Angioscopic predictors of early adverse outcome after coronary angioplasty in patients with unstable angina and non-Q-wave myocardial infarction

BACKGROUND: Clinical and angiographic criteria have a limited ability to predict adverse outcome in patients with unstable angina who are undergoing percutaneous transluminal coronary angioplasty (PTCA). We investigated whether the use of angioscopy can improve prediction of early adverse outcome after PTCA. METHODS AND RESULTS: Angioscopic characterization of the culprit lesion was performed before PTCA in 32 patients with unstable angina and 10 with non-Q-wave infarction. Seven patients (17%) had an adverse outcome (myocardial infarction, repeat PTCA, or need for coronary artery bypass graft surgery) within 24 hours after PTCA. Six of 18 patients with a yellow culprit lesion had an adverse outcome compared with 1 of 24 in whom the culprit lesion was white (P = .03). Six of 20 patients with plaque disruption suffered an adverse outcome compared with 1 of 22 with nondisrupted plaques (P = .04). Six of 17 patients with intraluminal thrombus had an adverse outcome, whereas only 1 of 25 patients without thrombus suffered an adverse outcome (P = .01). Yellow color, disruption, and thrombus at the culprit lesion site were associated with an eightfold increase in risk of adverse outcome after PTCA. The prediction of PTCA outcome based on characteristics of the plaque that were identifiable by angioscopy was superior to that estimated by the use of angiographic variables. CONCLUSIONS: In patients with unstable angina and non-Q-wave infarction, angioscopic features of disruption, yellow color, or thrombus at the culprit lesion site can identify patients at high risk of early adverse outcome after PTCA. Angioscopy was superior to angiography for prediction of PTCA outcome.     

Rationale and design of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study that evaluates atorvastatin in unstable angina pectoris and in non-Q-wave acute myocardial infarction

Pediococcus sp. is a nonpathogenic heat-resistant spoilage organism that has been used as a test organism in milk pasteurization studies. These characteristics make this bacterium an attractive test organism to study the mode of bacterial thermal inactivation in a food pilot plant. We report here the effect of growth medium on the thermal D value of this organism in skim milk, whole liquid egg, 10% glucose solution, pineapple juice, apple juice, tomato juice, and water at 60 degrees C. Thermal inactivation was done in a submerged coil; D values were calculated from the linear portion of the survival curves by linear regression analysis. The range of D values of stationary-phase cells grown at 28 degrees C in tryptone glucose yeast extract (TGY) or tryptic soy broth (TSB) was 0.14 to 12.05 min in all heating menstrua tested. The TSB-grown cells exhibited the highest thermal resistance with skim milk and 10% glucose solution as the heating menstrua. Survival curves of the TGY-grown cells indicated the presence of a cell population heterogeneous in thermal resistance. The TSB-grown cells exhibited a cell population uniform in thermal resistance and with a lag time for thermal inactivation. When compared to TGY-grown cells, Pediococcus sp. grown in TSB showed a significant (P < 0.05) increase in D values by up to eightfold in all heating menstrua. Results from this study suggested that thermal inactivation of Pediococcus sp. was dependent on the growth medium and on the heating menstruum with respect to both pH and composition.     

Pain intensity in nondiabetic patients with myocardial infarction or unstable angina. Its association with clinical and psychological features

OBJECTIVES: The aim of this study was to assess the incidence of incontinence and impotence in patients following total prostatectomy and assess the impact their symptoms have on their quality of life. PATIENTS AND METHODS: Between 1987 and 1994, one surgeon performed retropubic total prostatectomies on 89 patients, of which 87 were available for follow-up. All patients were sent an ICS-male questionnaire. Patients' ages ranged from 49 to 73 years (median 65). The interval between surgery and completing the questionnaire ranged from 7 to 87 months (median 22). RESULTS: The response rate was 95%. No patients reported incontinence pre-operatively. Postoperatively, 69% (57/83) of patients suffered to some degree of leakage of urine and 24% (29/83) used pads. Of these, 60% used 1 pad per day, 15% 2 pads and 25% (5 patients) used 3 or more. Nocturnal incontinence was reported by 20% of patients. Urinary incontinence was considered a problem in only 34% (28/83) of patients. Sixty-five percent of patients using pads considered urinary leakage to be a problem, but only 1 considered it a serious problem. 89% claimed to have been potent prior to surgery. The overall postoperative potency rate was 41% (30/74) in those potent pre-operatively. However, 67% of patients reporting potency had severely reduced rigidity, and only 12% (9/74) achieved what they considered full erections. Ten percent of all patients considered postoperative impotence to be a serious problem, and 47% stated that it was not a problem at all. CONCLUSIONS: The incidence of incontinence and impotence following total prostatectomy is higher than earlier reports suggest, but the impact of these complications appears to be surprisingly low. These results allow patients to be given realistic expectations when counselled prior to this operation.     

Prognostic value of plasma atrial natriuretic factor, norepinephrine and epinephrine in acute myocardial infarction

Case reports from the United Kingdom (UK) in 1989 have suggested that the introduction of human insulin in 1985 was associated with an increased risk of sudden death in insulin-treated diabetic patients. If human insulin increases the risk of sudden death, the number of these should have increased during the period where human insulin was introduced. We therefore identified all cases of sudden death in Denmark in younger insulin-treated diabetic patients, age at death below 50 years. During this period the consumption of human insulin went from 0.2% to 70% of the total consumption in Denmark. The total number of cases fulfilling the inclusion criteria was 226, and the annual number of sudden deaths did not change during the study period (p = 0.14). The number of deaths due to hypoglycaemia and cases with unexplained cause of death also remained constant (test for trend: p = 0.44). Chronic alcohol abuse or acute alcohol intoxication was found in 50% of the 135 patients dying from hypoglycaemia, ketoacidosis or unknown cause of death (including found dead in bed), while this was the case in only 16% of the remaining 91 cases dying from other natural causes. We conclude that introduction of human insulin in Denmark was not followed by an increase in sudden deaths among younger insulin-treated diabetic patients.     

Prognostic implications of detection of troponin I in patients with unstable angina pectoris

In our study, troponin I was not a predictor of cardiac events and a negative troponin I test did not exclude the presence of severe coronary artery disease. A positive troponin I test in patients with unstable angina identified a subgroup with probable, more active coronary disease (with higher levels of C-reactive protein).     

Effect of thrombolytic therapy on platelet expression and plasma concentration of PECAM-1 (CD31) in patients with acute myocardial infarction

OBJECTIVE: Cholelithiasis is a common problem in hospitals of the Peruvian Andes; however, its prevalence in Andean communities is unknown. To estimate the prevalence of gallstone disease in this locale, we conducted a cross-sectional community study in three high-altitude Peruvian rural villages (i.e., > 3000 m above sea level). METHODS: We examined 911 volunteers > 15 yr of age from three villages for gallstone disease by history and ultrasonography. Risk factors for gallstone disease were examined in 382 volunteers from one village. RESULTS: The age-adjusted prevalence of gallstone disease ranged from 4-10% in men and from 18-20% in women. Women had significantly higher age-adjusted prevalence rates than did men. The prevalence of gallstone disease increased significantly with age and decreased significantly with alcohol consumption. Although not statistically significant, we found a positive association between gallstone disease and body mass index. CONCLUSION: The results of this study indicate that gallstone disease, commonly perceived as a disease of the developed world, is also a common problem in high-altitude Peruvian communities.     

Prognostic value of Doppler transmitral flow velocity patterns in acute myocardial infarction

Doppler transmitral flow patterns are partially dependent on age. We investigated the correlations between the age-adjusted transmitral flow patterns, hemodynamic indexes, and the coronary and clinical outcome in 206 patients with acute myocardial infarction (AMI) and 102 normal control subjects. The peak flow velocity at atrial contraction was significantly lower in 50 of the 206 patients (24%) (low-A group) than in the 102 normal controls. Pulmonary capillary wedge pressure was significantly higher in the low-A group than in the remaining 156 patients with AMI (20 +/- 7 vs 11 +/- 5 mm Hg, p <0.001), and the cardiac index and left ventricular ejection fraction were significantly lower (2.2 +/- 0.6 vs 2.9 +/- 0.7 L/min/m2, p <0.001; 38 +/- 15% vs 52 +/- 13%, p <0.001). The incidence of cardiogenic shock was significantly higher in the low-A group than in the other patients with AMI (42% vs 19%, p <0.001). Regression analysis demonstrated a significant association between decreased atrial filling velocity and increased in-hospital mortality as well as the incidence of heart failure in AMI (p <0.001). The 5-year mortality rate was also significantly higher in the low-A group (p <0.001). The age-adjusted transmitral flow pattern in AMI can identify patients with left ventricular dysfunction, which can lead to a poor prognosis.     

Prognostic value of steroid hormone receptors concentration in patients with endometrial carcinoma

The concentrations of progesterone receptors in endometrial tumors of 160 patients were analyzed with respect to survival and presence of clinicopathologic prognostic factors. The concentration of 25 fmol/mg of proteins for progesterone receptors appeared to be most powerful for prediction of survival. The survival was also significantly correlated to age, depth of myometrial invasion and clinical stage of the tumor. Concentration of estrogen receptors could not be correlated with the probability of patients' actuarial survival.     

Detection of myocardial ischemia with a computer-assisted 12-lead 24-hour ECG monitoring system (EAGLE) in patients with suspected unstable angina

In order to study the relationship between physical fitness/sport-specific skills and sports injuries 136 physical education students were studied during their 4-years of training in a prospective investigation. Physical fitness was measured every year using a battery of fitness tests, and the performance marks of a number of sports scored at the exams of the academy were used as parameters for the sport-specific skills. Sports injuries were recorded every 3 weeks on standard forms. Relative risk ratios were calculated between the tertile groups good, average and poor for all variables of physical fitness and sport-specific skills. Injury-proneness was defined for all and for acute and chronic injuries separately near the median number of injuries sustained. In only 6 out of 126 computed relative risks was a significant difference found. Discriminant analysis revealed an explanation of 16%, 14% and 11% of the variance for respectively all, acute and chronic injuries, at which 5 or 6 variables in varying combination were included. From our findings it may be concluded that physical fitness and sport-specific skills have little impact on sports injuries for the following two main reasons. Firstly, subjects at risk for sports injuries participate per definition in sports activities and have consequently developed their fitness and skills compared to the sedentary population. Thus, the range in physical fitness or sports skills in the population at risk is relatively small (physical education students belong to the 7th-10th decile in fitness test scores within a general college student population) and therefore an effect is hard to show. Secondly, the total number of sports injuries is very small and moreover, it should be distributed over several categories for analysis. The favourable advantages of using physical education students to study intrinsic risk factors (comparable and varied sports program, excellent compliance) appeared to be insufficient to compensate for drawbacks of selection.     

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.     

Prognostic value of tissue polypeptide antigen (TPA) plasma levels in patients with malignant salivary gland tumors

Nine subject with various malignant salivary gland tumors were monitored with tissue polypeptide antigen (TPA) pre and post operatively utilizing TA radio-immunoassay kit. The TPA radioimmunoassay proved to be a specific and sensitive method aiding in diagnoses monitoring and a post operative follow up in malignancies.     

Adhesion and aggregation of neutrophils in patients with unstable angina

The adherence and aggregation abilities of neutrophils (PMNs) were evaluated in thirty three patients with unstable angina, who were qualified for PTCA procedure. The control group consisted of forty one clinically healthy persons. The blood for investigations was obtained from coronary sinus and basilic vein just before the procedure, while in the control group from basilic vein only. The adherence of PMNs to plastic surface (rest and stimulated by PMA) was estimated in vitro according to Oez's et al. method by measuring optical density of generated formazan, whereas the aggregation of PMNs was evaluated using the leukergy test according to the method of Fleck in Berliner's and Aronson's modification. In patients with unstable angina statistically significant higher (p < 0.001) adherence of peripheral blood PMNs, compared with control groups was found (patients: rest-0.525 +/- 0.245, stimulated-0.839 +/- 0.419, control group: rest-0.260 +/- 0.129, stimulated-0.522 +/- 0.377). The aggregation of peripheral blood PMNs was significantly higher (p < 0.05) in the sick than in the control group (the sick-10.98 +/- 4.29%, controls-4.65 +/- 3.01%). No differences in investigated parameters of PMNs obtained from peripheral or coronary sinus blood were found.     

Prognostic significance of ST-T segment alterations in patients with non-Q wave myocardial infarction

Legionella jordanis has seldom been reported as a cause of infection in humans. We describe a case of pneumonia due to L. jordanis that occurred in a non-immunocompromised 74-year-old patient and failed to respond to a combination of ceftriaxone and ofloxacin. Cure was achieved only after an erythromycin-rifampin combination was started.     

Prognostic value of vasodilator myocardial perfusion imaging in patients with left bundle-branch block

BACKGROUND: The prognostic value of tomographic myocardial perfusion imaging with dipyridamole or adenosine in patients with left bundle-branch block has not been established. METHODS AND RESULTS: The study group consisted of 245 patients with left bundle-branch block who underwent tomographic (single photon emission tomography) myocardial perfusion imaging with thallium-201 (n=173) or technetium-99m sestamibi (n=72) and either dipyridamole (n=153) or adenosine (n=92) stress. Patients were prospectively classified into two groups. Patients were classified as "high risk" if they had (1) a large severe fixed defect (n=28), (2) a large reversible defect (n=36), or (3) cardiac enlargement and either increased pulmonary uptake (thallium) or a decreased resting ejection fraction (sestamibi) (n=20). The remaining 161 patients (66% of the study group) were at "low risk." Follow-up was 99% complete at 3+/-1.4 years. Three-year overall survival was 57% in the high-risk group compared with 87% in the low-risk group (P<.0001). Survival free of cardiac death/nonfatal myocardial infarction/cardiac transplantation was 55% in the high-risk group and 93% in the low-risk group (P<.0001). The presence of a high-risk scan had significant incremental prognostic value after adjustment for age, sex, diabetes, and previous myocardial infarction (P<.0001). Patients with a low-risk scan had an overall survival that was not significantly different from that of a US age-matched population (P=.86). CONCLUSIONS: Tomographic myocardial perfusion imaging with adenosine or dipyridamole stress provides important prognostic information in patients with left bundle-branch block, which is incremental to clinical assessment.     

The role of low-molecular-weight heparin in unstable angina, acute myocardial infarction and post-elective percutaneous transluminal coronary angioplasty

A young woman with a large astigmatic refractive error obtained no visual improvement with glasses. Repeated manifest refractions revealed persistent variations in the apparent cylinder axis. A suitable choice of spectacle frames facilitated a satisfactory outcome. The pitfalls inherent in the clinical specification of cylinder axis, and the potential visual consequences, are discussed.     

Prognostic role of heart rate variability in patients with a recent acute myocardial infarction

A low heart rate variability (HRV) has been shown to be a powerful predictor of cardiac events in patients surviving an acute myocardial infarction (MI), but it is not clear yet which among the HRV parameters has the best predictive value. Time domain and frequency domain HRV was assessed on 24-hour predischarge Holter recording of 239 patients with a recent MI. Patients were followed up for 6 to 54 months (median 28), during which 26 deaths (11%) occurred, 19 of which were cardiac in origin and 12 were sudden. Most HRVs did not show any difference between patients with or without mortality end points, but the average low-frequency and low-frequency/high-frequency ratio was lower in patients with events. However, when dichotomized according to cut points that maximized the risk of sudden death, several HRVs were significantly predictive of clinical end points. Overall, the mean of the standard deviations of all RR intervals for all 5-minute segments and the standard deviation of the mean RR intervals for all 5-minute segments were the time domain variables most significantly associated with mortality end points, whereas very low frequency was the most predictive frequency domain variable. Compared with the best time domain variables, very low frequency showed a better sensitivity (0.27 to 0.42 vs 0.19 to 0.33) for end points with only a small loss in specificity (0.92 vs 0.96). On multivariate Cox proportional analysis, a left ventricular ejection fraction <40% and a number of ventricular premature beats > or = 10/hour were the most powerful independent predictors for all end points, whereas no HRV was independently associated with the events. A low frequency/high frequency ratio < 1.05 only had a borderline association with sudden death (RR = 2.86, p = 0.076). Our data show a strong association between HRV and mortality in patients surviving a recent MI, with a slight better sensitivity of frequency domain analysis. In our study, however, HRV did not add independent prognostic information to more classic prognostic variables (e.g., left ventricular function and ventricular arrhythmias).     

TNK-tissue plasminogen activator compared with front-loaded alteplase in acute myocardial infarction: results of the TIMI 10B trial. Thrombolysis in Myocardial Infarction (TIMI) 10B Investigators

BACKGROUND: Bolus thrombolytic therapy is a simplified means of administering thrombolysis that facilitates rapid time to treatment. TNK-tissue plasminogen activator (TNK-tPA) is a highly fibrin-specific single-bolus thrombolytic agent. METHODS AND RESULTS: In TIMI 10B, 886 patients with acute ST-elevation myocardial infarction presenting within 12 hours were randomized to receive either a single bolus of 30 or 50 mg TNK-tPA or front-loaded tPA and underwent immediate coronary angiography. The 50-mg dose was discontinued early because of increased intracranial hemorrhage and was replaced by a 40-mg dose, and heparin doses were decreased. TNK-tPA 40 mg and tPA produced similar rates of TIMI grade 3 flow at 90 minutes (62.8% versus 62.7%, respectively, P=NS); the rate for the 30-mg dose was significantly lower (54.3%, P=0.035) and was 65. 8% for the 50-mg dose (P=NS). A prespecified analysis of weight-based TNK-tPA dosing using median TIMI frame count demonstrated a dose response (P=0.001). Similar dose responses were observed for serious bleeding and intracranial hemorrhage, but significantly lower rates were observed for both TNK-tPA and tPA after the heparin doses were lowered and titration of the heparin was started at 6 hours. CONCLUSIONS: TNK-tPA, given as a single 40-mg bolus, achieved rates of TIMI grade 3 flow similar to those of the 90-minute bolus and infusion of tPA. Weight-adjusting TNK-tPA appears to be important in achieving optimal reperfusion; reduced heparin dosing appears to improve safety for both agents. Together with the safety results from the parallel Assessment of the Safety of a New Thrombolytic: TNK-tPA (ASSENT I) trial, an appropriate dose of this single-bolus thrombolytic agent has been identified for phase III testing.     

Long-term (10-year) outcome in patients with unstable angina pectoris treated by coronary balloon angioplasty

OBJECTIVES: We sought to examine completed 10-year survival and event-free survival in patients with stable and unstable angina pectoris treated by coronary balloon angioplasty. BACKGROUND: Patients with unstable angina are at increased risk for recurrent acute coronary events. METHODS: The study included 208 consecutive patients (133 with stable and 75 with unstable angina pectoris) undergoing angioplasty from 1984 to 1986. The balloon crossed the lesion in 185 patients (121 with stable and 64 with unstable angina pectoris). Angioplasty was performed in patients with unstable angina pectoris 12+/-15 days (median 8) after symptom onset. Patients with unstable angina pectoris were classified retrospectively into Braunwald class I (n=3), class II (n=20), class III (n=28), class B (n=52) and class C (n=12). Follow-up data were obtained from hospital charts, telephone interview and official death certificates where applicable. The study had >80% power to detect a clinically significant 20% difference in survival and a 20% difference in event-free survival between the stable and unstable patient groups. RESULTS: Despite similar baseline characteristics, early (40-day) mortality was slightly higher in patients with unstable angina (4.7% [3 of 64 patients] vs. 0.8% [1 of 121 patients], p=NS). Long-term outcome was not different, because survival curves were parallel thereafter (10-year survival was 83% for those with stable and 77% for those with unstable angina, p=NS). Survival free of myocardial infarction or coronary artery bypass graft surgery at 10 years was 53% in patients with stable and 47% in patients with unstable angina (p=NS), and survival free of infarction, bypass surgery or repeat angioplasty was 32% for both groups at 10 years. In patients with Braunwald class III unstable angina, 10-year survival was 80%, as compared with 85% in other patients with unstable angina, due to the early hazard (p=NS). Survival and event-free survival were similar in patients who had had a recent myocardial infarction (Braunwald class C) and in patients with acute electrocardiographic changes. Repeat hospital admissions were not more frequent in patients with unstable angina (3.1+/-3.5 vs. 3.0+/-2.6, p=NS). CONCLUSIONS: Ten-year survival and event-free survival were similar in patients with stable and unstable angina pectoris treated by coronary balloon angioplasty, with no evidence of an increased rate of recurrent cardiovascular events in the unstable group.