotic lesion with narrowing the lumen, high shear stress may be occurred. Recent observations suggested that high shear stress induces platelets aggregation named as shear stress induced platelet aggregation (SIPA), which may also have very important role for the pathogenesis in ACS.     

Use of platelet glycoprotein IIb/IIIa receptor inhibitors in acute coronary syndrome and coronary intervention

New strategies in the treatment of acute coronary syndromes have focused on the potential for blocking platelet aggregation through the use of platelet surface membrane glycoprotein (GP) IIb/IIIa receptor inhibitors. The benefits of GPIIb/IIIa inhibition in preventing ischemic complications of interventional treatment have been well defined in patients with unstable angina. In the future, major therapeutic applications for this class of agents may include the stabilization of patients with unstable angina and potentially as single medical therapy, as several recently completed trials have suggested. This article attempts to review recently published clinical trials regarding the use of GPIIb/IIIa receptor inhibitors, and clarify current problems in the use of this agent and directions for future investigation.     

Risk factors and clinical presentation of acute primary HIV infection in India

CONTEXT: Most previous studies of clinical presentation and risk factors in early human immunodeficiency virus (HIV) infection have relied on retrospective analyses and referred seroconverters, and thus were subject to possible bias. OBJECTIVES: To apply a method based on measurement of prevalent HIV-1 p24 antigenemia for identification of risk factors for newly acquired HIV infection and to describe the signs and symptoms of acute HIV infection. DESIGN AND SETTING: Nested case-control study in Pune, India. PARTICIPANTS: HIV antibody-negative persons attending 2 sexually transmitted disease (STD) clinics between May 1993 and June 1996. OUTCOME MEASURES: Prevalent p24 antigenemia, risk factors for HIV infection, and clinical symptoms of acute primary HIV infection. RESULTS: Of 3874 HIV antibody-negative persons tested, 58 (1.5%) were p24 antigen positive at initial presentation to the clinics. Unprotected sexual contact with a commercial sex worker (CSW) was reported by 39 (77%) of the 51 p24 antigenemic men, compared with 131 (51 %) of 255 control men (adjusted odds ratio [AOR], 3.4; 95% confidence interval [CI], 1.2-9.6; P=.02). The presence of an active genital ulcer at the time of screening was found in 46 (79%) of the 58 p24 antigenemic men and women, compared with 137 (47%) of the 290 control subjects (AOR, 4.2; 95% CI, 2.0-9.0; P<.001). Signs and symptoms independently associated with p24 antigenemia in HIV antibody-seronegative persons included fever, which was reported by 28 (48%) of the 58 p24 antigenemic subjects, but only 52 (18%) of the 290 control subjects (AOR, 4.7; 95% CI, 2.4-9.0; P<.001). Joint pain was reported by 10% of subjects recently HIV infected, compared with 2% of the control subjects (AOR, 6.5; 95% CI, 1.7-24.8; P=.006). Night sweats were reported by 9% of the p24 antigenemic, but only 1% of the control subjects (AOR, 9.1; 95% CI, 1.7-47.6; P=.009). Overall, fever, joint pain, and/or night sweats were reported in 27 (47%) of the 58 subjects with recent HIV infection. CONCLUSIONS: This systematic case-control study of p24 antigen screening in HIV-seronegative patients attending STD clinics in India identified unprotected sex with a CSW and a genital ulcer as independent risk factors associated with newly acquired HIV infection. In addition, p24 antigen positivity identified recent fever, night sweats, and arthralgias as symptoms that may be predictive of recent HIV infection. In a study of patients attending STD clinics in India, screening for p24 antigen in HIV antibody-negative persons was found to be a reliable and effective research method for determining recent risk behavior and identifying clinical signs of acute primary HIV infection.