Iatrogenic coronary artery dissections extending into and involving the aortic root.

We set out to determine the incidence of iatrogenic coronary artery dissection extending into the aorta and to characterize the aortic lesions. We reviewed the data from 43,143 cardiac catheterizations from September 1993 through September 1999 and found 9 coronary artery-aortic dissections for an overall incidence of 0.02%. Four of these patients were undergoing treatment for acute myocardial infarction (AMI) and aortic dissection was more common than for non-AMI patients (0.19% vs. 0.01%, P < 0.0006). Histologic analysis of tissue samples from 2 cases revealed age related changes only and no evidence of predisposing pathology. Patients with limited aortic involvement were successfully managed with stenting of the coronary dissection entry point whereas aortic dissection extending up the aorta >40 mm from the coronary os required surgical intervention.

Validation of a decision support tool for the evaluation of cardiac arrest victims.

BACKGROUND: There is currently no well-accepted model for early and accurate prediction of neurologic and vital outcomes after cardiac arrest. Recent studies indicate that individuals with acute myocardial ischemia as the etiology for the arrest may benefit from early revascularization. HYPOTHESIS: This study was undertaken to examine whether the cardiac arrest score is valid for predicting outcomes upon arrival at the emergency department. METHODS: We previously developed a cardiac arrest score based on time to return of spontaneous circulation, initial systolic blood pressure, and level of neurologic alertness in 127 patients (derivation set). This score was prospectively applied to 62 patients with similar clinical profiles (validation set). Utility of the score was evaluated by the area under the receiver operator characteristic curves (C) for both sets. Consistency was measured by using the alpha statistic applied to the cumulative survival at each ascending level of the score. RESULTS: The derivation and validation sets were similar with respect to baseline characteristics and proportions at each level of score. The survival to discharge was 41.7 and 53.2% for the two sets, respectively. The value of C was 0.89 +/- 0.03 and 0.93 +/- 0.03 for neurologic recovery and 0.81 +/- 0.04 and 0.92 +/- 0.04 for survival to discharge in the two sets, respectively. The level of agreement between the sets across the levels of the score was 0.98 and 0.99 (both p < 0.0001) for the two outcomes. CONCLUSIONS: The cardiac arrest score is a valid decision support tool in the evaluation of cardiac arrest victims. Patients with the most favorable scores may be considered for early angiography and revascularization if myocardial ischemia is the etiology of the arrest.

Prediction of death and neurologic outcome in the emergency department in out-of-hospital cardiac arrest survivors.

We reviewed the hospital records of 127 consecutive patients who were resuscitated from cardiac arrest in a retrospective cohort analysis. A cardiac arrest score utilizing time to return of spontaneous circulation, systolic blood pressure at the time of presentation, and initial neurologic exam were calculated. This score was analyzed with 39 other clinical variables for significance with regard to mortality or neurologic survival using multivariate analysis. Combining these variables into a cardiac arrest score (levels 0, 1, 2, 3, from least to most favorable) allowed prediction of neurologic outcomes and mortality from a single variable in an independent fashion (p < 0.0001). Logistic regression models found scores of 0, 1, 2, and 3 predicted in-hospital mortality rates of 90%, 71%, 42%, 18%, and neurologic recovery in 3%, 17%, 57%, and 89%, respectively. The cardiac arrest score was able to predict in-hospital mortality and neurologic outcomes in those who survived to emergency department arrival. This scoring scheme may aide in selection of patients for early aggressive measures, including triage coronary angiography and angioplasty.

Delayed progression or regression of coronary atherosclerosis with intensive risk factor modification. Effects of diet, drugs, and exercise.

Until the mid 1980s, secondary prevention of coronary atherosclerosis focused primarily on early ambulation, exercise training, and a 'prudent' diet. These regimens generally resulted in improved functional capacity, reduced myocardial demands at submaximal workrates, and modest decreases in cardiovascular mortality. However, reinfarction rates and the course of atherosclerotic heart disease remained largely unchanged with traditional treatment or usual care. Contemporary studies now suggest that multifactorial risk factor modification, and especially more intensive measures to control hyperlipidaemia with diet, drugs, and exercise, may slow, halt, and even reverse the progression of atherosclerotic coronary artery disease. Added benefits include a reduction in anginal symptoms, decreases in exercise-induced myocardial ischaemia, fewer recurrent cardiac events, and a diminished need for coronary revascularisation procedures. Several mechanisms may contribute to these improved clinical outcomes, including partial (albeit small) anatomic regression of coronary artery stenoses, a reduced incidence of plaque rupture, and improved coronary artery vasomotor function. These findings suggest a new paradigm in the treatment of patients with coronary artery disease.