Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease.

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.

High-risk coronary angioplasty with elective intra-aortic balloon pump support.

Percutaneous transluminal coronary angioplasty was attempted with elective percutaneous intra-aortic balloon pump support in 21 patients (mean age 60 years, range 40-82; 18 males) with unstable angina (n = 2), multivessel coronary disease requiring multivessel angioplasty (n = 2), severe left ventricular dysfunction (ejection fraction 10-30%; n = 16) or ventricular fibrillation at diagnostic angiography (n = 1). Fourteen patients had 3-vessel disease (1 with vein grafts also diseased), 6 had 2-vessel disease and 1 had isolated left anterior descending disease. Twenty-five procedures were performed (one in 18 patients, two in 2 patients and three in one patient) on 42 lesions in 34 vessels/grafts. There was no angioplasty-related death. Successful dilatation was achieved in 38/42 lesions (90%) in 21/25 procedures (84%) without major complication. Three procedures were complicated: one by major coronary dissection without sequelae, one by haemodynamic deterioration due to distal occlusion and one by an unstable residual stenosis in the attempted vessel necessitating urgent bypass surgery. The only complication related to the intra-aortic balloon pump was local haematoma in 2 patients. In conclusion, elective intra-aortic balloon pump support may be safely used to stabilise high-risk patients undergoing coronary angioplasty, leading to a satisfactory primary success rate.

The role of surgery in the management of solitary coronary artery aneurysm.

A 55-year-old lady presenting with angina was diagnosed on angiography as having a solitary aneurysm of a lateral circumflex artery. She underwent clipping of the aneurysm and a long saphenous vein bypass graft to the distal vessel. The role of surgery in the management of coronary aneurysms is discussed.

Is the waiting list a safe place for outpatients awaiting coronary bypass surgery?

This study was undertaken to identify the safety of outpatients awaiting coronary bypass surgery. An audit of the outcome of 92 such outpatients at one Regional centre was undertaken by a retrospective review of medical records. Outcome measures were: time on the waiting list, anti-ischaemic medications, readmission for unstable angina, myocardial infarction and death. Almost half of the patients underwent surgery within three months, and three-quarters waited less than six months. No outpatient death occurred. However, 4 of the 7 adverse events occurred within this period. Despite advanced disease, the safety of outpatients awaiting coronary surgery within such a short time frame appeared to be acceptable, the only adverse events being non-fatal and occurring unpredictably.

Efficacy of nisoldipine combined with beta-adrenergic-blocking drugs in the treatment of chronic stable angina.

A double-blind, placebo-controlled study was performed to assess whether a new calcium antagonist, nisoldipine, in doses of either 5 mg or 10 mg daily, in combination with beta-adrenergic-blocking drugs (combination therapy) was more effective than beta-adrenergic-blocking drugs alone (single therapy) in the treatment of chronic stable angina. Treatments were assessed at two-week intervals, using exercise electrocardiography and patients' anginal diaries. A significant improvement in exercise capacity and reduction in anginal attacks occurred only during nisoldipine (10 mg daily) combination therapy compared with single therapy. Mean exercise time increased from 419 +/- 146 s (single) to 454 +/- 158 s (p less than 0.02) after combination therapy. Exercise time to onset of 1 mm ST-segment depression improved from 326 +/- 145 s (single) to 331 +/- 139 s after combination therapy, although the change was not significant. Mean number of anginal attacks decreased from 21 +/- 22 (single to 15 +/- 19 (p less than 0.01) during combination treatment, with an associated significant reduction in glyceryl trinitrate consumption. Adverse effects during combined therapy were minor and tolerable. Thus patients limited by exertional angina despite beta-adrenergic-blocking drugs may obtain supplemental relief of angina and myocardial ischemia with the addition of nisoldipine in a dose of 10 mg daily.

The effects of oral nitrendipine and propranolol, alone and in combination, on hypertensive patients with special reference to AV conduction.

The effects of oral nitrendipine and oral propranolol, alone and in combination, on AV conduction have been examined in 11 patients with essential hypertension in whom arterial pressure was not adequately controlled despite treatment with thiazide diuretics. The study was performed double-blind. After a drug free period of 1 week, the patients received two 7 day courses of drug therapy after initial control measurements. Five of the eleven patients were randomised to receive nitrendipine 20 mg daily, the other six patients received propranolol (Inderal LA 160 mg daily) for the first week of therapy. During week 2, 10 patients received combined therapy. In the 10 patients who completed the study, oral nitrendipine, given either alone or in combination with oral propranolol, had no significant effect on resting PR, QRS, QT intervals nor on AV conduction as assessed by ambulatory electrocardiography. Propranolol did not affect the resting PR interval but significantly increased PR intervals on the ambulatory ECG recordings during single and combined therapy. However the maximum PR intervals remained within normal limits.

Management of ventricular arrhythmias associated with mitral valve prolapse by combined alpha and beta blockade.

Ventricular arrhythmias are common in patients with mitral valve prolapse. Ten patients with echocardiographically confirmed mitral valve prolapse and documented ventricular arrhythmias were included in this study. The aim was to assess the value of combined alpha- and beta-blockade (labetalol) compared with beta-blockade alone (propranolol) in the management of ventricular arrhythmias in these patients. The study was performed using physiological stress, such as the Valsalva manoeuvre, isometric exercise and treadmill exercise, to initiate ventricular arrhythmias before and after intravenous propranolol or labetalol and to document arrhythmias during 24 hour electrocardiography before and after oral medication. Labetalol and propranolol decreased the heart rate and blood pressure response to these manoeuvres to a similar extent but labetalol was more effective in the control of the ventricular arrhythmias. These findings suggest that alpha adrenergic receptors may play a role in the pathogenesis of the ventricular arrhythmias in mitral valve prolapse syndrome and that labetalol offers an alternative treatment for the management of this condition.

Relation between coronary anatomy and serial changes in left ventricular function on exercise: a study using first pass radionuclide angiography with gold-195m.

Serial changes in left ventricular function on exercise were assessed by first pass radionuclide angiography with gold-195m (half life 30.5 s) in 25 men with known coronary anatomy. In the seven patients with three vessel disease, abnormalities of global left ventricular function and regional wall motion occurred earlier during exercise, were of greater extent at peak exercise, and persisted longer after exercise than in the 11 patients with one and two vessel disease or the seven with normal coronary arteries. Although there were significant differences between the groups in absolute change in ejection fraction and the rate of change in ejection fraction related to exercise duration and heart rate, a considerable overlap of values between groups precluded the accurate prediction of coronary anatomy in individuals. These data suggest that the amount of myocardium at risk from ischaemia in some patients with one and two vessel disease may resemble that in patients with three vessel disease. This study shows that an anatomical classification based solely on the number of diseased vessels will not predict the extent of the impairment of left ventricular function on exercise.

Improved cardiac function after renal transplantation.

There are few reports of the outcome of renal transplantation in patients with severe left ventricular (LV) impairment. We describe three men with chronic disabling heart failure associated with LV dysfunction in whom a remarkable improvement in cardiac function followed renal transplantation. Transplantation may offer the prospect of successful rehabilitation in these circumstances. Undue pessimism as to the prognosis in such patients is unwarranted.

Ventricular arrhythmias complicating weight reduction therapy in a patient with a prolonged QT interval.

Serious ventricular arrhythmias are known to occur in patients with long QT intervals. We describe a case of torsade de pointes occurring in a patient with a prolonged QT interval while taking a 1000 calorie diet, diethylpropion hydrochloride (Tenuate Dospan) and bendrofluazide. In patients with long QT intervals, hypokalaemia and drugs which further delay repolarization may facilitate the development of life threatening arrhythmias.

Chest pain and electrocardiographic ST-segment elevation occurring in the recovery phase after exercise in a patient with normal coronary arteries.

Exercise-induced ST-segment elevation usually occurs in patients with coronary artery disease. We report a case in which ST-segment elevation occurred during the recovery phase of exercise in a patient with normal coronary arteries.

Hemothorax due to rupture of a benign thymoma.

Non-traumatic hemothorax is rare and in the case we report was due to rupture of a benign thymoma. The clinical course of the patient suggested rapid intrathoracic bleeding and emergency surgery was required to make the correct diagnosis.

Unusual form of bilateral partial anomalous pulmonary venous drainage.

A 23-year-old man with known valvular pulmonary stenosis was found to have a very unusual form of bilateral partial anomalous pulmonary venous drainage. The venous drainage from the upper parts of both lungs was anomalous, draining from the left lung via a persistent left-sided superior vena cava and from the right lung directly into the right atrial/right superior vena caval junction. The venous drainage from the lower parts of both lungs was normal. The embryological pathogenesis of the defect is discussed.

Proarrhythmic effects of the new antiarrhythmic agent flecainide acetate.

Flecainide acetate, a new potent class I antiarrhythmic agent, was given to 152 patients (46 orally and 106 intravenously) over a period of 22 months. Seven patients developed proarrhythmic effects. The only conduction abnormalities induced were PR interval prolongation and QRS complex widening, and no patient developed significant sinus bradyarrhythmias; patients with known serious abnormalities of impulse generation or conduction were excluded from this study. Five patients developed ventricular tachycardia or ventricular fibrillation of whom only three had preexisting ventricular arrhythmias. QT and QTc interval prolongation was observed but was due to QRS complex widening rather than to an increase in the JT interval. A patient with the Wolff-Parkinson-White syndrome had an inducible orthodromic atrioventricular (AV) tachycardia prior to flecainide, but only an antidromic tachycardia was induced after the drug. In one patient flecainide administration resulted in an increase of atrial flutter cycle length which resulted in development of 1:1 AV conduction and overall faster ventricular rate. Two patients who developed ventricular arrhythmias were taking other antiarrhythmic agents, and in this series proarrhythmic effects occurred with both normal and high flecainide concentrations.

Retrograde gap in fast pathway conduction accentuated by the class I antiarrhythmic agent, flecainide.

A case is reported of a patient with functional duality of AV nodal conduction in whom, during ventricular extrastimulus testing, there was a gap in retrograde fast pathway conduction which allowed the temporary expression of retrograde slow pathway conduction. The administration of the antiarrhythmic agent flecainide, which has disparate effects on retrograde fast and slow pathway conduction characteristics, accentuated this phenomenon. The electrophysiological basis of gap phenomena is discussed.

Coronary haemodynamic effects of nifedipine. Comparison with glyceryl trinitrate.

The coronary haemodynamic effects of nifedipine and glyceryl trinitrate were compared in 22 patients undergoing investigations for suspected coronary artery disease. Myocardial blood flow was estimated by the coronary sinus thermodilution technique. In sinus rhythm nifedipine increased mean coronary sinus flow from 135 ml/min to 152 ml/min, and reduced arterio-coronary sinus oxygen difference from 12.4 to 10.96 ml/100 ml without causing a significant change in coronary vascular resistance or in myocardial oxygen consumption. Glyceryl trinitrate reduced mean coronary sinus flow from 165 to 111 ml/min, myocardial oxygen consumption from 19.2 to 11.9 ml/min, and arterio-coronary sinus oxygen difference from 11.7 to 10.9 ml/100 ml. There was a rise in coronary vascular resistance from 54 355 to 74 364 dynes s cm-5. During atrial pacing nifedipine reduced the arterio-coronary sinus oxygen difference from 11.99 to 11.0 ml/100 ml but had no significant effect on the other variables measured. Glyceryl trinitrate caused a fall in mean coronary sinus flow from 207 ml/min to 168 ml/min; myocardial oxygen consumption fell from 24 ml/min to 18 ml/min, while coronary vascular resistance rose from 41 714 to 51 234 dynes s cm-5. Direct comparison of the two drugs showed a significant difference in effects on coronary sinus flow and coronary vascular resistance in sinus rhythm. Both drugs appeared effective in relieving ischaemia as judged by a reduction of the incidence of pacing induced angina and an improvement in lactate status.

Ambulatory monitoring of pulmonary artery pressure. A preliminary clinical evaluation.

Traditional measurement and recording methods are inadequate for continuous monitoring of ambulatory pulmonary artery pressure. Therefore a new miniaturised solid state system has been developed and assessed. A manometer tipped catheter, inserted via a subclavian or cephalic vein, was used together with an isolated amplifier and peak detectors to determine systolic and diastolic pressures. Pressures were averaged over 30 seconds and stored in digital memory. After a 24 hour recording period data were rapidly transferred to a microcomputer for numerical or graphical display. Thirteen patients had continuous ambulatory monitoring performed for between 24 and 96 hours, in seven to evaluate symptoms of dyspnoea in subjects with valvular or coronary disease (group 1), and in six to achieve optimal oral treatment for left heart failure (group 2). The catheter was calibrated before insertion and was rechecked after removal. There was less than 1% zero level drift and similar gain stability. Systolic pressures ranged from 10 to 97 (mean 39.5) mmHg, and diastolic from 1 to 46 (mean 15.3) mmHg. Four patients in group 1 had symptoms of dyspnoea associated with normal pressures, while three had raised pressures. Four of the six patients monitored in group 2 had major alterations in their treatment based on data obtained during monitoring. There were no complications. This system, which allows safe, reliable, and prolonged recording of ambulatory pulmonary artery pressure, represents a considerable advance in the ability to assess the cause of dyspnoea and to manage left heart failure.