Angiographic study of coronary artery disease in diabetic patients in comparison with nondiabetic patients.

Diabetes mellitus is known to be a major risk factor for the development of coronary artery disease (CAD). The aim of this study was to investigate angiographically the coronary arteries of diabetic persons, focusing on the type and distribution of CAD, sex differences in CAD anatomy, and the size of the coronary vessels. This was a randomized study and included two groups of patients with angiographically demonstrated CAD. Group A included 463 diabetics, aged 60.3 years, and Group B 210 nondiabetic patients, aged 58.5 years. The two groups were matched by age, sex, weight, and classic risk factors. The authors evaluated the regional location of CAD, left ventricular (LV) function, and the width of the lumen of coronary arteries. The diabetics had three-vessel disease more frequently (p<0.001) and one-vessel disease less frequently (p<0.001). The CAD was more extensive in Group A (mean 2.2 vessels, compared to 1.8 vessels in Group B, p<0.01). The right coronary artery was affected more often in diabetics (p<0.01), as was the anterior descending artery in three-vessel disease (p<0.05). The male diabetics had the same angiographic CAD severity as the females, although the latter had a better LV ejection fraction (p<0.05). The female diabetics < 55 years old had CAD findings comparable with those from women 4 years older in Group B. Diabetics show more diffuse and severe CAD than the general population. There are no sex-related differences in the severity of CAD.

Comparison of coronary collateral circulation in diabetic and nondiabetic patients suffering from coronary artery disease.

BACKGROUND AND HYPOTHESIS: Although it is well established that diabetes mellitus (DM) induces more severe coronary artery disease (CAD), it is not known whether it contributes to the development of coronary collateral circulation. The present study examines coronary collateral circulation in diabetic and nondiabetic patients with angiographically verified CAD. METHODS: The study group consisted of 463 diabetic patients (382 men, 81 women) with a mean age of 60.3 +/- 8.8 years, and 227 nondiabetic subjects (159 men, 68 women) with a mean age of 59.2 +/- 9 years. The extension and functional capacity of coronary collateral circulation was assessed according to the Cohen and Rentrop grading system of 0 to III. RESULTS: We found that diabetic patients had grade III collateral circulation more frequently than nondiabetic subjects (13.2 vs. 8.5%, p < 0.01). This finding was even more pronounced in diabetic men aged < 55 years compared with both nondiabetic men (20 vs. 3.4%, p < 0.001) and diabetic women (20 vs. 2.2%, p < 0.001). Grade III collateral circulation was found to develop mainly at the left anterior descending (LAD) coronary artery and the right coronary artery (RCA), where complete occlusions of coronary arteries usually occur. CONCLUSIONS: Diabetic patients with CAD develop more extensive coronary collateral circulation than nondiabetic subjects, especially men aged < 55 years. The collateral circulation mainly develops at the LAD and RCA.

Comparison of angiographic findings, risk factors, and long term follow-up between young and old patients with a history of myocardial infarction.

We compared the angiographic findings, coronary risk factors and five years prognosis in 200 patients < or =45, and 260 patients >45 years old who where admitted with an acute myocardial infarction. We found that family history and smoking were the most common risk factors in patients < or =45 years old P<0.04, P<0.0001, respectively, and hypertension and diabetes mellitus were more prevalent in patients >45 years, P<0.00001 for both. Young patients had a higher incidence of normal coronary arteries and a lesser one of triple vessel disease in comparison with old ones P<0.001 and P<0.04, respectively. There was also a tendency for young patients to have a higher frequency of single vessel disease. The long-term prognosis was favourable in the younger age group since the survival rate was much better, as well as the quality of life. Death in the young patients seems to be very often electrical owing to sudden ventricular fibrillation, whereas death in the elderly is more often associated with congestive heart failure.

Coronary-subclavian steal syndrome. Report of a case treated with subclavian angioplasty.

We describe the case of a man aged 42 who, five years before, had undergone aortocoronary bypass surgery using the internal mammary artery for the anterior and saphenous vein graft for the posterior descending arteries. Over the last one and a half years he had started to present angina pectoris as well as symptoms of vertebrobasilar insufficiency during exertion of the left upper extremity (recently during simple writing), whereas a full treadmill test was normal. Clinically, obstruction of the left subclavian artery was suspected with both coronary and subclavian steals. This suspicion was confirmed with triplex of the vessels of the aortic arch, coronary arteriography and carotid arteriography which demonstrated severe obstruction of the left subclavian artery at its origin and reversal of blood flow through the ipsilateral vertebral artery and the internal mammary artery graft. Angina subsided after balloon angioplasty of the subclavian artery. This combined steal, termed coronary-subclavian syndrome, is rare (our case is probably the 20th reported), but an increase of its incidence is anticipated due to the widespread use of internal mammary artery grafts. The prevention and treatment of this syndrome are discussed.

Systolic segmental disappearance of internal mammary artery graft. Correlation with prolonged spasm of the graft.

Vasospasm of the saphenous vein and internal mammary grafts may develop spontaneously under several conditions. We present for the first time spasm of a left internal mammary artery bypass graft during coronary arteriography. A patient who underwent coronary artery bypass operation 4 years ago was recatheterized because he developed chest pain. Selective catheterization of the left internal mammary artery graft showed disappearance of its lumen at its distal part during systole, whereas the patient developed angina. These phenomena disappeared after intravenous nitroglycerin administration.

Percutaneous balloon pericardiotomy for management of cardiac tamponade in a patient with lung cancer and large pericardial effusion.

We describe the case of a 32-year-old man with lung cancer involving the pericardium on which we performed pericardiotomy, using a balloon dilating catheter, to create a non-surgical pericardial window. For the percutaneous creation of pericardial window we advanced into the pericardium by subxiphoid approach a 0.035 inch guide wire through a 7f. pig-tail catheter. Subsequently a 22 mm diameter, 4 cm long balloon dilating catheter was advanced to the parietal pericardium and inflated for about 60 seconds until a tear in the pericardium was formed. We believe that percutaneous balloon pericardiotomy is helpful in the management of large pericardial effusions particularly in patients with malignancies and poor condition.

Spontaneous left anterior descending coronary artery dissection. Case report presentation and review of the relevant literature.

Spontaneous coronary artery dissection is a rare incident occurring usually in young patients, predominantly in females. It is usually fatal and found postmortem. We present the case of a middle aged man with spontaneous left anterior descending coronary artery dissection found angiographically which caused an anterior wall myocardial infarction. We also briefly review the relevant literature.

Colour Doppler echocardiography in the diagnosis of ruptured aneurysm of sinus of Valsalva.

In this report we present three cases of ruptured aneurysm of sinus of Valsalva which were detected by colour Doppler echocardiography. The diagnosis was confirmed by cardiac catheterization and at operation.

Hypertrophic peripheral neuropathy (Dejerine-Sottas disease) associated with heart block. Case report presentation and review of the literature.

We present a case of a male suffering from hypertrophic peripheral neuropathy (Dejerine-Sottas disease) and severe involvement of the cardiac conductive tissue causing syncopal attacks. It is the first time that an association of this neuromuscular disease with cardiac involvement is described.

Marfan's syndrome and coarctation. Coincidence or association? A case report.

The case of a patient with coexisting Marfan's syndrome and coarctation of the aorta is presented. The relevant literature is reviewed and the possible association between the two lesions is discussed.

The ST segment axis as a differential diagnostic feature between acute pericarditis and acute inferior myocardial infarction.

The ST segment electrical axis in the frontal plane was calculated in 20 patients with an acute inferior myocardial infarction (AIMI) and another 20 patients with the acute phase of pericarditis (AP). The ST segment axis of patients with AIMI ranged from 100 degrees-120 degrees (mean 114 degrees). The ST segment axis of patients with AP ranged from 30 degrees-60 degrees (mean 45 degrees). Thus, the ST segment axis can be used for the differential diagnosis in the early acute phase, especially when there are no other important distinguishing factors between these two conditions.

Exercise testing after acute myocardial infarction. How much? How soon?

Exercise testing shortly after acute myocardial infarction is considered safe and valuable for the determination of long-term prognosis. One point of discussion is whether a submaximal pre-discharge test or a maximal test at 6-8 weeks, which has a higher sensitivity for diagnosing multivessel disease should be preferred. The former is the authors' choice, since the submaximal predischarge test has excellent prognostic value for adverse effects, and because approximately 1.5% of patients who have a positive test have been noted to present with early ischemic deaths which ideally could have been prevented. In patients unable to exercise, mortality is about 19%. In these, the ejection fraction should be determined, and "stress" tests should be carried out administering dipyridamole or dobutamine intravenously and probably augmenting the diagnostic sensitivity of the test by radionuclide or echocardiographic evaluation.

The effects of long-term antithrombotic treatment on left ventricular thrombi in patients after an acute myocardial infarction.

Sixty patients (48 men and 12 women; aged 36 to 72 years, mean 48 +/- 9), who survived an acute anterior myocardial infarction and in whom left ventricular thrombus was detected by cross-sectional echocardiography 1 to 2 days before they were discharged from the hospital, were prospectively studied. All had evidence of left apical wall motion abnormalities. They were randomly divided into three groups of 20 patients each. Group A was given a full dose of oral anticoagulants, group B was given aspirin, 650 mg/day, and group C received no antithrombotic therapy. Echocardiography was performed every 3 months in all patients, and they were followed for 9 to 24 months (mean 16 +/- 5 months). Twelve patients in group A had complete resolution of the thrombus and three had a significant decrease in the size of the thrombus (greater than or equal to 50% of initial thickness) during the first trimester after acute infarction. In group B the thrombus resolved in nine patients and was significantly diminished in four during the first trimester of follow-up. In group C the thrombus resolved in two patients during the first trimester and showed a significant decrease in size in two patients during the second trimester of follow-up. Two patients in group C initially had recurrent transient cerebral ischemic attacks, which did not recur after aneurysmectomy. One patient in group C had a peripheral embolic episode in the femoral artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of nifedipine on the sick sinus syndrome.

The effect of nifedipine (N) on sinus node (SN) function was studied in 15 patients (9 males, 6 females) sixty-two to seventy-six (mean 68.1 +/- 11) years old, with sick sinus syndrome (SSS). SSS was characterized electrophysiologically by a prolonged corrected sinus node recovery time (CSNRT greater than 535 msec) and/or prolonged sinoatrial conduction time (SACT greater than 125 msec), assessed by applying premature atrial stimulation. Ten mg N was given sublingually, and CSNRT and SACT were again evaluated sixty minutes after N administration, and again ten minutes after 1.5 mg atropine (A) was given IV. Heart rate increased significantly after N (p less than 0.005), systolic blood pressure (SBP) diminished significantly (p less than 0.005), and CSNRT and SACT shortened significantly (p less than 0.005, p less than 0.005) and became normal in 7 and 5 patients respectively. After A administration, a further significant increase of heart rate (p less than 0.005) and decrease of CSNRT (p less than 0.005) and SACT (p less than 0.005) were observed. CSNRT and SACT became normal in 8 and 7 patients respectively. SBP remained stable.

The effective treatment of multifocal atrial tachycardia with amiodarone.

Multifocal atrial tachycardia (MAT) was observed in 9 patients aged 60-85 (mean 72.1 +/- 8.6) years during exacerbation of their chronic lung and/or cardiac disease. Four, in whom the rapid heart rate caused symptoms of pulmonary congestion, were treated with intravenous amiodarone (450-900 mg over 2 hours) with restoration of sinus rhythm soon after the termination of the drug infusion. In 1, with recurrence of MAT, the same intravenous dosage was repeated for 2 consecutive days, with final achievement of stable sinus rhythm. Five patients, apart from the conventional management of their underlying disease (digitalis, diuretics, aminophylline) were treated with oral amiodarone (600 mg/day). Sinus rhythm was restored in all and remained stable during their hospitalization, under alpha maintenance dosage of 200-400 mg daily. Amiodarone may be the drug of choice for the treatment of MAT, for which up to now no effective therapy has been established.

Atrial septal defect and constrictive pericarditis. An unusual combination.

We describe a case of atrial septal defect associated with constrictive pericarditis. This combination is extremely rare and clinically misleading, since it may simulate other more common conditions. A variety of techniques, such as computerized tomography, echocardiography and cardiac catheterization were necessary for establishing the right diagnosis. Although there are suggestions of a possible association of atrial septal defect with pericardial disease, it is difficult to prove that this combination is other than coincidence.

Q and non-Q wave myocardial infarction: current views.

The new terminology "Q and non-Q wave myocardial infarction" (MI) tends to replace the traditional terms "transmural" and "subendocardial" MI since the anatomy cannot be accurately predicted by electrocardiography. Although some subtypes of non-QMI display a favorable early or in-hospital prognosis, the long-term outlook seems less benign, particularly when early or late recurrence of MI occurs. Coronary arteriograms show an equal number of diseased vessels in both types of MI, but complete coronary artery occlusion is less frequent in non-QMI. The management of patients with non-QMI should be mainly directed to preventing extension or recurrence of MI by using either drugs such as thrombolytic agents and drugs against coronary artery spasm or invasive techniques like percutaneous transluminal coronary angioplasty.

Increased mortality of diabetics after acute myocardial infarction attributed to diffusely impaired left ventricular performance as assessed by echocardiography.

Five hundred and forty-eight patients who sustained their first acute myocardial infarction (AMI) were admitted to the coronary care unit (CCU). Ninety-eight of them were known diabetics. The diabetic patients were younger, 50 +/- 12 vs. 64 +/- 18 years of age (p less than 0.05), and the proportion of females in their group was higher than in the nondiabetics, 44% vs. 33.4% (p less than 0.05). The in hospital mortality rate was 30% for diabetics and 16% for nondiabetics (p less than 0.001). Diabetics had a higher percentage of mortality caused by left ventricular failure (LVF) (p less than 0.025) and a tendency for more frequent complete A-V block (p less than 0.01) compared to nondiabetics. Obesity and a positive family history for coronary heart disease were more prevalent in the diabetic group (both p less than 0.01). The echocardiographic assessment of left ventricular function, performed in 125 consecutively admitted patients (25 diabetics and 100 nondiabetics) on the 3rd-5th post-infarct day, showed that the indices of myocardial contractility, that is, E point septal separation (EPSS), ejection fraction (EF) and fractional shortening (FS) were far more impaired in diabetics than in nondiabetics (p less than 0.01, p less than 0.005, p less than 0.005, respectively). No significant difference was found in the prevalence of dyskinetic, akinetic and hypokinetic segments between the two categories of patients, suggesting no difference in the amount of myocardial mass affected by the AMI. Our results indicate that the increased incidence of LVF developed in diabetics after an AMI compared to nondiabetics may be caused by other factors, probably some form of latent diabetic cardiomyopathy as a result of either small vessel disease or metabolic disorder.

Arrhythmogenic right ventricular dysplasia: case report presentation and review of the literature.

A man complaining of palpitations was found to have ventricular tachycardia (VT) with LBBB configuration. From the investigations which followed, he was diagnosed as having arrhythmogenic right ventricular dysplasia (ARVD). The patient has been treated with amiodarone and propafenon for 7 months without VT recurrence. ARVD and Uhl's anomaly, which is its most extreme form, may be familial and represent an important cause of sudden death among young people: Prophylactic antiarrhythmic therapy and sometimes surgical treatment are required in case of refractory VT.

Unstable angina pectoris as a warning symptom before acute myocardial infarction.

Four hundred patients who were admitted over the last three years with myocardial infarction were questioned about the presence and pattern of angina before its onset. Two hundred and twenty-four (56 per cent) patients had angina before their infarction; 184 (46 per cent) had the unstable pattern of angina. That such a high proportion of patients experience unstable angina as a prodromal symptom makes it possible that myocardial infarction could be prevented in some of these patients. Patients with previous angina had a higher incidence of subendocardial infarction than patients without angina (stable or unstable) (p less than 0.01). In-hospital prognosis was better in patients with chronic or unstable angina than in patients without angina (p less than 0.05).