Influence of socioeconomic status on clinical outcomes and quality of life after percutaneous coronary intervention.

OBJECTIVES: To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI). DESIGN: Prospective observational study. SETTING: Two interventional cardiac centres. PARTICIPANTS: 1346 consecutive patients undergoing PCI over a 12-month period. OUTCOMES: Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code. MAIN RESULTS: No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES. CONCLUSIONS: Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.

Differences in myocardial velocity gradient measured throughout the cardiac cycle in patients with hypertrophic cardiomyopathy, athletes and patients with left ventricular hypertrophy due to hypertension.

OBJECTIVES: We sought to compare the myocardial velocity gradient (MVG) measured across the left ventricular (LV) posterior wall during the cardiac cycle between patients with hypertrophic cardiomyopathy (HCM), athletes and patients with LV hypertrophy due to systemic hypertension and to determine whether it might be used to discriminate these groups. BACKGROUND: The MVG is a new ultrasound variable, based on the color Doppler technique, that quantifies the spatial distribution of transmyocardial velocities. METHODS: A cohort of 158 subjects was subdivided by age into two groups: Group I (mean [+/-SD] 30 +/- 7 years) and Group II (58 +/- 8 years). Within each group there were three categories of subjects: Group Ia consisted of patients with HCM (n = 25), Group Ib consisted of athletes (n = 21), and Group Ic consisted of normal subjects; Group IIa consisted of patients with HCM (n = 19), Group IIb consisted of hypertensive patients (n = 27), and Group IIc consisted of normal subjects (n = 33). RESULTS: The MVG (mean [+/-SD] s-1) measured in systole was lower (p < 0.01) in patients with HCM (Group Ia 3.2 +/- 1.1; Group IIa 2.9 +/- 1.2) compared with athletes (Group Ib 4.6 +/- 1.1), hypertensive patients (Group IIb 4.2 +/- 1.8) and normal subjects (Group Ic 4.4 +/- 0.8; Group IIc 4.8 +/- 0.8). In early diastole, the MVG was lower (p < 0.05) in patients with HCM (Group Ia 3.7 +/- 1.5; Group IIa 2.6 +/- 0.9) than in athletes (Group Ib 9.9 +/- 1.9) and normal subjects (Group Ic 9.2 +/- 2.0; Group IIc 3.6 +/- 1.5), but not hypertensive patients (Group IIb 3.3 +/- 1.3). In late diastole, the MVG in patients with HCM (Group Ia 1.3 +/- 0.8; Group IIa 1.4 +/- 0.8) was lower (p < 0.01) than that in hypertensive patients (Group IIb 4.3 +/- 1.7) and normal subjects (Group IIc 3.8 +/- 0.9). An MVG < or = 7 s-1, as a single diagnostic approach, differentiated accurately (0.96 positive and 0.94 negative predictive value) between patients with HCM and athletes when the measurements were taken during early diastole. CONCLUSIONS: In both age groups, the MVG was lower in both systole and diastole in patients with HCM than in athletes, hypertensive patients or normal subjects. The MVG measured in early diastole in a group of subjects 18 to 45 years old would appear to be an accurate variable used to discriminate between HCM and hypertrophy in athletes.

Design of a placebo-controlled clinical trial of long-acting diltiazem and aspirin versus aspirin alone in patients receiving thrombolysis with a first acute myocardial infarction. Incomplete Infarction Trial of European Research Collaborators Evaluating Prognosis Post-Thrombolysis (diltiazem) (INTERCEPT) Research Group.

Several pharmacologic forms of adjunctive therapy, designed to enhance the efficacy of thrombolysis following acute myocardial infarction (AMI), are being explored. However, few studies have assessed the use of standard secondary prevention therapies (beta-blockers, angiotensin-converting enzyme inhibitors, magnesium, calcium antagonists, etc.) for antecedent thrombolysis. Although calcium antagonists have not been shown to alter post-AMI mortality, diltiazem has been shown to reduce recurrent nonfatal infarction and myocardial ischemia following non-Q-wave AMI. Because both non-Q-wave AMI and AMI treated with thrombolytic therapy result in early reperfusion and clinical manifestations of "incomplete infarction" (i.e., aborted transmural infarction), we hypothesize that prophylactic administration of diltiazem to AMI patients who receive thrombolysis before other therapies might decrease ischemic complications. We have initiated a multicenter, randomized, placebo-controlled, double-blind, parallel-group comparison of long-acting diltiazem 300 mg/day and aspirin 160 mg/day versus aspirin 160 mg/day alone in up to 920 patients with an uncomplicated first AMI (no heart failure or left ventricular dysfunction) within 36 to 96 hours of receiving thrombolysis. Active enrollment is under way at 46 centers in the United Kingdom, Belgium, The Netherlands, and Denmark. This trial (known as the Incomplete INfarction Trial of European Research Collaborators Evaluating Prognosis Post-Thrombolysis [diltiazem], or INTERCEPT) represents the first long-term, large-scale, prospective study of a calcium antagonist administered post-thrombolysis as adjunctive therapy to AMI patients in which the primary trial objective is to assess the effect of blinded therapy on the 6-month cumulative occurrence of a combined clinical end point (cardiac death, recurrent nonfatal AMI, and medically refractory ischemia).

Outcome from a rapid-assessment chest pain clinic.

Chest pain accounts for much of the rising numbers of emergency admissions, but in-patient assessment is not necessarily the best way of dealing with these patients. We ran a 'rapid-assessment chest pain clinic' to provide an alternative route of assessment, and audited its outcome. General practitioners referred patients with recent-onset chest pain, increasing chest pain, chest pain at rest, or other chest pain of concern, on the understanding that they would be seen within 24 h. During 8 1/2 months, 334 patients were referred and 317 patients were seen, most of whom had exercise electrocardiography. A median of 6 months later, 278 patients were personally contacted to determine outcome. Of these, 18% had been admitted immediately with acute coronary syndromes, and 49% had been diagnosed as non-coronary chest pain (none of whom subsequently infarcted or died). Continuing symptoms were infrequent, and satisfaction was high, although 13% of patients had been revascularized. A significant number of patients required immediate admission and/or ultimate revascularization, but many more did not. The majority of these patients had non-coronary chest pain, and this diagnosis was substantiated by their excellent outcome and (in some cases) by further investigation.

Characterisation of coronary atherosclerotic morphology by spectral analysis of radiofrequency signal: in vitro intravascular ultrasound study with histological and radiological validation.

OBJECTIVE: To determine whether spectral analysis of unprocessed radiofrequency (RF) signal offers advantages over standard videodensitometric analysis in identifying the morphology of coronary atherosclerotic plaques. METHODS: 97 regions of interest (ROI) were imaged at 30 MHz from postmortem, pressure perfused (80 mm Hg) coronary arteries in saline baths. RF data were digitised at 250 MHz. Two different sizes of ROI were identified from scan converted images, and relative amplitudes of different frequency components were analysed from raw data. Normalised spectra was used to calculate spectral slope (dB/MHz), y-axis intercept (dB), mean power (dB), and maximum power (dB) over a given bandwidth (17-42 MHz). RF images were constructed and compared with comparative histology derived from microscopy and radiological techniques in three dimensions. RESULTS: Mean power was similar from dense fibrotic tissue and heavy calcium, but spectral slope was steeper in heavy calcium (-0.45 (0.1)) than in dense fibrotic tissue (-0.31 (0.1)), and maximum power was higher for heavy calcium (-7.7 (2.0)) than for dense fibrotic tissue (-10.2 (3.9)). Maximum power was significantly higher in heavy calcium (-7.7 (2.0) dB) and dense fibrotic tissue (-10.2 (3.9) dB) than in microcalcification (-13.9 (3.8) dB). Y-axis intercept was higher in microcalcification (-5.8 (1.1) dB) than in moderately fibrotic tissue (-11.9 (2.0) dB). Moderate and dense fibrotic tissue were discriminated with mean power: moderate -20.2 (1.1) dB, dense -14.7 (3.7) dB; and y-axis intercept: moderate -11.9 (2.0) dB, dense -5.5 (5.4) dB. Different densities of fibrosis, loose, moderate, and dense, were discriminated with both y-axis intercept, spectral slope, and mean power. Lipid could be differentiated from other types of plaque tissue on the basis of spectral slope, lipid -0.17 (0.08). Also y-axis intercept from lipid (-17.6 (3.9)) differed significantly from moderately fibrotic tissue, dense fibrotic tissue, microcalcification, and heavy calcium. No significant differences in any of the measured parameters were seen between the results obtained from small and large ROIs. CONCLUSION: Frequency based spectral analysis of unprocessed ultrasound signal may lead to accurate identification of atherosclerotic plaque morphology.

A prospective study of left atrial spontaneous echo contrast and thrombus in 100 consecutive patients referred for balloon dilation of the mitral valve.

The aim of this study was to determine the clinical, echocardiographic, and hemodynamic predictors of left atrial spontaneous echo contrast (SEC) and thrombus, respectively, in patients referred for balloon dilation of the mitral valve and to establish the relationship between the two phenomena in this group of patients. One hundred consecutive patients (mean age 57 +/- 14 years) referred for mitral balloon (Inoue) dilation were studied prospectively with transthoracic and transesophageal (83 biplane and 17 single plane) echocardiography (TEE) combined with spectral and color Doppler modalities, immediately before the procedure. TEE was repeated within 24 hours of valvotomy in the first 55 patients. All patients also underwent comprehensive left- and right-sided heart catheterization. TEE was performed successfully in 96 patients. SEC was detected in all 65 patients in atrial fibrillation and in 14 (45%) of 31 patients in sinus rhythm. Patients with SEC were significantly older (61 +/- 13 vs 45 +/- 12 years; p < 0.001) and had larger left atrial volume (98 +/- 48 vs 64 +/- 24 ml; p < 0.001), higher mitral valve echocardiographic scores (7.4 +/- 3.2 vs 5.3 +/- 2.6; p = 0.016), lower cardiac output (3.5 +/- 1.1 versus 4.6 +/- 0.9 L/min; p < 0.001), lower peak systolic pulmonary vein flow velocity (SVm) (24 +/- 12 versus 45 +/- 11 cm/sec; p < 0.001), and correspondingly lower systolic velocity-time integral (4.0 +/- 2.6 vs 7.9 +/- 2.9 cm; p < 0.001) than had patients without SEC. There were no significant associations between SEC and either mitral valve area or anticoagulant therapy. SVm and atrial fibrillation were found to be independent predictors of SEC. In patients in sinus rhythm, SVm was the only independent predictor of SEC. After mitral balloon dilation, SEC disappeared in only two of 35 patients in atrial fibrillation and in five of eight patients in sinus rhythm. Significant mitral regurgitation occurred in the two patients in atrial fibrillation. TEE detected left atrial thrombus in 14 patients. Thrombus was significantly associated with age, mitral valve area, and the severity of SEC. The latter was found to be an independent predictor of thrombus. Two patients in sinus rhythm had evidence of left atrial mechanical dysfunction. Both patients had left atrial SEC and one had thrombus in the appendage. It is concluded that SEC in patients with severe mitral stenosis is dependent on left atrial systolic function and peak systolic pulmonary vein velocity. It is not related to mitral valve area or anticoagulant therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

HLA antigens and other risk factors in the development of retinopathy in type 1 diabetes.

Factors possibly influencing the development of diabetic retinopathy were studied in 112 randomly selected type 1 diabetics having no or minimal retinopathy (group A) and in 82 type 1 diabetics with known severe diabetic retinopathy. The latter comprised those with severe background retinopathy (group B, n = 17) and those having proliferative retinopathy without (group C, n = 38) and with group D, n = 27) diabetic nephropathy. Nonretinopaths (group A) were of similar sex ratio, body weight, and age at diagnosis of diabetes but had been diabetic longer (p less than 0.001) and were thus older (p less than 0.001) than retinopaths (groups B-D). The distribution of HLA antigens of the A, B, and C loci was similar in nonretinopaths and retinopaths with the exception that HLA B7 showed a reduced (p less than 0.05) prevalence in the retinopaths (6% versus 17%) and was singularly underrepresented in group D, where no patients had this antigen. Mean postprandial plasma glucose and HbA1 concentrations were higher (p less than 0.01 and p less than 0.001) and cigarette smoking was more prevalent (p less than 0.01) in the retinopathy groups B-D than in group A. Systolic and diastolic blood pressures were similar in groups A-C, with higher (p less than 0.001) values only in group D. There was no association between insulin antibody binding in the serum or measurable plasma C-peptide immunoreactivity and retinopathy status. The risk of development of diabetic retinopathy in type 1 diabetes may be related to HLA-associated genetic factors and to cigarette smoking.

Characterisation of red and white thrombus by intravascular ultrasound using radiofrequency and videodensitometric data-based texture analysis.

Visual assessment of intravascular ultrasound (IVUS) video images cannot reliably identify thrombus. We examined if texture analysis of radiofrequency (r.f.) data or videodensitometric data (VD) could distinguish thrombi of different ages and cell compositions. Whole human blood (red clot = RC), platelet-rich plasma (white clot = WC) and plasma (n = 6/group) were imaged at 4 and 24 h with 30 MHz IVUS transducers. At 4 h, VD- and r.f.-based analyses revealed significant differences between RC and WC with variance (VD red 26.4 +/- 2.5, white 33.9 +/- 7.8; r.f. red 1.4 +/- 0.5, white 4.9 +/- 1.3), kurtosis (VD red 0.29 +/- 0.9, white 0.23 +/- 0.3) and skewness (VD red 0.23 +/- 0.13, white 0.35 +/- 0.52; r.f. red 0.06 +/- 0.01, white -0.06 +/- 0.05). Also mean grey-level from both data sets was higher in RC (VD 134.8 +/- 18.0; r.f. -13.3 +/- 1.2) than in WC (VD 105.3 +/- 17.4, r.f. 16.5 +/- 2.2) (p < 0.01). With increasing time, variance increased in WC (5.5 +/- 1.5 at 24 h) and decreased in RC (0.9 +/- 0.3.3 at 24 h). The more heterogeneous structure of WC may be distinguished from that of RC using texture analysis of either VD or r.f.-signals.

A study of the quantitative and qualitative impact of catheter shaft angulation in a mechanical intravascular ultrasound system.

Nonuniform rotation of mechanical intravascular ultrasound transducers may give rise to a geometric distortion of the ultrasound image known as the rotation angle artefact. This investigation studied the influence of different degrees and combinations of catheter shaft angulation on image morphology and the quantitative impact of the artefact using a circular perspex phantom and 3.5 F, 30 MHz Boston Scientific "Sonicath" catheters connected to a Hewlett Packard Sonos intravascular scanner. Major and minor diameters, cross-sectional area and circumference of the phantom lumen were measured and a "distortion index" calculated. Visually apparent geometric distortion was graded from 1 (absent) to 4 (severe). As expected, eccentric transducer location was associated much more frequently with identifiable distortion (70%) than was a concentric location (6%). Greater distortion occurred with increasing degrees of catheter shaft angulation, and was more pronounced in images from older catheters. The lumen area measurements in images in which no artefact was identified were accurate to within +/- 10% in 97% of cases, compared to only 81% of cases when an artefact was noted. The quantitative accuracy of an image in which geometric distortion is identified is thus not reliable. The direction of the quantitative error cannot be confidently predicted in any given case, although the mean lumen area tends to increase as the grade of distortion increases.

Predisposing factors for cerebral infarction: the Oxfordshire community stroke project.

The frequency of known causative factors of cerebral infarction was studied in 244 cases of first ever stroke due to cerebral infarction proved by computed tomography or at necropsy who were registered in the first two years of a prospective community based study. Risk factors for cerebral infarction were present in 196 (80%) cases; hypertension in 126 (52%); ischaemic heart disease in 92 (38%); peripheral vascular disease in 60 (25%); a cardiac lesion that was a major potential source of embolism to the brain in 50 (20%); transient ischaemic attacks in 35 (14%); cervical arterial bruit in 33 (14%); and diabetes mellitus in 24 (10%). Thirty one patients (13%) were in atrial fibrillation. Of the 48 patients who were free of risk factors or a major potential cardiac source of embolism at the time of the stroke, 18 were found to have hypertension after the stroke and 10 to have non-atheromatous non-embolic conditions (migrainous cerebral infarction (three), arteritis (two), inflammatory bowel disease (one), arterial trauma (one), autoimmune disease (one), carcinoma of the thyroid (one), and major operation (one). In 20 patients no causative factors could be identified. In this unselected series of patients with first ever stroke due to cerebral infarction most of the strokes were presumed to be due to either atheromatous arterial disease or embolism from the heart, and only 4% (95% confidence interval 2 to 7%) were probably due to non-atheromatous non-embolic causes. This has implications for research into strokes and allocation of public health expenditure.

Elderly and younger patients selected to undergo coronary angiography.

OBJECTIVE: To establish and compare the characteristics of older (greater than or equal to 70 years) and younger patients with chest pain selected to undergo coronary angiography and by analysis of their subsequent management to assess the value of coronary angiography for older patients with chest pain. DESIGN: Retrospective analysis of clinical case notes and coronary angiography reports. SETTING: Cardiology department with referral population of one million in an Edinburgh hospital. PATIENTS: 134 consecutive patients with chest pain aged 70 years or over investigated by coronary angiography between 1978 and 1988; 134 randomly selected patients aged under 70 investigated over the same period. MAIN OUTCOME MEASURES: Clinical and angiographic features at time of angiography and management after angiography. RESULTS: Older patients represented a small, but increasing, proportion of those investigated. Older patients had more severe symptoms at the time of angiography, were taking more antianginal drugs, and had had their symptoms for longer than younger patients. At angiography more older patients had triple vessel coronary disease, left main stem stenosis, or left ventricular impairment. After angiography similar proportions of older and younger patients underwent coronary artery surgery, with more elderly patients requiring urgent operation; although operative mortality was higher for elderly patients, symptomatic benefit was similar to that in younger patients. CONCLUSIONS: Older patients with angina selected to undergo coronary angiography and subsequent coronary surgery have more severe symptoms and underlying cardiac disease. Earlier referral and investigation might yield a population with lower operative risk. Selection of patients for coronary angiography and coronary artery surgery should be based on the potential for benefit and should avoid "agism."

Open access echocardiography in management of heart failure in the community.

OBJECTIVE: To assess the value of an open access echocardiography service. DESIGN: Study of new open access service for general practitioners, who were invited to refer patients taking diuretics for suspected heart failure, untreated patients with symptoms of possible heart failure, and asymptomatic patients with risk factors for left ventricular systolic dysfunction. SETTING: Regional cardiology centre. SUBJECTS: 259 consecutive patients. MAIN OUTCOME MEASURES: Presence or absence of left ventricular systolic dysfunction and consequent changes in clinical management. RESULTS: 119 treated patients, 99 untreated patients, and nine asymptomatic patients were referred over five months. 32 were considered to be inappropriately referred. Among the treated patients, 31 had impaired left ventricular systolic function and five had valvular disease; angiotensin converting enzyme inhibitors were recommended for 34 of these patients. In addition, 53 were thought not to need diuretics. Eight untreated patients had impaired systolic function and six valvular disease. CONCLUSIONS: The service was well used by general practitioners and led to advice to change management in more than two thirds of patients.

Psychiatric aspects of acute poisoning with tricyclic and related antidepressants--a ten-year review.

The incidence of acute self-poisoning with tricyclic and related antidepressant drugs has increased in recent years so that now approximately 20 per cent of all acute overdoses in patients above the age of 12 are due to this cause. We report the results of a ten-year review of the psychiatric aspects associated with this poisoning in 316 consecutive patients admitted to a District General Hospital. Fifty-four per cent of these patients had sought medical advice in the period immediately prior to the overdosage. The final psychiatric diagnosis following the poisoning is related to the events previously and an attempt is made to judge how appropriate was the original treatment with antidepressant drugs. The important opportunities for prevention of this poisoning are discussed and suggestions made.

Survival from extreme lactic and keto-acidosis in diabetes mellitus.

A case report of extreme acidosis associated with diabetic metabolic decompensation is described. Treatment with conventional therapy and sodium bicarbonate resulted in complete recovery.

Success of audit in reducing the time taken to administer thrombolysis and aspirin in patients with acute myocardial infarction.

We assessed whether audit might reduce the time taken to give thrombolysis and aspirin in patients with acute myocardial infarction (N = 116). A retrospective analysis was performed of the sources of delay in giving the drugs (N-60) and the data were presented to clinical staff accompanied by guidelines aimed at eliminating delays. A prospective survey was undertaken (N = 56) after these interventions. Audit resulted in an overall 31% reduction (P = 0.013) in the time to administer thrombolysis (median 55 minutes [range 21-148] v 38 [15-155]): there was a 57% fall (P < 0.0001) in the time to record an electrocardiogram (14 minutes [4-34] v 6 [1-19]) and a 33% decrease (P = 0.047) in the time taken to begin thrombolysis in the coronary care unit (15 minutes [0-110) v 10 [5-70]). The time taken to give aspirin was also reduced (P = 0.001) from 58 minutes (15-400) to 15 (3-235). The time taken to administer thrombolysis and aspirin to patients admitted with acute myocardial infarction can be reduced by audit.

Unemployment and deprivation are associated with a poorer outcome following percutaneous coronary angioplasty.

This prospective observational study aimed to assess the impact of employment status and deprivation on quality of life 12 months after percutaneous coronary intervention (PCI). Patients completed a questionnaire at baseline and at 1 year follow-up including a health utility score (EQ-5D), symptoms and employment status. Deprivation was assessed using the Carstairs' deprivation category based on area postcodes. The majority (79.6%) of patients of working age returned to work within 12 months. Unemployment was associated with a lower quality of life (QoL) at baseline (0.49 (0.32) vs 0.61 (0.27), p=0.002) and less improvement in QoL 1 year after PCI (0.15 (0.37) vs 0.26 (0.31), p<0.012). Furthermore, unemployed patients had significantly less improvement in chest pain score (p=0.002) and breathlessness (p<0.001). Unemployed patients from the most deprived areas had lowest QoL at follow-up and least improvement in QoL at 1 year. Unemployment and deprivation are associated with poorer outcomes following PCI.