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INTRODUCTION: Elevated plasma matrix metalloproteinase-9 (MMP-9) levels have been suggested to precede the development of microalbuminuria. As angiotensin-converting enzyme (ACE) inhibitors effectively reduce urinary albumin excretion (UAE), in the present study we have investigated the potential association of plasma MMP-9 levels with UAE and treatment effects of ACE-inhibition. MATERIAL AND METHODS: In a placebo-controlled randomised trial we determined plasma MMP-9 levels at baseline and after three months of randomisation to either placebo (n=202) or fosinopril (20 mg/day, n=204) treatment. RESULTS: Baseline plasma MMP-9 levels were not related to baseline UAE (r=-0.008, p=0.871). Three months of fosinopril treatment effectively reduced UAE compared to placebo treatment (-10.4+/-2.4 vs. 1.8+/-1.3 mg/24 hours, p<0.001, respectively). However, fosinopril treatment failed to significantly change plasma MMP-9 levels compared to placebo (-0.47+/-7.68 vs. 0.06+/-9.20, p=0.646, respectively). In addition, the change in UAE was not related with change in MMP-9 levels. CONCLUSION: The effective reduction of UAE with fosinopril was not related to plasma MMP-9 levels.
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Albuminúria/sangue , Albuminúria/tratamento farmacológico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Diabetes Mellitus/sangue , Fosinopril/uso terapêutico , Metaloproteinase 9 da Matriz/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , PlacebosRESUMO
There is evidence that coronary collaterals improve the prognosis in patients with acute myocardial infarction (MI). However, there is limited clinical information on the protective role of collaterals in patients with stable coronary artery disease. This information may help risk stratification and the development of novel therapies, such as arteriogenesis and angiogenesis. The relation between collaterals and cardiac death or MI at 1 year after coronary revascularization was studied in 561 patients who were enrolled in a randomized study that compared stent implantation with bypass grafting. Collaterals were assessed on an angiogram using Rentrop's classification and considered present with a Rentrop grade >1. Unadjusted and adjusted odds ratios for cardiac death or MI at 1 year were calculated using univariate and multivariate regression analyses. In addition, determinants of collaterals were assessed using univariate and multivariate analyses. Collaterals were present in 176 patients (31%). The adjusted odds ratio of cardiac death or infarction was 0.18 (95% confidence interval 0.04 to 0.78) in the presence of collaterals. Independent determinants of collaterals were age (odds ratio 0.97, 95% confidence interval 0.95 to 0.99), multivessel disease (odds ratio 1.60, 95% confidence interval 1.02 to 2.51), impaired ventricular function (odds ratio 1.85, 95% confidence interval 1.04 to 3.29), type C lesion (odds ratio 3.72, 95% confidence interval 2.33 to 5.95), and stenosis severity >90% (odds ratio 9.08, 95% confidence interval 4.65 to 17.73). In conclusion, in patients with a low risk profile, the presence of collaterals protects against cardiac death and MI at 1 year after coronary revascularization. Variables that reflect the duration and severity of the atherosclerotic and ischemic burden determine their presence.
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Circulação Colateral , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Circulação Coronária , Morte Súbita Cardíaca/prevenção & controle , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/prevenção & controle , Prognóstico , StentsRESUMO
UNLABELLED: OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm. METHODS: Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site. RESULTS: From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up. CONCLUSIONS: The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.
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Falso Aneurisma/tratamento farmacológico , Falso Aneurisma/metabolismo , Colágeno/uso terapêutico , Artéria Femoral/química , Artéria Femoral/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Feminino , Seguimentos , Humanos , Doença Iatrogênica , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Países Baixos , Resultado do TratamentoRESUMO
INTRODUCTION: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal-dominant vascular dysplasia with a high prevalence of pulmonary arteriovenous malformation (PAVM). Recent studies report an increased prevalence of migraine in patients with a cardiac right-to-left shunt. The aim of our study was to evaluate whether there is also an increased prevalence of migraine in patients with a pulmonary right-to-left shunt (PAVM). METHODS: All patients with HHT referred to our hospital till April 2004 with or without PAVM and with or without migraine were included in the study. RESULTS: In total, 538 HHT patients (41.6% men; mean age +/- SD, 39.3 +/- 18.6 years) could be included. PAVM was present in 208 patients (38.7%; mean age, 39.3 +/- 17.6 years). Significantly more women were present in the PAVM subgroup compared to the non-PAVM subgroup, 65.4% vs 53.9% (p = 0.009). Migraine occurred in 88 patients with HHT, a prevalence of 16.4%. The prevalence of migraine in women with HHT was significantly higher compared to men, 19.4% vs 12.1%, respectively (p = 0.03) The prevalence of migraine in patients with PAVM was 21.2%, which was significantly higher then in patients without PAVM, 13.3% (p = 0.02). The occurrence of PAVM in the patients with migraine is significantly higher than in those without migraine, 50.0% vs 36.4%, respectively (p = 0.02). CONCLUSION: This study showed a higher prevalence of PAVM in patients with migraine and HHT. The right-to-left shunt due to the PAVM might play a causal role in the pathogenesis of migraine in patients with HHT. This needs to be determined in further studies.
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Derivação Arteriovenosa Cirúrgica , Transtornos de Enxaqueca/epidemiologia , Artéria Pulmonar/cirurgia , Veias Pulmonares/cirurgia , Telangiectasia Hemorrágica Hereditária/cirurgia , Adulto , Malformações Arteriovenosas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/fisiopatologia , Prevalência , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Telangiectasia Hemorrágica Hereditária/classificação , Telangiectasia Hemorrágica Hereditária/complicaçõesRESUMO
OBJECTIVE: Registry to report our single-centre experience in closing defects of the atrial septum. METHODS: Between 1996 and 2001, transcatheter device closure of significant atrial septal defects was performed in 32 adults (mean age 45.1 years, range from 15 to 76 years), using different device types. Six patients had a patent foramen ovale (PFO) and 26 patients had a secundum atrial septal defect (ASD II). Defects were selected by means of two-dimensional transoesophageal echocardiography (2D TOE). For 12 defects additional three-dimensional transoesophageal echocardiography (3D TOE) was performed. RESULTS: Mean balloon-stretched diameter was 19.3 mm (range from 11 to 24 mm). A device was successfully placed in all PFO patients (100%) without complications at follow-up. Successful immediate device placement occurred in 24 out of 26 ASD patients. Two immediate placement failures, 1 device embolisation and 1 device non-fixation, occurred and required urgent surgery. There was 1 patient with pericardial effusion after the intervention, requiring pericardiocentesis. Three late placement failures occurred: 2 device embolisations and 1 device dislocation. Clinical success after 3 to 6 months follow-up, defined as the absence of shunt or small shunt, was achieved in all 6 PFO patients and in 21 out of 23 ASD patients (1 device embolisation, requiring surgery, occurred before follow-up was completed). Two patients with significant shunt, 1 late device dislocation and 1 late device embolisation, underwent elective surgery. For patient selection, 3D TOE proved useful in the evaluation of large and/or complex defects. CONCLUSION: Transcatheter device closure of carefully selected atrial septal defects is an alternative to surgery. Although the results are promising, surgical back-up is often needed.
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Cateterismo Cardíaco , Comunicação Interatrial/terapia , Próteses e Implantes , Adolescente , Adulto , Idoso , Ecocardiografia Tridimensional , Feminino , Comunicação Interatrial/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: In this study we evaluate the value of baseline concentrations of acute-phase reactants on prognosis after percutaneous coronary intervention (PCI). METHODS: Blood samples were drawn immediately before PCI to measure baseline concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), lipoprotein(a) (Lp(a)), and fibrinogen. Follow-up data were collected at 8 months. Repeat PCI, CABG, myocardial infarction, and death were recorded as major adverse clinical events (MACE). Furthermore the recurrence of angina pectoris was noted. RESULTS: The study included 600 consecutive patients after a successful PCI. Sixty-four percent of the patients were stented. The mean age was 61.6 years and 68.9% were male. CRP levels were significantly higher in patients who were to have repeat angina as compared with those who were not (P=0.0322). IL-6 levels were not correlated with angina or MACE. Lp(a) and fibrinogen concentrations were both significantly related to MACE (P=0.0337 and P=0.0253, respectively). CONCLUSION: Our study clearly supports the role of inflammation in restenosis after PCI as measured in statistically higher levels of Lp(a) and fibrinogen in patients with MACE and CRP in patients with repeat angina.
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Proteínas de Fase Aguda/análise , Angioplastia Coronária com Balão , Doença das Coronárias/sangue , Doença das Coronárias/terapia , Idoso , Biomarcadores/sangue , Proteína C-Reativa/análise , Doença das Coronárias/mortalidade , Feminino , Fibrinogênio/análise , Seguimentos , Humanos , Interleucina-6/sangue , Lipoproteína(a)/sangue , Masculino , Pessoa de Meia-Idade , Prognóstico , Recidiva , Stents , Taxa de SobrevidaRESUMO
BACKGROUND: Differences in the indication and outcome of balloon angioplasty for coarctation in children and adults have not been elucidated sufficiently. The results of balloon angioplasty for coarctation are compared between pediatric and adult age groups. METHODS: Balloon angioplasty for coarctation of the aorta was performed in 85 patients who were classified according to age and native coarctation/recoarctation. Groups A (patients aged <16 years, n = 32) and B (patients aged > or =16 years, n = 17) included patients with native coarctations. Groups rCoA A (patients aged <16 years, n = 33) and rCoA B (patients aged > or =16 years, n = 3) included patients with recoarctations. Follow-up included 2-dimensional Doppler scanning echocardiography and additional angiography or magnetic resonance imaging. Gradient reductions in groups were compared by use of the independent-samples t test. Kaplan-Meier and log-rank analyses were performed as a means of comparing long-term outcome. RESULTS: No mortality occurred. Immediate success was equal in groups A, B, and rCoA A (94%). Dilatation was unsuccessful in 2 patients in group rCoA B. Pressure gradients decreased 23 mm Hg in group A, 31 mm Hg in group B, 18 mm Hg in group rCoA A, and 11 mm Hg in group rCoA B. Pressure gradient drops, compared between groups A and B, showed a significant difference (P <.001). The length of hospital stay ranged from 12 to 48 hours. The period of follow-up ranged from 6 months to 12 years (mean, 4.9 years). Kaplan-Meier curves of groups A and B are not different, as determined by means of log-rank analysis. No aneurysm formation was encountered. CONCLUSIONS: The results of balloon angioplasty for native coarctation in both selected children and adults are excellent. In recoarctation, we recommend balloon angioplasty in the pediatric patients.
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Angioplastia com Balão , Coartação Aórtica/terapia , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do TratamentoRESUMO
BACKGROUND: The aim of our study was to investigate the influence of prior cytomegalovirus (CMV) or Chlamydia pneumoniae (CP) infection on prognosis after percutaneous coronary intervention (PCI). METHODS: Using the enzyme-linked immunosorbent assay technique preprocedural anti-CMV immunoglobulin G and anti-CP immunoglobulin A (CP IgA), immunoglobulin M, and immunoglobulin G antibodies were measured. Repeat anginal complaints and major adverse clinical events (MACE), including PCI, coronary artery bypass grafting, myocardial infarction, and death, were recorded at 8-month follow-up. RESULTS: Six hundred consecutive patients were included after successful PCI. Sixty-four percent of the patients were stented. The mean age was 61.6 years, and 68.9% were male. The rate of seropositivity for CP IgA in patients with MACE as compared with patients without MACE was 50.9% versus 35.4% (P =.0276). In patients with repeat anginal complaints, CP IgA seropositivity was 41.6% versus 34.6% in patients without repeat angina (P =.1057). The negative effect of CP on prognosis was confirmed after calculating the odds ratios for MACE (1.9, 95% CI 1.1-3.3). The rates of seropositivity for anti-CMV immunoglobulin G were not significantly different between both groups, although we found an association between infectious burden and repeat angina pectoris (odds ratio 1.8, 95% CI 1.1-3.0). CONCLUSIONS: We conclude that preprocedural seropositivity of CP IgA is a risk factor for MACE and angina pectoris after PCI. Although no such relation was found for CMV alone, the cumulative infectious burden was also related to these clinical manifestations of restenosis.
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Angioplastia Coronária com Balão , Infecções por Chlamydophila/complicações , Chlamydophila pneumoniae , Doença das Coronárias/terapia , Reestenose Coronária/etiologia , Infecções por Citomegalovirus/complicações , Angina Pectoris/etiologia , Chlamydophila pneumoniae/isolamento & purificação , Ponte de Artéria Coronária , Doença das Coronárias/complicações , Citomegalovirus/isolamento & purificação , Intervalo Livre de Doença , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Prognóstico , RecidivaRESUMO
BACKGROUND: To improve patients' quality of life (QoL) we need to identify modifiable determinants, such as illness perceptions. Patients' illness perceptions are known to regulate emotional responses and health-behaviour. Illness perceptions comprise several components: consequences, control, coherence, changeability and emotional representations. AIMS: To examine (a) the relation between patient characteristics and illness perceptions, and (b) the independent predictive value of illness perceptions for future QoL. METHODS: A longitudinal study in 845 patients with congenital heart disease was conducted. Patients completed three questionnaires: the IPQ-R (illness perceptions) and two years later the SF-36 and TAAQOL-CHD (QoL). Linear regression analyses were performed relating illness perceptions to patient characteristics (sex, age, disease complexity and functional status) and QoL. RESULTS: Patients with a complex defect or poor functional status reported poor illness perceptions. Independent of patient characteristics, poor illness perceptions (i.e. a strong belief that the illness has severe consequences; a weak belief that you have a coherent illness understanding and that the illness can be controlled by treatment; and a strong belief that the illness is changeable and causes negative emotions) were predictive of future QoL. CONCLUSION: Illness perceptions independently predict QoL, suggesting that QoL may be improved by altering patients' beliefs about their illness. For example, increasing patients' knowledge regarding their disease and informing them about treatment opportunities may enhance their QoL.
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Atitude Frente a Saúde , Conhecimentos, Atitudes e Prática em Saúde , Cardiopatias Congênitas/psicologia , Qualidade de Vida , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Emoções , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Negativismo , Percepção , Valor Preditivo dos Testes , Inquéritos e Questionários , Adulto JovemRESUMO
OBJECTIVE: A first step in the delivery of tailored care is answering the following question: does health care meet the needs of patients? Therefore patients' perspective on health care use and their needs was examined. The design used was cross-sectional questionnaire study. PATIENTS: A total of 1109 adult congenital heart defect (CHD) patients attending one of eight Dutch hospitals were randomly selected from a national database (10% of all registered patients). MAIN OUTCOME MEASURES: Patient reported questionnaires on in- and outpatient health care use during the past year and need for additional care. RESULTS: A total of 66% and 40% of patients had contact with their cardiologist and general practitioner, respectively. Six to 10 percent were hospitalized, operated upon, or visited the emergency room. For the majority, the amount of contact was sufficient. Most patients indicated that the communication skills and expertise of the cardiologist and general practitioner were sufficient, and health care improvements were not necessary. Frequent health care users had a poor functional status and frequent contact with their cardiologist and general practitioner. Patients who want more contact with their cardiologist rated the communication skills of the cardiologist as insufficient. CONCLUSIONS: For most patients, the amount and quality of care are both sufficient. Patients who rate the communication skills of the cardiologist as insufficient have need more contact. In addition to the recommended training program as described in the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines, we recommend the incorporation of communication training. This is the first study to provide insight into health care use and needs of CHD patients in countries with a compulsory health insurance system from the patient perspective.