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BACKGROUND: Guidelines for patients with ST-elevation myocardial infarction include a door-to-balloon time (DTBT) of ≤90 min for primary percutaneous coronary intervention. AIM: The aim of this study was to assess temporal trends (2006-2010) in DTBT and determine if a reduction in DTBT was associated with improved clinical outcomes. METHODS: We compared annual median DTBT in 1926 STEMI patients undergoing primary percutaneous coronary intervention from the Melbourne Interventional Group registry. ST-elevation myocardial infarction presenting >12 h and rescue percutaneous coronary intervention was excluded. Major adverse cardiac events were analysed according to DTBT (dichotomised as ≤90 min vs >90 min). A multivariable analysis for predictors of mortality (including DTBT) was performed. RESULTS: Baseline demographics, clinical and procedural characteristics were similar in the STEMI cohort across the 5 years, apart from an increase in out-of-hospital cardiac arrest (3.6% in 2006 vs 9.4% in 2010, P < 0.0001) and cardiogenic shock (7.7-9.6%, P = 0.07). The median DTBT (interquartile range) was reduced from 95 (74-130) min in 2006 to 75 (51-100) min in 2010 (P < 0.01). In this period, the proportion of patients achieving a DTBT of ≤90 min increased from 45% to 67% (P < 0.01). Lower mortality and major adverse cardiac event rates were observed with DTBT ≤90 min (all P < 0.01). Multivariable analysis showed that a DTBT of ≤90 min was associated with improved clinical outcomes at 12 months (odds ratio 0.48; 95% confidence interval 0.33-0.73, P < 0.01). CONCLUSION: There has been a decline in median DTBT in the Melbourne Interventional Group registry over 5 years. DTBT of ≤90 min is associated with improved clinical outcomes at 12 months.
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Angioplastia Coronaria con Balón/tendencias , Infarto del Miocardio/terapia , Anciano , Terapia Combinada , Comorbilidad , Trombosis Coronaria/mortalidad , Trombosis Coronaria/cirugía , Trombosis Coronaria/terapia , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Sistema de Registros , Terapia Recuperativa , Stents/estadística & datos numéricos , Análisis de Supervivencia , Centros de Atención Terciaria/estadística & datos numéricos , Trombectomía , Factores de Tiempo , Resultado del Tratamiento , Victoria/epidemiologíaRESUMEN
BACKGROUND: Stroke neurologists, vascular surgeons, interventional neuroradiologists and interventional cardiologists have embraced carotid angioplasty and stenting (CAS) because of potential advantages over carotid endarterectomy (CEA). At Austin Health, a multidisciplinary neuro-interventional group was formed to standardise indications and facilitate training. The aims of this study were to describe our organisational model and to determine whether 30-day complications and early outcomes were similar to those of major trials. METHODS: A clinical protocol was developed to ensure optimal management. CAS was performed on patients with high medical risk for CEA, with technically difficult anatomy for CEA, or who were randomised to CAS in a trial. RESULTS: From October 2003 to May 2008, 47 patients (34 male, mean age 71.5) underwent CAS of 50 carotid arteries. Forty-three cases had ipsilateral carotid territory symptoms within the previous 12 months. The main indications for CAS were high risk for CEA (n= 17) and randomised to CAS (n= 21). Interventionists were proctored in 27 cases. The procedural success rate was 94% with two cases abandoned because of anatomical problems and one because of on-table angina. Hypotension requiring vasopressor therapy occurred in 12 cases (24%). The duration of follow up was one to 44 months (mean 6.8 months). The 30-day rate of peri-procedural stroke or death was 6% and the one-year rate of peri-procedural stroke or death or subsequent ipsilateral stroke was 10.6%. Restenosis occurred in 13% (all asymptomatic). CONCLUSION: A multidisciplinary approach is a useful strategy for initiating and sustaining a CAS programme.
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Angioplastia de Balón/métodos , Estenosis Carotídea/terapia , Protocolos Clínicos , Grupo de Atención al Paciente/organización & administración , Stents , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/patología , Endarterectomía Carotidea/métodos , Femenino , Humanos , Comunicación Interdisciplinaria , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de RegistrosRESUMEN
Although post-mortem studies would suggest that cardiac metastases occur frequently, many of these metastases remain clinically silent. However, symptomatic lesions may also remain unrecognized due to overshadowing by other symptoms of the primary malignancy. Patients undergoing treatment for cancer are not routinely screened using echocardiography, unless their chemotherapeutic regimen includes cardiotoxic agents. The current era of research and development of targeted biological agents (such as trastuzumab and epidermal growth factor receptor inhibitors) for cancer may lead to prolonged survival of oncology patients. In future, metastases that were once rare may become increasingly recognized as these new treatments augment the natural history of the disease. There have been several case reports of small, asymptomatic left ventricular metastases, but clinically significant ventricular metastases are very rare. There are no reports in the current literature of a symptomatic ventricular metastasis, occurring in the absence of other metastatic disease. We report an unusual case of a large solitary ventricular metastasis, leading to left ventricular outflow tract obstruction and haemodynamic compromise. Echocardiographic imaging led to the diagnosis of a recurrence of soft-tissue fibrosarcoma 9 years after original resection.
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Fibrosarcoma/secundario , Neoplasias Cardíacas/secundario , Neoplasias de los Tejidos Blandos/secundario , Anciano , Disnea/etiología , Ecocardiografía , Resultado Fatal , Fibrosarcoma/cirugía , Neoplasias Cardíacas/diagnóstico por imagen , Neoplasias Cardíacas/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/patología , Humanos , Masculino , Neoplasias de los Tejidos Blandos/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/cirugía , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiologíaRESUMEN
Carrier wave shocking is studied using the pseudospectral spatial-domain (PSSD) technique. We describe the shock detection diagnostics necessary for this numerical study and verify them against theoretical shocking predictions for the dispersionless case. These predictions show a carrier envelope phase and pulse bandwidth sensitivity in the single-cycle regime. The flexible dispersion management offered by the PSSD enables us to independently control the linear and nonlinear dispersion. Customized dispersion profiles allow us to analyze the development of both carrier self-steepening and shocks. The results exhibit a marked asymmetry between normal and anomalous dispersion, both in the limits of the shocking regime and in the (near) shocked pulse wave forms. Combining these insights, we offer some suggestions on how carrier shocking (or at least extreme self-steepening) might be realized experimentally.
RESUMEN
BACKGROUND: The distal-balloon protection system is being evaluated for its efficacy in preventing embolic neurological events during carotid stenting (CAS). We sought to determine the effect of this system on the frequency of Doppler-detected microembolic signals (MES) during CAS. METHODS AND RESULTS: Using transcranial Doppler, we compared the frequency of MES during CAS in 2 groups: 39 patients without distal protection and 37 who used the distal-balloon protection system (GuardWire). There were no significant differences in the clinical or angiographic characteristics between the 2 groups. Three phases with increased MES counts were identified during unprotected CAS; these were stent deployment, predilation, and postdilation (75+/-57, 32+/-36, and 27+/-25 METS, respectively). The distal-balloon protection significantly reduced the frequency of MES during CAS (MES counts: 164+/-108 in the control versus 68+/-83 in the protection group; P=0.002), particularly during these 3 phases. MES in the protection group were detected predominantly during sheath placement, guidewire manipulation, and distal-balloon deflation. CONCLUSION: Three phases with increased MES counts were identified during unprotected CAS (eg, stent deployment, predilation, and postdilation). The distal-balloon protection system significantly reduced the frequency of MES during CAS, particularly during these 3 phases.
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Implantación de Prótesis Vascular/métodos , Enfermedades de las Arterias Carótidas/cirugía , Cateterismo/métodos , Embolia Intracraneal/prevención & control , Stents , Anciano , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Cateterismo/efectos adversos , Cateterismo/instrumentación , Femenino , Humanos , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiología , Periodo Intraoperatorio , Masculino , Estudios Prospectivos , Stents/efectos adversos , Hemorragia Subaracnoidea/etiología , Tasa de Supervivencia , Resultado del Tratamiento , Ultrasonografía Doppler TranscranealRESUMEN
BACKGROUND: Carotid stenting is a less invasive percutaneous procedure than carotid endarterectomy for the treatment of carotid stenosis. Reports suggest that it can be performed with periprocedural complication rates similar to those of carotid endarterectomy. The purpose of this study was to determine short- and long-term outcomes in the largest prospective cohort of carotid stenting patients. METHODS AND RESULTS: This study followed 528 consecutive patients (604 hemispheres/arteries) undergoing carotid stenting. There was a 0.6% (n=3) fatal stroke rate and 1% (n=5) nonstroke death rate at 30 days. The major stroke rate was 1% (n=6), and the minor stroke rate was 4.8% (n=29). The overall 30-day stroke and death rate was 7.4% (n=43). Over the 5-year study period, the 30-day minor stroke rate improved from 7.1% (n=7) for the first year to 3.1% (n=5) for the fifth year (P:<0.05 for trend). The best predictor of 30-day stroke and death was age >/=80 years. After the 30-day period, the incidence of fatal and nonfatal stroke was 3.2% (n=31). On Kaplan-Meier analysis, the 3-year freedom from ipsilateral or fatal stroke was 92+/-1%. CONCLUSIONS: Experience from a single group of operators demonstrates that carotid stenting can be performed with an acceptable 30-day complication rate. Late follow-up also demonstrates a low rate of fatal and nonfatal stroke. These results suggest that carotid stenting may be comparable to carotid endarterectomy, and it underscores the clinical equipoise and premise for the National Institute of Health-supported, randomized Carotid Revascularization Endarterectomy Versus Stent Trial comparing carotid stenting with carotid endarterectomy.
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Arterias Carótidas/cirugía , Estenosis Carotídea/cirugía , Stents , Factores de Edad , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/mortalidad , Estenosis Carotídea/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Accidente Cerebrovascular/etiología , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: This study sought to examine the effects of long-term estrogen therapy on vascular function in male to female transsexuals and to compare the findings with those observed in men and premenopausal women. BACKGROUND: Gender differences in coronary artery disease have largely been attributed to the beneficial effects of estrogen on vascular function and plasma lipids in women. However, the effects of estrogen on the male vasculature have not been widely studied. METHODS: We compared the effects of estrogen on vascular function in 14 male to female transsexuals, 14 age-matched men and 15 premenopausal women. Flow-mediated vasodilation and response to nitroglycerin were assessed in the brachial artery using noninvasive ultrasound. RESULTS: Flow-mediated vasodilation was similar in transsexuals and women but greater than that in men ([mean +/- SE] 11.5 +/- 1.3% and 9.4 +/- 1.1% vs. 5.2 +/- 1.0% respectively, p < 0.005). Responses to nitroglycerin were also greater in transsexuals and women than in men (21.6 +/- 1.7% and 21.0 +/- 0.9% vs. 14.5 +/- 1.2%, respectively, p = 0.0005). These differences persisted even after adjusting for vessel size. Despite similar total cholesterol levels, transsexuals had high density lipoprotein cholesterol levels similar to those in women and greater than those observed in men (1.76 +/- 0.12 and 1.82 +/- 0.11 mmol/liter vs. 1.35 +/- 0.07 mmol/liter, respectively, p < 0.005). Moreover, triglyceride levels were greater in transsexuals than in men and women, and low density lipoprotein cholesterol (LDL-C) particle size was smaller (25.7 +/- 0.2 nm vs. 26.2 +/- 0.1 and 26.6 +/- 0.1 nm, respectively, p = 0.0001). Serum testosterone (an index of estrogen therapy in transsexuals) was markedly suppressed in transsexuals and similar to that in women. Univariate analysis revealed that there was a strong inverse correlation between serum testosterone and flow-mediated vasodilation (r(s) = -0.48, p < 0.005). Multivariate analysis revealed that the best combination of predictors of flow-mediated vasodilation was serum testosterone, vessel size and LDL-C (R2 = 0.3, p < 0.005). CONCLUSIONS: Long-term estrogen therapy appears to improve vascular function in male to female transsexuals and occurs despite higher triglyceride levels and the presence of small, dense LDL-C. The beneficial effects of estrogen are not gender specific or solely mediated through endothelium-derived nitric oxide.
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Vasos Sanguíneos/efectos de los fármacos , Congéneres del Estradiol/farmacología , Transexualidad , Vasodilatación/efectos de los fármacos , Adulto , Vasos Sanguíneos/fisiología , LDL-Colesterol/sangre , Estudios Transversales , Congéneres del Estradiol/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Testosterona/sangre , Triglicéridos/sangreRESUMEN
OBJECTIVE: Hypercholesterolemia has been shown to impair endothelium-mediated, nitric oxide (NO)-dependent responses to acetylcholine (ACh), serotonin, substance P and flow-mediated dilation. We have recently shown that NO contributes to metabolic vasodilation in the human forearm. We sought to determine whether metabolic vasodilation is impaired in healthy subjects with hypercholesterolemia. METHODS: We compared the forearm blood flow (FBF) responses to isotonic exercise, ACh and the endothelium-independent vasodilator sodium nitroprusside in young, otherwise healthy volunteers with hypercholesterolemia and controls before and after the NO inhibitor NG-monomethyl-L-arginine (L-NMMA). FBF was measured using venous occlusion plethysmography. Hypercholesterolemic (n = 20) and control (n = 20) subjects were age- and gender-matched. RESULTS: Total cholesterol (6.9 +/- 0.3 vs. 4.6 +/- 0.1 mmol/l, P < 0.0001), low density lipoprotein (4.9 +/- 0.4 vs. 2.7 +/- 0.1 mmol/l, P < 0.001) and triglyceride (1.3 +/- 0.2 vs. 0.8 +/- 0.1 mmol/l, P = 0.005) levels were higher in the hypercholesterolemic group. Basal FBF and resistance were similar in the two groups. Hypercholesterolemia impaired the peak FBF response to ACh (11.1 +/- 1.9 vs. 17.6 +/- 2.2 ml/100 ml/min, P = 0.03), and reduced the peak response to sodium nitroprusside (6.0 +/- 0.4 vs. 8.1 +/- 0.6 ml/100 ml/min, P < 0.01). However, hypercholesterolemia did not affect peak hyperemic FBF (13.1 +/- 1.0 vs. 13.2 +/- 1.0 ml/100 ml/min, P = 1.0) or the FBF volume repayment during the 1 or 5 min after exercise. Resting FBF was reduced by L-NMMA to a similar degree (by 33% vs. 40%, P = 0.17) in both groups. Although L-NMMA reduced peak hyperemic FBF (by 16% vs. 17%, P = 0.93) and the volume repaid after exercise in both groups, there were no differences between the two groups. CONCLUSIONS: Exercise-induced metabolic vasodilation is in part dependent on NO release. Hypercholesterolemia impairs NO-mediated vasodilation, but is not associated with a reduction in exercise-induced hyperemia. This may indicate that multiple compensatory mechanisms are operative in skeletal muscle metabolic vasodilation.
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Endotelio Vascular/metabolismo , Antebrazo/irrigación sanguínea , Hipercolesterolemia/metabolismo , Hipercolesterolemia/fisiopatología , Óxido Nítrico/metabolismo , Acetilcolina , Adulto , Estudios de Casos y Controles , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/fisiopatología , Inhibidores Enzimáticos , Ejercicio Físico , Femenino , Humanos , Masculino , Óxido Nítrico Sintasa/antagonistas & inhibidores , Nitroprusiato , Pletismografía , Flujo Sanguíneo Regional/efectos de los fármacos , Vasodilatadores , omega-N-MetilargininaRESUMEN
BACKGROUND AND PURPOSE: Ambulatory procedures increase patient comfort and enhance cost-effectiveness. We sought to determine the feasibility and safety of ambulatory carotid stenting. METHODS: A selected group of patients was admitted and discharged the same day after the carotid stenting procedure. Immediate and short-term outcomes are reported. RESULTS: A total of 98 ambulatory carotid stenting procedures (98 hemispheres in 92 patients) were performed. There were 66 men (72%), and the mean age was 70+/-9 years. Of the patients, 28% had neurological symptoms related to the treated artery within 3 months before the procedure. Sixteen percent of the patients had prior carotid endarterectomy, 4% had prior ipsilateral neck radiation, and 8% had complete occlusion of the contralateral internal carotid artery. Successful access site hemostasis was ensured in all patients with suture-mediated vascular closure devices in 96 (98%) and manual compression in 2. Clinical follow-up was available for 96% of the patients at a mean time of 6+/-4 months. There were no neurological events, deaths, repeated procedures, or major access site complications. CONCLUSIONS: Ambulatory carotid stenting is both safe and feasible. This approach will enhance the applicability of the procedure by increasing patient comfort and potentially reducing procedural costs.
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Instituciones de Atención Ambulatoria , Procedimientos Quirúrgicos Ambulatorios , Implantación de Prótesis Vascular , Enfermedades de las Arterias Carótidas/cirugía , Stents , Anciano , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Hemostasis Quirúrgica , Humanos , Masculino , Selección de Paciente , Stents/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND AND PURPOSE: Carotid endarterectomy (CEA) is one of the most frequently performed operations in the United States. To offer patients a less invasive means to achieve the same goal, carotid artery stenting (CAS) is investigated as an alternative treatment to CEA. METHODS: Three hundred ninety patients underwent CAS, with 451 vessels treated. CAS was performed using a coaxial system with a 7F 90-cm sheath for predilation, stent placement, and stent dilation. Pretreatment antiplatelet therapy was administered. We currently practice same-day admissions and 23-hour discharges. RESULTS: The technical success rate was 98%. The 30-day mortality/morbidity rates were as follows: death, 1.7% (two [0.5%] neurologic and five [1.2%] systemic] major strokes, 0.9% (two of four were related to the intervention); minor strokes, 5.5%. Among 25 patients who suffered minor strokes, 14 achieved complete recovery. On an annual basis, the incidence of minor stroke declined from 6.8% (1994-1995), to 5.8% (1995-1996), 5.3% (1996-1997), and then 4% (1997-1998), with no major strokes or neurologic deaths occurring during the 1997 to 1998 period. CONCLUSION: CAS is an effective treatment for carotid stenosis. With proper selection of patients and meticulous technique, complication rates compare favorably with those of CEA.
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Arterias Carótidas , Estenosis Carotídea/terapia , Stents , Adulto , Anciano , Anciano de 80 o más Años , Arterias Carótidas/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía Intervencional , Stents/efectos adversosRESUMEN
BACKGROUND: Studies have shown that chronic oestrogen treatment improves both lipid profile and vascular reactivity in postmenopausal women, in whom it also appears to have a beneficial effect on vascular haemodynamics and compliance. Whether oestrogen has a similar effect in men is unknown. OBJECTIVE: To determine whether long-term oestrogen treatment alters arterial compliance and haemodynamics in biological males. METHODS: We compared the effects of chronic oestrogen treatment on blood pressure, heart rate and arterial compliance in 21 male-to-female transsexuals prescribed long-term oestrogen treatment with those in 20 age-matched healthy males. Systemic arterial compliance was assessed using the 'area method', by the simultaneous measurement of aortic flow and driving pressure. RESULTS: Mean systemic arterial compliance was similar in transsexuals and age-matched males (mean +/- SE 0.66 +/- 0.06 ml/mmHg compared with 0.58 +/- 0.05 ml/mmHg, P = 0.34). These results did not differ after the exclusion of transsexuals with coronary risk factors or vascular disease. Heart rate (67 +/- 2 beats/min compared with 64 +/- 3 beats/min, P = 0.41), systolic blood pressure (119 +/- 3 mmHg compared with 119 +/- 2 mmHg, P = 0.95), pulse pressure (55 +/- 3 mmHg compared with 50 +/- 2 mmHg, P = 0.13), diastolic blood pressure (64 +/- 2 mmHg compared with 69 +/- 2 mmHg, P = 0.06) and mean arterial pressure (84 +/- 2 mmHg compared with 89 +/- 2 mmHg, P = 0.09) were also similar at baseline between the two groups. Serum testosterone (an index of oestrogen treatment) was markedly suppressed in the transsexuals compared with the males (0.8 +/- 0.5 nmol/l compared with 25.3 +/- 12.6 nmol/l, P < 0.0001). Univariate analysis revealed that the best predictors of arterial compliance were the pulse pressure (rs = -0.41, P = 0.02) and the systolic blood pressure (rs = -0.35, P = 0.02). On multivariate analysis, the best combination of predictors of compliance were the pulse pressure, testosterone and low-density lipoprotein cholesterol concentrations (R2 = 0.29, P = 0.01). CONCLUSIONS: Although previous evidence suggests chronic oestrogen treatment can improve endothelium-dependent vasodilatation and favourably alter the lipid profile in biological males, these changes are not reflected in changes in systemic arterial compliance. Changes in arterial compliance may not be central to the beneficial effects of oestrogen on vascular function, at least in males.
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Arterias/efectos de los fármacos , Estrógenos/farmacología , Hemodinámica/efectos de los fármacos , Adulto , Arterias/fisiología , Estrógenos/uso terapéutico , Humanos , Lípidos/sangre , Masculino , Valor Predictivo de las Pruebas , Análisis de Regresión , Factores de Tiempo , Transexualidad , Vasodilatación/efectos de los fármacosRESUMEN
The technique of carotid stenting has undergone significant refinement since its introduction and continues to improve as experience with the procedure matures and more suitable equipment becomes available. Improved stent designs and the utilization of cerebral protection devices are expected to significantly impact on the technique, its ultimate outcomes, and widespread application. In using the currently available technology for carotid stenting, patient selection and meticulous attention to procedural details are very important in minimizing embolic events. In this article, we provide a comprehensive practical discussion of the state-of-the-art carotid stenting techniques that have allowed us to maintain low event rates.
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Arterias Carótidas/cirugía , Stents , Diseño de Equipo , Humanos , Selección de Paciente , Cuidados Preoperatorios , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
Recurrent stenosis post-carotid endarterectomy (CEA) is not a solitary or unusual phenomenon. Compared to the initial CEA, the reoperation is often more technically challenging and frequently results in local and neurological complications. Carotid artery angioplasty with stenting (CAS) is currently being investigated as an alternative to carotid endarterectomy. In our study, ninety-nine patients underwent CAS in 110 arteries. Procedural success was 99% (109/110). Our results show that CAS treatment in post-CEA restenosis, especially with improved technique and distal protection, is safe with a low neurological complication rate, without any "local" complications and without any cranial nerve palsies. This study suggests that the future primary mode of treatment of post-CEA restenosis might be carotid stenting rather than surgery.
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Angioplastia de Balón , Estenosis Carotídea/terapia , Endarterectomía Carotidea , Stents , Anciano , Estenosis Carotídea/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
Carotid stenting is a percutaneous, minimally invasive treatment for carotid stenosis. It does not carry the surgical risks of carotid endarterectomy and therefore can be applied to the elderly and to patients with comorbidities. Complications and late events appear low.
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Aterectomía/instrumentación , Aterectomía/mortalidad , Enfermedades de las Arterias Carótidas/terapia , Endarterectomía/mortalidad , Anciano , Aterectomía/métodos , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/mortalidad , Endarterectomía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Sensibilidad y Especificidad , Stents , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Aneurisma de la Aorta/etiología , Disección Aórtica/etiología , Puente de Arteria Coronaria/efectos adversos , Enfermedad Iatrogénica , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular , Femenino , Humanos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: Obstructive coronary artery disease (CAD) is evident in only half of patients referred for diagnostic angiography. Five-minute heart rate variability (HRV) is a non-invasive marker for autonomic control of the vasculature, which this study hypothesised could risk-stratify cardiac patients and reduce unnecessary angiograms. DESIGN: A prospective observational study (the Alternative Risk Markers in Coronary Artery Disease (ARM-CAD) study). SETTING: Three cardiac centres in Melbourne, Australia. PATIENTS: 470 consecutive patients undergoing elective angiography (with predominantly normal cardiac rhythm), regardless of co-morbidity. MAIN OUTCOME MEASURES: The presence of obstructive CAD (≥50% stenosis) on angiography. RESULTS: Patients with obstructive CAD had significantly reduced HRV, particularly in the low frequency (LF) range (median 180 vs 267 ms(2) without CAD; p<0.001). There was a linear trend with the severity of CAD; median LF power (IQR) in patients with normal coronaries was 275 (612), with minor coronary irregularities 255 (400), single-vessel CAD 212 (396) and more severe disease 170 (327) ms(2); p value for trend 0.003. There was a similar reduction in LF power regardless of the anatomical location of coronary stenoses. Comparing patients with LF less than 250 and 250 ms(2) or greater, the adjusted OR for obstructive CAD using multivariate regression was 2.42, 95% CI 1.33 to 4.38 (p=0.004). No interactions were noted in subgroup analysis and HRV added to risk prediction irrespective of the baseline Framingham risk (p<0.0001). CONCLUSION: Low HRV is strongly predictive of angiographic coronary disease regardless of other co-morbidities and is clinically useful as a risk predictor in patients with sinus rhythm. CLINICAL TRIAL REGISTRATION INFORMATION: http://clinicaltrials.gov/ct2/show/NCT00403351 www.armcad.com.
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Angiografía Coronaria/métodos , Estenosis Coronaria/fisiopatología , Electrocardiografía , Prueba de Esfuerzo/métodos , Frecuencia Cardíaca/fisiología , Medición de Riesgo/métodos , Anciano , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Victoria/epidemiologíaAsunto(s)
Arteria Carótida Interna , Estenosis Carotídea/terapia , Péptidos/administración & dosificación , Inhibidores de Agregación Plaquetaria/administración & dosificación , Stents , Anciano , Angiografía , Estenosis Carotídea/diagnóstico por imagen , Terapia Combinada , Eptifibatida , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Masculino , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
A short-pulse source based on optical parametric chirped-pulse amplification (OPCPA) technology has been developed with properties that make it a suitable seed for a high-energy OPCPA system. This source generated a diffraction-limited pulse at 910 nm with a full bandwidth of > 165 nm and a spectrum having a transform-limited pulse duration of less than 15 fs. The technique has potential for generating bandwidths > 200 nm and pulse durations < 10 fs.