Stress Echocardiography

Stress echocardiography is based on the identification of regional wall motion abnormalities, which occur as a result of an increase in oxygen demand without a matched increased in oxygen supply in the presence of a coronary stenosis. The test has gained increasing acceptance with the introduction of digital echocardiography, harmonic imaging, and the use of contrast agents, all of which have incrementally contributed to increased image quality, reproducibility, and accuracy. However, the...

Anatomic Pattern of Coronary Artery Disease

Autopsy and angiographic studies have shown that patients with diabetes more frequently have left main coronary artery lesions, multivessel disease, and diffuse CAD. A recent angiographic study on 534 patients with angina demonstrated that the greater the impairment of glucose metabolism (i.e., normal, IGT, newly diagnosed diabetes, or known diabetes), the smaller the average vessel diameter and longer the coronary lesions.30 It is common belief that diabetic patients have an impaired ability...

Nonstelevation Acute Coronary Syndromes

The high prevalence of abnormal glucose metabolism in patients with CAD, and in particular among those with acute manifestations of the disease, was recently confirmed in large-scale surveys in both the United States and Europe. Within the U.S. CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC AHA guidelines) registry, among 46,410 patients with non-ST-elevation ACS, the prevalence of diabetes was 33 .89 Within the...

Stelevation Myocardial Infarction

Paralleling the observations for non-ST-elevation ACS, diabetes is also an independent predictor of morbidity and mortality in STEMI. A retrospective study evaluating admission glucose of 141,680 patients presenting with acute MI demonstrated a linear correlation between glucose level and mortality (Fig. 2-10).98 Compared with individuals with admission glucose levels of 110mg dL or less, the hazard ratios for mortality for those with glucose Figure 2-10. Relationship between admission plasma...

STSegment Elevation Myocardial Infarction

In acute MI, fibrinolysis reduces the mortality rate by 18 , compared with conservative treatment, as was shown by a meta-analysis of the randomized trials in this setting.8 In addition to this benefit, coronary reperfusion by primary PCI reduces in-hospital mortality by an additional 35 .9 This risk reduction is consistent with the pooled analysis of registry data of more than 100,000 patients (Fig. 6-1). In addition to its effect on survival, PCI compared with fibrin-olysis reduces the risk...

NonSTSegment Elevation Acute Coronary Syndromes

In acute coronary syndromes without ST-segment elevation, there has been a long-standing debate about two competing treatment strategies.11 The conservative strategy reserves coronary angiography and revascularization for those patients who continue to have spontaneous or inducible myocardial ischemia despite maximal medical therapy. The invasive strategy, on the other hand, recommends coronary angi-ography and revascularization regardless of the primary success of medical treatment. Various...

Acute Coronary Syndromes

Women who present with ACS are older and have higher incidences of diabetes and hypertension compared to men. They also have less severe CAD, with greater absence of critical obstructions and more preserved LV function. In ACS, women were more likely to have elevated C-reactive protein (CRP) and brain natriuretic peptide (BNP), whereas men were more likely to have elevated creatine kinase-MB (CK-MB) and troponin.33 There have been four major randomized trials that compared invasive versus...

Coronary Artery Disease

Heart disease is the leading cause of death for all races in the U.S. population. African Americans experience the highest rates of mortality from heart disease, 1.6 times that of whites.1 The average annual death rate due to heart disease by race is shown in Table 8-5. The prevalence of CAD is also higher in African Americans compared to their white counterparts, regardless of gender.1 Furthermore, onset of disease occurs 5 years earlier in African Americans. Death rates from stroke are also...

Intensive Statin Therapy In Stable Coronary Artery Disease

Complementary benefit of percutaneous coronary intervention and intensive statin therapy in patients with acute coronary syndrome. (Redrawn from Ambrose JA, Martinez EE A new paradigm for plaque stabilization. Circulation 2002 105 2000-2004.) Figure 11-4. Complementary benefit of percutaneous coronary intervention and intensive statin therapy in patients with acute coronary syndrome. (Redrawn from Ambrose JA, Martinez EE A new paradigm for plaque stabilization. Circulation 2002 105...

Early Benefits Of Intensive Statin Therapy For Acute Coronary Syndrome

The risk of adverse clinical events is greatest in the first 6 months after the index ACS event. The early trials of statin therapy in patients with stable CAD suggested that the benefits of statin therapy appeared only after 1 to 2 years.13,14 Although plaque rupture is a feature of ACS (Fig. 11-6), it has become apparent that ACS is a pancoronary process with multiple vulnerable or ruptured plaques (Fig. 11-7). Although angioplasty and stenting treat a culprit lesion effectively, potent...

Angiotensin Receptor Blockers in Myocardial Infarction

With the demonstrated benefits of an ACE inhibitor after MI, the question of whether more selective blockade of the RAS with an ARB would result in even further improvements in clinical outcomes in this population could be done and interpreted only in the context of a comparator arm of a proven ACE inhibitor. Two major trials tested the relative value of an ARB in high-risk MI patients both used captopril titrated to 50 mg three times daily as the comparator. The Optimal Therapy in Myocardial...

Recommendations for Beta Blockade during Acute Myocardial Infarction

Given COMMIT's applicability to the modern era, and its enormous size (almost twice as many patients as all others combined), the COMMIT data must form the core basis for any recommendations. Accordingly, early intravenous P-blocker therapy for acute MI cannot be recommended for all patients. Nevertheless, the neutrality of the primary end points was driven by excess of cardiogenic shock in patients at increased baseline risk of developing shock. It is rational to consider early P-blockade in...

Clinical Trials Of Percutaneous Transluminal Coronary Angioplasty In Coronary Artery Disease

Overall, the objectives of coronary revasculariza-tion are the treatment of symptoms (e.g., angina), improvement in long-term survival, and prevention of nonfatal events (e.g., acute coronary syndromes, heart failure, arrhythmias). Although the risks of serious complications are small, careful patient selection must be undertaken before proceeding with PTCA. For instance, in the multicenter NHLBI Registry of PTCA experience from 1985 to 1986 of intervention in patients with single-vessel...

Acute Myocardial Infarction

After coronary bypass surgery, approximately 3 of patients experience acute MI annually.142 Because these patients were excluded from early reperfusion trials, therapy has been based on clinical experience and remains controversial. Reports from the Myocardial Infarction Triage and the Intervention Registry and the National Registry of Myocardial Infarction-2 indicate that patients with prior bypass surgery have a high in-hospital mortality rate with reperfusion strategies,143,144 probably...

Distal Embolization and Periprocedural Myocardial Infarction

Although distal embolization associated with endo-thelial injury has been recognized for years, the importance of this phenomenon in relation to PCI has not been fully appreciated until the last decade.23 Platelet aggregates have been identified in the distal microcirculation and atherosclerotic debris retrieved from arteries downstream from the site of angio-plasty using filter devices (Fig. 27-2). Clinically, intravascular ultrasound (IVUS) studies provided further insight into the...

The Case For And Against Regionalized Care For Acute Coronary Syndromes

Where and how patients with acute ischemic heart disease are treated have been the subjects of debate. Some believe that the real issue is not whether the creation of specialized centers for care of those ACS patients would provide an important advance, but how to create them,7-9 Others contend that clear, compelling evidence of the benefits of ACS regional-ization within the United States and a better understanding of its potential consequences are needed before implementing a national policy...

Future Care of Patients with STSegment Elevation Myocardial Infarction

The lack of a coordinated system of care denies many patients the benefit of primary PCI. A coordinated system for the provision of PCI could prevent an estimated six to eight major adverse cardiovascular or cerebrovascular events per 100 STEMI patients treated and therefore could affect 35,000 patients yearly.23 However, the current scheme for cardiovascular reimbursement could penalize community hospitals without cardiac catheterization laboratories when patients are transferred or admitted...

Clinical Presentation

Women are much more commonly affected (70 ) than men. The classic presentation of this disease is postprandial abdominal discomfort with significant weight loss (Fig. 42-1). The abdominal discomfort associated with eating leads these patients to avoid Figure 42-1. Initial clinical presentation of patients with chronic mesenteric ischemia. GI, gastrointestinal. (From Silva JA, White CJ, Collins TJ, et al Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol 2006 47 944-950.)...

Diagnostic Criteria For Diabetes Prediabetes And Metabolic Syndrome

Definitions of the Metabolic Syndrome Central obesity (ethnicity-specific) PLUS any > 100 mg dL (5.6 mmol L) or previously diagnosed > 130 or > 85 mm Hg or treatment of previously diagnosed hypertension > 150 mg dL (1.7 mmol L) or specific treatment for this abnormality Europid* men waist circumference > 94 cm Europid* women waist circumference > 80 cm > 20 g min or albumin-creatinine ratio > 30 mg g BMI, body mass index HDL, high-density lipoprotein IDF,...

Cardiovascular Disease In Diabetes

Heart disease and stroke account for more than two thirds of all deaths among diabetic patients.2 A recent population-based study documented that diabetes confers a CV risk equivalent to aging 15 years.25 In 2001, the Adult Treatment Panel III of the National Cholesterol Education Program (NCEP ATP III) recommended that diabetes be considered a CAD risk equivalent, thus mandating aggressive CV risk pre-vention.26 The notion of diabetes as a CAD risk equivalent came initially from a Finnish...

Cardiovascular Diagnostic Modalities In Diabetes Patients

Summary of Studies Using Stress Testing in the Diagnosis of Suspected Coronary Artery Disease in Diabetic Patients Type of Test Study* N Reference Standard Sensitivity ( ) Specificity ( ) PPV ( ) NPV ( ) ECG Lee et DSE Hennessy et Nuclear Kang et *Full references for studies can be found in the source article. ECG, exercise electrocardiographic stress test DSE, dobutamine stress echocardiography NA, not available NPV, negative predictive value PPV, positive predictive value. From...

Revascularization In Diabetic Patients With Stable Coronary Disease

Almost 1.5 million coronary revascularization procedures, either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), are performed each year in the United States, and approximately one quarter of them involve diabetic patients.41 The randomized data on diabetic patients are scarce and are mainly derived from subgroup analyses of revascularization trials of patients with multivessel disease initiated in the late 1980s and early 1990s. Overall, diabetic patients...

Antithrombotic Therapy In Diabetes

With respect to patients undergoing PCI, the Clopidogrel for the Reduction of Events During Observation (CREDO) study randomized patients either to a 300-mg loading dose followed by 12 months of clopidogrel therapy or to no loading dose and clopidogrel treatment for 1 month on top of aspirin. Among 560 diabetic patients, the benefit of pretreatment and prolonged clopidogrel therapy was modest (RRR 11.2 ) compared with the benefit of this regimen observed among 1556...

Special Considerations in Diabetic Patients

Compared with nondiabetic patients, patients with diabetes often have a more advanced coronary atherosclerosis with diffuse disease in small-lumen vessels. With any treatment modality for coronary revascularization, diabetic patients have an inferior outcome compared with nondiabetics. This was first shown for CABG. In patients with diabetes mellitus, CABG is associated with a more rapid progression of atherosclerosis of both grafted and nongrafted vessels, as well as an accelerated...

Reduction in the Incidence of Diabetes

The observations that fewer patients randomized to captopril developed diabetes than those randomized to the P-blocker in the CAPPP trial was initially met with skepticism about whether it was a real reduction with the ACE inhibitor or an increase in incidence of diabetes produced by the P-blocker comparator.6 However, this objection cannot apply to the results of the HOPE trial, which showed a 30 reduction in the new incidence of diabetes in the ramipril arm.98 There has been a rather...

In Diabetes

Coronary artery disease is more prevalent, is more severe, and occurs at a younger age in patients with diabetes. Several metabolic abnormalities, including chronic hyperglycemia, dyslipidemia, and insulin Table 2-1. Diagnostic Criteria for Diabetes Mellitus, Impaired Glucose Tolerance, and Impaired Fasting Glucose According to the American Diabetes Association Rights were not granted to include this table in electronic media. Please refer to the printed publication. From Diagnosis and...

Insulin Resistance

Together with dyslipidemia, hypertension, and obesity, insulin resistance is a key feature of the metabolic syndrome. In addition, it is the first measurable metabolic disturbance among individuals who will subsequently develop type 2 diabetes. Insulin resistance describes a reduced sensitivity in body tissues to the action of insulin, which affects both glucose disposal in muscles and fat and insulin suppression of hepatic glucose output. As a consequence, higher concentrations of insulin are...

Diabetes Prevention

The best way to prevent CV complications in diabetes is to prevent the disease itself. Several studies performed over the last decade have shown that, in subjects at high risk for development of diabetes, lifestyle modifications and pharmacologic interventions may effectively prevent or delay the onset of the disease. Regular physical activity, diet, and weight reduction in high-risk subjects with IGT were shown to reduce the risk of developing diabetes by 31 to 58 . Several drugs also were...

Pregnancy Associated Plasma Protein A

Pregnancy-associated plasma protein A (PAPP-A), a zinc-binding metalloproteinase that is secreted by activated macrophages, fibroblasts, vascular smooth muscle cells, osteoblasts, and placental syncytiotro-phoblasts, functions to activate insulin-like growth factor-1 (lGF-1) through actions on IGF-binding protein (IGF-BP). Although the role for PAPP-A as a biomarker for Down syndrome during pregnancy is well established, its potential role with respect to coronary atherosclerosis and ACS has...

Genetic Basis For Inflammation

Angiogram demonstrating in-stent restenosis of a sirolimus-eluting stent in the middle left anterior descending artery (arrow). Figure 1-4. Angiogram demonstrating in-stent restenosis of a sirolimus-eluting stent in the middle left anterior descending artery (arrow). Figure 1-5. Intravascular ultrasound (IVUS) demonstrating severe in-stent restenosis. Figure 1-5. Intravascular ultrasound (IVUS) demonstrating severe in-stent restenosis. arterial medial fracture, particularly deep...

Genetics Inflammation And Restenosis

Inflammation as a response to injury in the post-PCI population is not a universal phenomenon and begs the question of individual genetic susceptibility. The presence of genetic polymorphisms may help define susceptibility and may affect the selection of therapy for certain patients undergoing PCI. The inflammatory response may, in part, be determined by underlying genetic predisposition. The value of such information, beyond traditional risk factors of restenosis (e.g., diabetes), will be...

The Burden Of The Disease

Worldwide, the estimated prevalence of diabetes for all age groups was 2.8 in the year 2000 and will be 4.4 in the year 2030.1 As a consequence, the total number of people affected from this condition is expected to double during the same period, from 171 million to 366 million. Within the United States, according to the American Diabetes Association (ADA), diabetes affected 20.6 million people in 2005, corresponding to 9.6 of all individuals older than 20 years of age.2 In that same year, 1.5...

Endothelial Dysfunction

Diabetes vascular disease is characterized by endothelial dysfunction, a biologic abnormality that has been related to hyperglycemia, increased free fatty acid production, decreased bioavailability of endothelium-derived NO, formation of advanced glycation end products (AGE), altered lipoproteins, hypertension, and, as previously mentioned, insulin resistance.11 A decreased bioavailability of endothelium-derived NO, with subsequent impaired endo-thelium-dependent vasodilation, has been observed...

Plaque Instability and Impaired Vascular Repair

In addition to promoting atherogenesis, diabetes conveys plaque instability.21 It has been shown that atherosclerotic lesions in diabetic patients have fewer vascular smooth muscle cells compared with those of controls. As the source of collagen, vascular smooth muscle cells strengthen the atheroma, making it less likely to rupture and cause thrombosis. In addition, diabetic endothelial cells may produce an excess of cytokines that decrease the de novo synthesis of collagen by vascular smooth...

Heart Failure and Diabetic Cardiomyopathy

Epidemiologic and clinical evidence links diabetes and heart failure. The Framingham study documented increases of 2.5-fold and fivefold in the inci dence of heart failure in diabetic men and women, respectively. Diabetes has been shown to promote both systolic and diastolic heart failure. Abnormal echocardiographic findings compatible with diastolic dysfunction were found in approximately one third of diabetic patients after exclusion of left ventricular hypertrophy or ischemia.32 In the...

Peripheral Arterial and Cerebrovascular Disease

Epidemiologic evidence confirms an association between diabetes and PAD, with a twofold to fourfold increased incidence compared with nondiabetic individuals. In the Framingham cohort, the presence of diabetes increased the risk of claudication by fourfold in men and ninefold in women. A study addressing the prevalence of PAD among 631 patients according to the degree of associated metabolic disturbance found that the rate of abnormal ankle-brachial index ranged from 7 in individuals with...

Adjunctive Metabolic Intervention at the Time of Coronary Revascularization

Recent studies have underscored the importance of optimal glycemic control at the time of coronary revascularization, both in the setting of PCI and with CABG. A prospective single-center analysis correlated HbA1c and the 12-month TVR rate in 179 diabetic patients undergoing PCI and demonstrated that diabetic patients with optimal glycemic control (i.e., HbA1c < 7 ) had a TVR rate similar to that of nondia-betic patients (n 60) 15 versus 18 .65 Those with HbA1c greater than 7 had a...

Early Invasive Versus Conservative Strategy

In diabetic patients with non-ST-segment elevation ACS, the positive impact of an early invasive strategy can be derived from subgroup analyses of large-scale randomized studies. The Fragmin and Fast Re-vascularisation during InStability in Coronary artery disease (FRISC II) study randomized 2457 patients to an invasive or conservative strategy and detected a significant survival benefit associated with the invasive strategy at 1 year.94 The reduction in 1-year death or MI associated with early...

Coronary Artery Bypass Surgery

The only randomized trial that has compared CABG with PCI in patients with ACS was the AWESOME trial.97 This study compared the two revascularization strategies in patients who had medically refractory unstable angina and were at high risk for adverse outcomes with CABG. Among 2431 patients identified, 454 were considered acceptable for both PCI and CABG 1650 patients were not deemed to be candidate for both therapies and entered a physician-directed registry, and the 327 who were considered...

Aspirin and Clopidogrel

Data on the efficacy of antiplatelet therapy for primary prevention in patients with diabetes are limited. The only prospective randomized study has been the Early Treatment Diabetic Retinopathy Study (ETDRS), which enrolled 3711 diabetic patients in the 1980s and randomized them to aspirin 650 mg day or placebo.107 The administration of aspirin over 5 years was associated with a nonsignificant reduction in all-cause mortality and in fatal or nonfatal MI (RR 0.91 and 0.83, respectively). In the...

Glycoprotein IIbIIIa Receptor Antagonists

The use of intravenous platelet GP IIb IIIa receptor inhibitors and stents has markedly reduced the early hazard in diabetic patients undergoing PCI. In the Evaluation of Platelet IIb IIIa Inhibitor for Stenting (EPISTENT) trial, abciximab halved the risk of death, MI, or urgent revascularization at 30 days among diabetic patients undergoing stenting compared with placebo (12.1 versus 5.6 , respectively). The observed event rate was comparable to that of abcix-imab-treated nondiabetic patients...

Endocannabinoid Blockers

The endocannabinoid system contributes to the physiologic regulation of energy balance, food intake, and lipid and glucose metabolism through central and peripheral effects. This system consists of endogenous ligands and two types of G protein-coupled cannabinoid receptors. The CB1 receptor is located in several brain areas and in a variety of peripheral tissues, including adipose tissue. Compared with wild-type animals, CB1-knockout mice have leaner body composition, but this lean phenotype is...

Guiding Interventions with MDCT

Because of its 3D capabilities, MDCT has a great potential to be used to guide interventions. In elec-trophysiology, MDCT has already been adopted, because it provides an anatomic roadmap for complex electrophysiologic procedures such as radiofrequency ablation of atrial fibrillation. Certain properties need to be understood when comparing MDCT and invasive coronary angiography 1. In MDCT, 3D images of the coronary arteries include atherosclerotic wall plaques. Therefore, in most cases, it is...

Radiation Biology And Mechanism

For the prevention of restenosis, radiation biology intervenes in the cell cycle to cause cell death to radiosensitive cells, especially those undergoing mitosis after vascular injury. The cell death results from chromosomal damage, which depends on the cumulative dose, the dose rate, and the cell cycle. Cells in the M and G2 phases are the most sensitive to radiation, those in G1 are sensitive only in the early G1 phase, and cells in G0 are radioresistant (Fig. 33-2). Ionizing radiation can...

Radiation Physics And Systems

Different isotopes on various platforms and systems have been developed for the use of endovascular brachytherapy. The main platforms that deliver radiation are catheter-based systems such as line source wires, radioactive seeds, radioactive gas- and liquid-filled balloons, or stents using beta or gamma emitters. Isotope selection and dosimetry for intracoronary brachytherapy are derived from the anatomy of the vessel and the treated lesion, and by knowing the target tissue for this therapy....

Understanding Beta Radiation

Beta rays are high-energy electrons emitted by nuclei that contain too many or too few neutrons. These negatively charged particles have a wide variety of energies, including transition energy, particularly between parent-daughter cells, and have a wide variety of half-lives, from several minutes (62Cu) to 30 years (90Sr 90Y). Beta emitters rapidly lose their energy to the surrounding tissue, and their range is within 1 cm of tissue. They are associated with a higher gradient to the near wall....

Screening And Diagnostic Tests

Despite being the most common curable cause of hypertension, RAS occurs in fewer than 1 of patients with mild hypertension.12 However, the incidence of RAS varies dramatically according to the clinical setting. For instance, 10 to 45 of white patients with severe or malignant hypertension have RAS.13 Ideally, all patients should be screened for curable causes of hypertension however, this strategy would not be economically viable because of the high prevalence of idiopathic hypertension....

Duplex Ultrasonography

Duplex ultrasonography has largely replaced invasive venography for the diagnosis of DVT. It has many positive features there is no requirement for neph-rotoxic contrast agents, the test is noninvasive, and there is no need for ionizing radiation. In addition, it is widely available and can be performed at the bedside. Duplex ultrasonography has high sensitivity and specificity for peripheral (jugular, distal subcla-vian, axillary) UEDVT.75 However, acoustic shadowing from the clavicle limit...

Anatomy Of The Left Atrial Appendage Embryology

A, Drawing of a left atrial appendage (LAA) anatomic specimen consisting of three lobes. Each protrusion from the body comprises a separate lobe. Directional changes or bends in the tail do not usually comprise new lobes. B, LAA with two lobes (1 and 2). C, Measurements of the LAA in a gross pathologic specimen. The echocardiographic orifice (Oe) is larger than the anatomic orifice (Oa). The length (L) of the appendage is a curvilinear distance (dashed line) from Oa to the tip of...

PMC in Patients with High Surgical Risk

Valvuloplasty is the only solution when surgery is contraindicated. It is also preferable to surgery, at least as the first attempt, in patients with an increased risk for surgery of cardiac origin, as in the following situations. Preliminary reports have suggested that valvulo-plasty can be performed safely and effectively in patients with severe pulmonary hypertension.46 These results are encouraging even though they concern a limited number of patients. In Western countries, many patients...

Treatment and Outcomes

Surgical repair has long been the mainstay of treatment for ASDs.100,101,104 However, over the last decade, substantial advances have been made with percutaneous closure devices. At this time, percutaneous closure of secundum ASDs is considered the standard of care.105-107 Currently in the United States, two devices are approved for use by the Food and Drug Administration (FDA) the Amplatzer Septal Occluder (AGA Medical, Golden Valley, MN) and the Helix Septal Occluder (W. L. Gore and...

Pediatric and Other Congenital Applications

There are settings where interventional MRI may have value even in straightforward catheter-based procedures. The advantages of MRI might include avoiding radiation or iodinated radiocontrast or reducing operator musculoskeletal injury from lead aprons. Children with congenital cardiovascular abnormalities are subjected to multiple catheter procedures during their lifetime and may accumulate a large radiation exposure with excess malignancy risk. Schalla, Higgins, Moore, and colleagues at the...

John A Bittl

Pivotal mechanistic studies have claimed that atheroabla-tive techniques and thrombectomy devices achieve better angiographic results than percutaneous transluminal coronary angioplasty. Randomized trials have failed to show that atheroablative techniques and thrombectomy devices achieve better clinical outcomes than percutaneous transluminal coronary angioplasty. Certain advantages of atheroablative and thrombectomy procedures have not been amenable to study in large, multicenter studies and...

Prognostic Implications of Periprocedural Myocardial Infarction

Although there is much controversy about the definition and prevalence of PMI with everyday PCI, there is no dispute that significant PMI is associated with an increased mortality risk. The controversy still exists about the pathophysiologic mechanisms underlying this association, the definition, and the size of PMI that would confer such increased risk. However, there is convincing evidence that any PMI is associated with some degree of increased risk of death, particularly with longer...

References

MDGs Chronic diseases are not on the agenda. Lancet 2005 366 1512-1514. 2. Fuster V, Moreno PR, Fayad ZA, et al Atherothrombosis and high-risk plaque. Part I Evolving concepts. J Am Coll Cardiol 2005 46 937-954. 3. Schaar JA, De Korte CL, Mastik F, et al Characterizing vulnerable plaque features with intravascular elastography. Circulation 2003 108 2636-2641. 4. Feder B In Quest to Improve Heart Therapies Plaque Gets a Fresh Look. New York Times. November 27, 2006 A1. 5....

Heparin Pharmacology

Unfractionated heparin is a heterogeneous group of glycosaminoglycans of various lengths (5000 to 30,000 daltons mean, 15,000 daltons) that exhibits a high-affinity for antithrombin. This binding augments antithrombin's enzymatic inactivation of thrombin, factor Xa, and factor IXa, with its effects on thrombin being the most pronounced.11 Given heparin's reliance on antithrombin for a therapeutic effect, it is considered as an indirect antithrombin. The antithrombin effect of heparin requires...

The Future Of Percutaneous Intervention

The thorny issues in patients with prior bypass surgery remain vein graft atheroembolism and restenosis and progressive vein graft disease. Major expansion of indications in this subgroup of patients awaits solutions to these problems. To avoid embolization, vein graft atheroma must be removed, excluded from the circulation, fragmented and removed, or ablated. Even with the permissively large lumen of many Figure 25-16. A, An 80-year-old man with unstable angina was found to have a long...

Procedural Technique

Coronary Ethanol Injection

Given the fact that most patients with HOCM are diagnosed noninvasively with echocardiography and many have not had invasive hemodynamic studies performed before presenting for ablation, many operators reconfirm the presence of significant LVOT obstruction by positioning an end-hole catheter in the ventricular apex and recording a slow pullback under fluoroscopy. Alternatively, simultaneous measurement of the ascending aortic and intracavity pressures may be obtained via placement of an...

Drug Eluting Stents

Although BMSs improve initial and long-term outcomes of SVG PCI, the impact is modest because of restenosis and disease progression. DESs have been Survival time in years Survival time 1-year 2-year 3-year 4-year 5-year Diabetic group 0.88 0.80 0.73 0.68 0.63 A Nondiabetic group 0.95 0.91 0.87 0.83 0.79 Survival time in years Survival time 1-year 2-year 3-year 4-year 5-year Diabetic group 0.88 0.80 0.73 0.68 0.63 A Nondiabetic group 0.95 0.91 0.87 0.83 0.79 Survival time 1-year 2-year 3-year...

Electrocardiographic Stress Testing

From the beginning, the application of exercise stress testing for the diagnosis of obstructive CAD has been focused on the presence and extent of ST-segment deviations during and immediately after exercise. This is obtained by serial recordings of the 12-lead electrocardiograph (ECG), which is often aided by computer analysis. Exercise ECG testing has modest diagnostic utility, mostly in patients with an intermediate pretest likelihood for having disease. It is now recognized that the early...

Tomographic Imaging Techniques

Irregular Vertebral Arrtery Waveform

Tomographic imaging techniques such as CTA and MRA are excellent noninvasive, high-resolution imaging techniques that are useful tools for establishing the diagnosis of proximal arch and upper extremity vascular disease. They are capable of defining complex anatomy (as in the case of a congenital abnormality or prior intervention), allow visualization of the vasculature in multiple planes without the problem of overlap, and also show extravascular structures. MRA has the advantage over CTA (and...

Transmyocardial Delivery Of Biologic Compounds

Endocardial Injection With Catheter

The delivery of biologic compounds (e.g., genetic sequences or progenitor cells) has been considered as an alternative and more natural approach for restoration of myocardial perfusion and or mechanical function in the diseased heart. One of the fundamental biologic processes being explored is myocardial HIF-1, HIF-2, VEGF, Ang-2, A MMP, PA Smooth muscle cell migration, matrix remodeling Figure 57-5. Schematic diagram of the various stages of angiogenesis attached to the formation of branching...

Symptomatic Indication For Revascularization Pci Versus Medical Therapy Alone

Several studies from the pre-stent era compared PCI with lone medical therapy in patients with single- or double-vessel disease without a prognostic indication for CABG. The Veterans Affairs ACME trial was the first randomized trial to compare plain balloon angioplasty with medical therapy.91 In this study, 212 patients with single-vessel disease, stable angina pectoris, and positive results on stress testing or MI within the preceding 3 months were randomized to an initial strategy of plain...

Plaato

Nitinol Laa

The PLAATO device (ev3, Inc., Plymouth, MN) was the first percutaneously implanted occluder to find human use (see Fig. 49-8). Its framework is a nitinol basket with a tissue anchoring system on the struts designed to maintain position. A minimally throm-bogenic expanded polytetrafluoroethylene (ePTFE) membrane covers the basket and is designed to seal the LAA orifice and allow endothelialization. Figure 49-7. A, Postmortem human heart reveals the three-dimensional internal anatomy of the left...

Chronic Venous Disease

Chronic venous insufficiency is a significant problem in the United States, affecting as much as a quarter of the population. Venous valve incompetence is central to the venous hypertension that appears to underlie most or all signs of chronic venous disease. Chronic venous disease afflicts a younger segment of the population, and the morbidity of edema, leg pain, and ulceration may result in lifestyle alterations, loss of work, and frequent hospitalizations. The prevalence of venous...

Mid Stent

Stent strut discontinuity (fracture) observed 8 months after deployment of three overlapping drug-eluting stents. On the cross-sectional intravascular ultrasound (IVUS) image (bottom, middle), an abnormal paucity of stent struts, not seen at implantation, is detected at a portion of the mid stent. The longitudinal IVUS image (top) shows an acute-angled bend at the corresponding segment. In this particular case, the strut discontinuity is not associated with increased intimal...

Revascularization and Outcomes in the Symptomatic Patient

The two main reasons to consider revascularization in any patient with CAD are improvement of prognosis and alleviation of symptoms to improve the QOL. The risk of major adverse events in patients with CCS is low, but the costs are significant. Methods by which the clinician can identify patient subsets at higher risk are numerous. Despite the high prevalence of chronic stable angina, relatively little is known about the impact on outcomes of modern coronary revascularization in contemporary...

Laser Tissue Effects

Laser energy has specific tissue interactions that are fundamental for achieving controlled channel formation and tissue response, thereby avoiding unwarranted excessive myocardial damage.28 In general, thermal injury leads to intense collagen deposition and scarring.29,30 The myocardial tissue response to a laser energy source has been characterized acutely by sharply demarcated tracks appearing as open channels surrounded by a rim of necrotic tissue secondary to excessive heat (Fig. 57-1).31...

Accesssite Complications

Vasoseal Datascope

Local vascular complications at the site of catheter insertion constitute the most common adverse events after cardiovascular interventions. Vascular complications can extend the patient's length of hospitalization and increase the associated procedural costs. Vascular access complications include external bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, vessel dissection, acute vessel closure, retro-peritoneal hemorrhage, neural damage, infection, and venous thrombosis. One way to...

Perioperative Myocardial Infarction Pathophysiology

Similar to myocardial infarction (MI) outside the context of surgery, perioperative MI can result either from atherosclerotic plaque rupture, with subsequent thrombotic occlusion of the involved coronary artery, or from a transient stress-induced mismatch of myo-cardial oxygen supply and demand, often in the setting of a fixed coronary artery stenosis. Among patients with fatal perioperative MI, autopsy series have demonstrated histologic characteristics of recent plaque rupture in...

Etiology and Prevalence

TOS is commonly classified as either neurogenic or vascular (Table 40-5). Neurogenic TOS, which refers to the symptomatic compression of the brachial plexus, is thought to account for 95 of cases. The site of compression is usually in the scalene triangle. Seventy percent of neurogenic TOS cases occur in female patients. Vascular TOS accounts for the remaining 5 of cases, with the majority of those affecting the subclavian artery and the minority affecting the subclavian vein. The site of...

Choice and Use of Contrast Agent

The choice of contrast agent is an important intra-procedural consideration and has evolved considerably over the last several years with the development of low- and iso-osmolar contrast agents. Traditional iodine-based contrast agents were hypertonic and included ionic compounds such as diatrizoate (Hypaque, Renografin) that frequently caused mild hemodynamic changes in addition to contrast-related nephropathy. Given substantially lower costs in recent years, most laboratories have switched to...

The Very Different Advantages And Disadvantages Of Pci And Cabg

*Babapulle MN, Joseph L, Belisle P, et al A hierarchical Bayesian meta-analysis of randomized clinical trials of drug-eluting stents. Lancet 2004 364 583-591. 'Antonucci D, Valenti R, Migliorini A, et al Abciximab therapy improves survival in patients with acute myocardial infarction compliated by early cardiogenic shock undergoing coronory artery stent implantation. Am J Cardiol 2002 90 353-357. 'Valgimigli M, Malagutti P, Aoki J, et al Sirolimus-eluting versus paclitaxel-eluting stent...

Cost Study Structures CostEffectiveness Analysis

Cost studies generally fall into one of three categories randomized, controlled trials observational studies and cost-effectiveness models. Cost-effectiveness models are discussed in the next section. A cost study in a randomized clinical trial is usually ancillary to the primary objective of the trial. Typically, cost or resource consumption patterns are a secondary end point in a trial that has either a composite clinical or (preferably) a mortality primary end point. Some have argued that...

Continuous Quality Improvement in the Cardiac Catheterization Laboratory

Continuous quality improvement (CQI) is a methodology to improve the processes associated with providing a product or service to meet or exceed consumer expectations.1 Based on the work of pioneers in industrial management, specifically Deming and Juran, the CQI process is a collection of techniques borrowed from the fields of systems theory, statistics, engineering, and psychology.36 CQI is an organized, scientific process for evaluating, planning, improving, and controlling quality. The goal...

Planning Access

Femoral Artery Puncture

The selection of an appropriate access site is frequently a key issue for the successful completion of coronary or peripheral vascular procedures. Proficiency with all available vascular puncture techniques is therefore a basic requirement for the interventionalist. It is important to review clinical reports and perform preprocedural vascular assessment of the quality of all peripheral pulses, presence of bruits, blood pressure difference between arms, and other pertinent findings, such as skin...

Cardiac Neuropathy

Cardiac neuropathy is characterized by an attenuation of heart rate variability in response to breathing, Valsalva and posture maneuvers, and an impairment of heart rate recovery following exercise. A recent population-based study including more than 2000 individuals demonstrated that diabetes was the primary contributor to reduced heart rate variabil-ity.35 Growing evidence suggests that cardiac neuropathy in diabetes mediates alterations in the regulation of coronary vasodilator function in...

Fibromuscular Dysplasia

The gold standard for evaluating renal artery FMD, as for atherosclerotic RAS, is DSA. Different pathologic lesions have different angiographic patterns. Medial fibroplasia has the classic string of beads appearance, with the diameter of the beading larger than the diameter of the artery (aneurysmal). In perimedial fibroplasia, the beads are smaller than the diameter of the artery and less numerous than in medial fibroplasia. Medial hyperplasia and intimal fibroplasia manifest as concentric...

Contributors

Fellow, Interventional Cardiology, Mayo Clinic College Balloon Angioplasty Is It Still a Viable Intervention Research Associate, Harvard Medical School Assistant Director, Angiographic Core Laboratory, Brigham and Women's Hospital, Boston, Massachusetts Qualitative and Quantitative Coronary Angiography Associate Professor of Medicine and Director of Interventional Cardiology, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida Elective...

Monarc Percutaneous Transvenous Mitral Annuloplasty System

Originally developed as the VIKING system (Edwards Lifesciences Inc., Irvine, CA), the first iteration of this device consisted of a distal self-expanding anchor, a spring-like bridge segment, and a proximal self-expanding anchor. The distal anchor is deployed in the great cardiac vein, and the proximal anchor deployed in the proximal coronary sinus. The bridge segment was designed with shape-memory properties that lead to shortening of the device at body temperature. A new iteration of the...

Patent Foramen Ovale

Fluoroscopy Ablation

The details of this procedure are covered in Chapter 48. Briefly, under normal embryologic processes, the septum primum and secundum (two independent, crescent-shaped membranes) make up the IAS. During fetal life, the mobile septum primum allows right-to-left shunting to maintain life. However, after birth, left atrial pressure increases and helps to fuse these two membranes. In about 15 to 20 of individuals, this fusion does not occur and allows occasional right-to-left shunting, which is...

Low Risk Patients

Concordant with the findings of the surgical revascularization versus medical therapy trials, very-low-risk patients with coronary artery disease without ACS or demonstrable ischemia need to be triaged carefully to an invasive strategy. Results from the early stent era 341-patient Atorvastatin versus Revas-cularization Treatments (AVERT) trial suggested that aggressive lipid lowering with 80 mg of atorvastatin might be as effective as PCI and usual care in reducing ischemic events during...

Central Venous Stenosis

Risk factors for chronic venous disease Genetic factors Female sex (progesterone) Pregnancy Age Greater height Prolonged standing Obesity Figure 45-1. Venous hypertension as the hypothetical cause of the clinical manifestations of chronic venous disease, emphasizing the importance of inflammation. SVC syndrome is a serious disorder resulting from impeded venous return from the upper body caused by obstruction of the SVC. The symptoms include severe congestion and edema of the face, arms, and...

Diabetic Nephropathy

Renal failure is a major independent predictor of cardiovascular events. Diabetes is the leading cause of renal failure in Western countries. In 2002 in the United States, diabetic nephropathy accounted for more than 40 of the new cases of renal failure, and 44,000 diabetic patients began treatment for endstage renal disease.2 The condition underlying diabetic nephropathy is microvascular disease. Even in the absence of renal failure, albuminuria is a frequent finding in diabetes. Any degree of...

Conclusion

Defining inflammatory status in patients with ACS and in those with coronary atherosclerosis is becoming paramount to the efficient risk assessment and appropriate treatment of patients. As our grasp of molecular and genetic tools improves, the ability to break down the complex pathways and modulate them as potential therapeutic targets in susceptible individuals will take hold. The implications are far reaching and hold the potential to significantly alter the way clinical medicine is...

Percutaneous Mechanical Thrombectomy

Circulation Dvt Unit Mechanical

Issues surrounding CDT for lower extremity DVT include the time to lysis, need for intensive care monitoring, hemorrhagic risks, cost, and lack of prospective, randomized clinical trials. With these issues in mind, PMT is conceptually attractive because such a technique may result in a shorter time to vein patency, shorter length of stay, reduction in hemor-rhagic risk, and overall cost savings because of reduced hospitalization and elimination or reduction in thrombolytic drugs. From a...

Chronic Kidney Disease

Mehran Score

The population of patients with CKD worldwide is growing at a tremendous rate. Consequently, these high-risk patents are now encountered much more frequently in the cardiac catheterization laboratory. In one recent registry, for example, 25 of patients undergoing PCI had at least mild CKD.14 For the interventional cardiologist, identifying these patients is important for two reasons. First, this group Figure 5-2. Risk score for determining risk of contrast-induced nephropathy and dialysis after...

Future Directions

There is room for improvement in the current DES delivery systems. Better flexibility and conformabil-ity are likely high on the wish list of most modern interventional cardiologists, who no longer fear Figure 32-7. Cumulative frequency distribution of in-segment minimal luminal diameter on quantitative coronary angiography. Data are shown for the uncoated-balloon group and the coated-balloon group before the procedure, after the procedure, and at 6 months. (From Scheller B, Hehrlein C, Bocksch...

Manual Compression

Popliteal Artery Puncture Technique

Digital compression should be considered the gold standard for compressive methods. Performed properly, it can prevent bleeding and maintain distal perfusion. This procedure may be performed by a physician, nurse, or technician who has received formal training. Before sheath removal, the distal pulses and the access site are assessed for signs of an existing hematoma. The duration of manual compression and the time of immobilization are proportional to the size of the introducer sheath and the...

Interventional Treatment and Surgery

The decision regarding management of CLI depends on the risk profile of the patient (e.g., expected operative mortality, underlying renal function and the risk of contrast nephropathy) and the anatomic profile of the patient (e.g., multisegment and or multivessel disease, number of runoffs, suitability of the disease to PTA versus surgery). Figure 39-8 outlines a general approach to the management of CLI. Figure 39-8. Treatment algorithm for patients with critical limb ischemia. (Redrawn from...

Complications and Followup

The equipment used to perform percutaneous renal artery revascularization has changed dramatically in the last decade, and the procedure has become safer and more reliably successful. However, deterioration in renal function is still the most important complication of the procedure and can be multifactorial (e.g., contrast toxicity, embolization, incorrect patient selection). Every effort should be made to avoid using an excessive volume of contrast material, and great care should be exercised...

Studies on Plain Balloon Angioplasty

Four of the studies comparing CABG with plain balloon angioplasty for multivessel disease reported subgroup analyses for diabetics. The largest of these subgroup analyses was derived from BARI, which included 353 patients with diabetes. During the 5-year follow-up, the mortality rate of diabetics randomized to plain balloon angioplasty was 34.5 , and after seven years it was 44.3 , whereas after CABG the respective mortality rates were 19.4 (P .03) and 23.6 (P .01).57 The difference in...

National Percutaneous Coronary Intervention Registries

The role of national registries focusing on PCI and cardiac catheterization has grown substantially, particularly since the launching of the ACC-NCDR CathPCI registry in 1998 (Fig. 66-6). This registry, created under the auspices of the ACCF, was developed to respond to clinicians' and hospitals' needs for standardized elements to accurately describe clinical outcomes it offers risk-adjusted quarterly data reports with comparisons against national and like hospital benchmarks.44 Table 66-2...