Is statin-induced diabetes clinically relevant? A comprehensive review of the literature.

In those predisposed to the development of diabetes (the insulin resistant, obese and older patients) statins may increase the risk of developing diabetes. Despite the fact that the conversion to diabetes is generated from post hoc analyses, it seems to be a class effect with a dose-response relationship. However, statins have not been clearly shown to increase diabetic microvascular complications (retinopathy, nephropathy and neuropathy). Thus, the clinical significance of increased glucose levels in patients treated on statins is uncertain. While the exact mechanism for how statins increase the risk of diabetes is unknown, a possible explanation is through a reduction in adiponectin levels. Despite the fact that higher statin doses are more likely to lead to new-onset diabetes, for every case of diabetes caused, there are approximately three cardiovascular events reduced with high dose versus moderate dose statin therapy. Overall, the small risk of developing type 2 diabetes with statin therapy is far outweighed by the potential of statins to decrease cardiac events.

Therapies for diabetic dyslipidaemia.

Correction of diabetic dyslipidaemia in diabetic patients is the most important factor in reducing cardiac risk. Diabetic dyslipidaemia is characterized by elevated triglycerides, low total high-density lipoprotein (HDL) and small dense low-density lipoprotein (LDL) particles. The most important therapeutic goal in diabetic dyslipidaemia is correction of the non-HDL-cholesterol (HDL-C) level. Glycaemic control with particular attention to postprandial glucose control plays a role not only in improving dyslipidaemia but also in lowering cardiac events. Pioglitazone is particularly effective for improving the manifestations of diabetic dyslipidaemia, in addition to its favorable effects on systemic inflammation and hyperglycaemia. Use of statins in addition to lifestyle change is recommended in most if not all type 2 diabetic patients and the goal should be to lower the LDL to a level recommended for the patient with existing cardiovascular disease (CVD) (non-HDL-C level <100 mg/dl). In addition, therapies for normalization of HDL and triglyceride levels should be deployed. Most patients with type 2 diabetes (T2D) will require combining a lipid-lowering therapy with therapeutic lifestyle changes to achieve optimal lipid levels. Combinations usually include two or more of the following: a statin, nicotinic acid, omega-3 fats and bile acid sequestrants (BASs). Fibrates may also be of use in diabetic patients with persistently elevated triglycerides and depressed HDL-C levels, although their role in lowering adverse CV events is questionable.

Eplerenone improves prognosis in postmyocardial infarction diabetic patients with heart failure: results from EPHESUS.

BACKGROUND: The Epleronone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) trial demonstrated that selective aldosterone blockade with eplerenone significantly reduced total mortality by 15%, combined cardiovascular (CV) mortality/CV hospitalization by 13%, CV mortality by 17% and sudden cardiac death by 21%, vs. placebo when added to standard care in patients with left ventricular systolic dysfunction (LVSD) and signs of congestive heart failure (CHF) following acute myocardial infarction (AMI). We retrospectively evaluated the effect of eplerenone vs. placebo in a subset of 1483 diabetic patients with LVSD and signs of CHF following AMI. METHODS: Diabetic status was determined from medical histories at screening. Analyses were based on time to first occurrence of an event. Results were based on a Cox's proportional hazards regression model stratified by region with treatment, subgroup and treatment-by-subgroup interaction as factors. The 95% confidence intervals for the risk ratios were based on the Wald's test. RESULTS: Treatment with eplerenone in diabetic patients with CHF following AMI reduced the risk of the primary endpoint, a composite of CV mortality or CV hospitalization, by 17% (p = 0.031). The absolute risk reduction of the primary endpoint was greater in the diabetic cohort (5.1%) than in the non-diabetic cohort (3%). Hyperkalaemia occurred more often with eplerenone than with placebo (5.6 vs. 3%, p = 0.015). Among the diabetic cohorts, the prespecified endpoint of 'any CV disorder' occurred in 28% of the eplerenone group and 35% of the placebo group (p = 0.007). CONCLUSION: Eplerenone treatment may reduce adverse CV events in diabetic patients with LVSD and signs of CHF following AMI.

Adenosine thallium-201 is superior to exercise thallium-201 for detecting coronary artery disease in patients with left bundle branch block.

OBJECTIVES: We sought to assess the comparative diagnostic accuracy of adenosine versus exercise in conjunction with thallium-201 scintigraphy for the detection and localization of coronary artery disease in patients with left bundle branch block on the rest electrocardiogram (ECG). BACKGROUND: Patients with left bundle branch block on the rest ECG frequently have artifactual reversible septal perfusion defects on exercise thallium-201 scintigraphy. Adenosine thallium scintigraphy is a theoretically attractive alternative in these patients. METHODS: One hundred seventy-three consecutive patients with left bundle branch block were evaluated with either exercise thallium (n = 56) or adenosine thallium (n = 117) scintigraphy. The tomographic thallium images were interpreted visually with adjunctive quantitative analysis. Follow-up cardiac catheterization was performed in 31 of the 56 patients in the exercise thallium group and 42 of the 117 patients in the adenosine thallium group. RESULTS: Minor subjective side effects were noted in most patients in the adenosine thallium group (86%); atrioventricular block occurred in seven patients (6%). The overall predictive accuracy was 93% in the adenosine thallium group and 68% in the exercise thallium group (p = 0.01). The combined specificity for the detection of disease in the coronary arteries subtending the septum (the left anterior descending and right coronary arteries) was only 42% with exercise thallium scintigraphy versus 82% with adenosine thallium scintigraphy (p < 0.0002). CONCLUSIONS: Adenosine thallium imaging 1) was superior to exercise thallium imaging in the detection of coronary artery disease in patients with left bundle branch block; 2) obviated septal artifacts, thereby markedly improving the specificity in the left anterior descending and right coronary arteries; and 3) was safe in patients with left bundle branch block.

Should an angiotensin-converting enzyme inhibitor be standard therapy for patients with atherosclerotic disease?

Angiotensin-converting enzyme (ACE) inhibitors appear to possess unique cardioprotective benefits, even when used in patients without high blood pressure or left ventricular dysfunction (the traditional indications for ACE inhibitor therapy). The ACE inhibitors improve endothelial function and regress both left ventricular hypertrophy and arterial mass better than other antihypertensive agents that lower blood pressure equally as well. These agents promote collateral vessel development and improve prognosis in patients who have had a coronary revascularization procedure (i.e., percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery). Insulin resistance, present not only in type 2 diabetes but also commonly in patients with hypertension or coronary artery disease, or both, sensitizes the vasculature to the trophic effects of angiotensin II and aldosterone. This may partly explain the improvement in prognosis noted when patients who have atherosclerosis or diabetes are treated with an ACE inhibitor. Therapy with ACE inhibitors has also been shown, in two large, randomized trials, to reduce the incidence of new-onset type 2 diabetes through largely unknown mechanisms. The ACE inhibitors are safe, well tolerated and affordable medications. The data suggest that most people with atherosclerosis should be considered candidates for ACE inhibitor therapy, unless they are intolerant to the medication, or have systolic blood pressures consistently <100 mm Hg. Patients who show evidence of insulin resistance (with or without overt type 2 diabetes) should also be considered as candidates for prophylactic ACE inhibitor therapy. Although angiotensin receptor blockers should not be considered equivalent to ACE inhibitors for this indication, they may be a reasonable alternative for patients intolerant of ACE inhibitors.

Estrogen replacement therapy after coronary angioplasty in women.

OBJECTIVES: The purpose of this study was to assess the effects of estrogen replacement therapy on long-term outcome, including restenosis, myocardial infarction, stroke and death after a first percutaneous transluminal coronary angioplasty (PTCA) procedure, in postmenopausal women. BACKGROUND: Observational and epidemiologic studies, basic laboratory research and clinical trials consistently suggest that estrogen replacement therapy is associated with beneficial cardiovascular effects in women. These cardioprotective actions may be particularly relevant to women with coronary artery disease, such as those who have undergone PTCA. METHODS: This was a retrospective study that included 337 women who underwent elective PTCA between 1982 and 1994. The treatment group consisted of 137 consecutive women receiving long-term estrogen therapy at the time of elective PTCA and during follow-up. The control group comprised 200 women who were computer-matched with the estrogen group. The mean follow-up period was 65 +/- 35 months. RESULTS: Actuarial survival was superior in the estrogen group; the 7-year survival rate was 93% for the estrogen group versus 75% for the control group (p = 0.001). The cardiovascular event rate (death, nonfatal myocardial infarction or nonfatal stroke) was significantly lower in the estrogen group at 7 years (12% vs. 35% in the control group, p = 0.001). The need for subsequent revascularization during follow-up was similar in the two groups. Multivariable analysis identified diabetes, estrogen therapy (adjusted risk ratio 0.38, 95% confidence interval 0.19 to 0.79) and left ventricular ejection fraction < 40% as independent correlates of cardiovascular death or myocardial infarction during follow-up. CONCLUSIONS: Estrogen replacement therapy was associated with an improved long-term outcome after PTCA in postmenopausal women.

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery.

OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.

Coronary angioplasty versus bypass surgery in patients > 70 years old matched for ventricular function.

OBJECTIVES: This study compared the relative risks and benefits of coronary angioplasty and coronary artery bypass graft surgery in patients > 70 years old. BACKGROUND: Few objective, comparative data exist to guide the clinician in the decision to use bypass surgery or angioplasty in elderly patients. METHODS: The study was a case-control, retrospective analysis of 195 consecutive patients who underwent bypass surgery in 1987 and 1988 and were compared with a concurrent cohort of 195 coronary angioplasty-treated patients. The groups were matched for left ventricular function, age and gender mix. RESULTS: The in-hospital morbidity and mortality rates were significantly lower in the coronary angioplasty-treated patients. Mean postprocedural hospital stay was 4.8 and 14.3 days for angioplasty and surgical group patients, respectively (p < 0.001). In-hospital death occurred in 2% of angioplasty-treated patients compared with 9% of surgically treated patients (p = 0.007). Serious in-hospital stroke occurred in no patient in the angioplasty group and in 5% of patients in the surgical group (p < 0.0001). Q wave infarction occurred in 1% of angioplasty-treated patients and 6% of bypass-treated patients (p = 0.01). The 5-year actuarial survival rate was similar in the two groups: 63% in the angioplasty group, 65% in the bypass group (p = NS). However, surgical group patients experienced less recurrent angina, required fewer repeat revascularization procedures and had fewer Q wave infarctions during follow-up compared with angioplasty group patients. CONCLUSIONS: When performed in patients > 70 years old, angioplasty and coronary bypass surgery result in similar long-term survival rates but otherwise distinctly different clinical courses.

Multivessel coronary angioplasty from 1980 to 1989: procedural results and long-term outcome.

From June 1980 to January 1989, 3,186 patients had coronary angioplasty of two (2,399 patients) or three (787 patients) of the three major epicardial coronary systems. A mean of 3.6 lesions (range 2 to 14) were dilated per patient, with a 96% success rate. Acute complications were seen in 94 patients (2.9%) and included Q wave infarction in 47 (1.4%), urgent coronary artery bypass surgery in 33 (1%) and death in 31 (1%). Multivariate correlates of in-hospital death included impaired left ventricular function, age greater than or equal to 70 years and female gender. Complete long-term follow-up data were available for the first 700 patients and the follow-up period averaged 54 +/- 15 months in duration. Actuarial 1 and 5 year survival rates were 97% and 88%, respectively, and were not different in patients with two or three vessel disease. By Cox regression analysis, age greater than or equal to 70 years, left ventricular ejection fraction less than or equal to 40% and prior coronary artery bypass surgery were associated with an increased mortality rate during the follow-up period. Repeat revascularization procedures were required in 322 patients (46%). Restenosis resulted in either repeat angioplasty or bypass surgery in 227 patients (32%). Repeat coronary angioplasty was performed for isolated restenosis in 126 patients (18%), for restenosis and disease progression at new sites in 85 patients (12%) and for new disease progression alone in 54 patients (8%). Coronary bypass surgery was required in 110 patients (16%) during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Ineffectiveness of colchicine for the prevention of restenosis after coronary angioplasty.

Colchicine, an antimitogenic agent, has shown promise in preventing restenosis after coronary angioplasty in experimental animal models. A prospective trial was conducted involving 197 patients randomized in a 2:1 fashion to treatment with oral colchicine, 0.6 mg twice daily (130 patients), or placebo (67 patients) for 6 months after elective coronary angioplasty. Treatment in all patients began between 12 h before angioplasty and 24 h after angioplasty. Compliance monitoring revealed that 96% of all prescribed pills were ingested. Demographic characteristics were similar in colchicine- and placebo-treated groups. A mean of 2.7 lesions/patient were dilated. Side effects resulted in a 6.9% dropout rate in the colchicine-treated patients. Complete quantitative angiographic follow-up was obtained in 145 patients (74%) with 393 dilated lesions. Quantitative angiographic measurements were obtained in two orthogonal views at baseline before angioplasty and immediately and at 6 months after angioplasty. The quantitative mean lumen diameter stenosis before angioplasty was 67% both in the 152 lesions in the placebo-treated group and in the 241 lesions in the colchicine-treated group; this value was reduced to 24% immediately after angioplasty in the lesions in both treatment groups. At the 6-month angiogram, lesions had restenosed to 47% lumen diameter narrowing in the placebo-treated group compared with 46% in the colchicine-treated group (p = NS). Forty-one percent of colchicine-treated patients developed restenosis in at least one lesion compared with 45% of the placebo-treated group (p = NS). In conclusion, colchicine was ineffective for preventing restenosis after coronary angioplasty.

Baseline and 6-month costs of primary angioplasty therapy for acute myocardial infarction: results from the primary angioplasty registry.

OBJECTIVES: This study sought to describe the economic outcomes from a prospective multicenter registry of primary coronary angioplasty. BACKGROUND: Interest in coronary angioplasty without preceding thrombolytic therapy as a primary reperfusion strategy has increased as a result of three recent randomized trials showing outcomes equivalent to or better than standard thrombolytic therapy. METHODS: The Primary Angioplasty Registry enrolled 270 patients with acute myocardial infarction at six private tertiary care medical centers. Baseline and follow-up medical costs and counts of resources consumed were collected from enrollment to the 6-month follow-up visit. Correlates and predictors of cost were identified with multivariable linear regression modeling. RESULTS: Ninety-five percent of patients had a revascularization procedure during the baseline hospital period: 85% had coronary angioplasty only; 4% had coronary bypass surgery only; 6% had both procedures. The total mean baseline hospital cost (not charge) was $13,113, with mean physician fees of $5,694. During the follow-up period, repeat coronary angiography was performed in 21% of patients, whereas 13% had repeat angioplasty and 3% bypass surgery. Mean hospital follow-up costs were $3,174, with mean physician fees of $1,443. Independent correlates of higher baseline hospital costs included older age (p = 0.049), anterior infarction (p = 0.03), initial Killip class (p < 0.0001), more severe coronary disease (p = 0.0015), need for bypass surgery alone or in addition to angioplasty (p < 0.0001) and recurrent ischemia (p < 0.0001). CONCLUSIONS: Costs of primary angioplasty for patients with acute myocardial infarction eligible for thrombolysis were strongly influenced by infarction- and procedure-related complications but only modestly influenced by patient selection factors.

Failed direct coronary angioplasty for acute myocardial infarction: in-hospital outcome and predictors of death.

OBJECTIVES: The purpose of this study was to compare the mechanisms, predictors and outcome of patients with failed direct coronary angioplasty of the infarct-related artery with those in patients with successful direct angioplasty. BACKGROUND: Direct coronary angioplasty of the infarct-related artery, without antecedent thrombolytic therapy, is an effective treatment for patients with acute myocardial infarction. Concern has been expressed over high mortality rates in patients with failed direct infarct angioplasty. METHODS: All patients treated by angioplasty were prospectively entered into a computer data base. The characteristics and outcome of all patients with failed direct angioplasty were reviewed and compared with those of patients with successful direct angioplasty. RESULTS: Direct angioplasty was successful in 705 (94%) of 750 patients and unsuccessful in 45 (6%). Patients in the failure group were more likely to be in cardiogenic shock (22% vs. 7%, p < 0.003), to have had a previous myocardial infarction (44% vs. 28%, p < 0.03) and to have three-vessel coronary artery disease (44% vs. 23%, p < 0.003). Age, gender, ejection fraction, previous bypass surgery and diabetes mellitus were similar in both groups. Only the presence of multivessel coronary artery disease (p < 0.004) and cardiogenic shock (p < 0.025) were independent predictors of failed direct angioplasty. In-hospital death (31% vs. 4.8%, p < 0.001) and the need for emergency coronary artery bypass surgery (27% vs. 0.5%, p < 0.0001) were more frequent in patients with unsuccessful than in patients with successful direct angioplasty. Patients with failed direct angioplasty and in-hospital death usually had multiple high risk characteristics, including cardiogenic shock (50%), previous myocardial infarction (43%) and multivessel coronary artery disease (93%). CONCLUSIONS: Direct coronary angioplasty is an effective method for establishing reperfusion in acute myocardial infarction. Procedural failure is infrequent, usually occurring in patients with high risk baseline characteristics.

A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit.

CONTEXT: Intercessory prayer (praying for others) has been a common response to sickness for millennia, but it has received little scientific attention. The positive findings of a previous controlled trial of intercessory prayer have yet to be replicated. OBJECTIVE: To determine whether remote, intercessory prayer for hospitalized, cardiac patients will reduce overall adverse events and length of stay. DESIGN: Randomized, controlled, double-blind, prospective, parallel-group trial. SETTING: Private, university-associated hospital. PATIENTS: Nine hundred ninety consecutive patients who were newly admitted to the coronary care unit (CCU). INTERVENTION: At the time of admission, patients were randomized to receive remote, intercessory prayer (prayer group) or not (usual care group). The first names of patients in the prayer group were given to a team of outside intercessors who prayed for them daily for 4 weeks. Patients were unaware that they were being prayed for, and the intercessors did not know and never met the patients. MAIN OUTCOME MEASURES: The medical course from CCU admission to hospital discharge was summarized in a CCU course score derived from blinded, retrospective chart review. RESULTS: Compared with the usual care group (n = 524), the prayer group (n = 466) had lower mean +/- SEM weighted (6.35 +/- 0.26 vs 7.13 +/- 0.27; P=.04) and unweighted (2.7 +/- 0.1 vs 3.0 +/- 0.1; P=.04) CCU course scores. Lengths of CCU and hospital stays were not different. CONCLUSIONS: Remote, intercessory prayer was associated with lower CCU course scores. This result suggests that prayer may be an effective adjunct to standard medical care.

Value of normal electrocardiographic findings in predicting resting left ventricular function in patients with chest pain and suspected coronary artery disease.

PURPOSE: Characterization of left ventricular function is important in managing patients with coronary artery disease. Although many methods are available to assess left ventricular function, most are either expensive, invasive, or both. In this study, we examined the ability of normal or near-normal resting electrocardiographic findings to predict resting left ventricular ejection fraction, measured by resting radionuclide angiography, in 874 patients with chest pain and suspected coronary artery disease. PATIENTS AND METHODS: A retrospective review was undertaken of 4,410 Mayo Clinic patients who underwent rest and exercise radionuclide ventriculography for the evaluation of chest pain and known or suspected coronary artery disease; of these, 874 patients met the inclusion criteria for the current study. A 15-lead electrocardiogram, which was interpreted by the cardiologist or cardiology trainee working in the laboratory, was obtained at the same evaluation as the radionuclide study. RESULTS: In 590 patients with no previous history of a myocardial infarction and entirely normal resting electrocardiographic results without nonspecific ST-T wave abnormalities, the mean left ventricular ejection fraction was 0.63 +/- 0.004, and 559 patients (95%) had a normal resting ejection fraction (defined as 0.50 or more). Both nonspecific ST-T wave abnormalities (p less than 0.001) and, to a lesser degree, a history of myocardial infarction (p = 0.06) were independent predictors of an abnormal resting ejection fraction. In 185 patients with nonspecific ST-T wave abnormalities and no history of myocardial infarction, the mean left ventricular ejection fraction was 0.61 +/- 0.009, and 85% had a normal resting ejection fraction. In 36 patients with nonspecific ST-T wave abnormalities and a history of myocardial infarction, the mean left ventricular ejection fraction was 0.53 +/- 0.021, and 72% had a normal resting ejection fraction. CONCLUSION: Thus, an entirely normal result on a resting 12-lead electrocardiogram in patients with suspected coronary disease but no history of a previous myocardial infarction is a reliable (95%) predictor of normal left ventricular function. If nonspecific ST-T wave abnormalities are noted, particularly if there is a history of a previous infarction, the predictive value of the electrocardiographic findings is diminished.

Extended acquisition for minimizing attenuation artifact in SPECT cardiac perfusion imaging.

Artifacts due to attenuation can complicate the interpretation of SPECT cardiac perfusion images, especially when the attenuated region corresponds to that of a coronary vascular distribution. Since methods of correction are limited, some patients undergo coronary angiography unnecessarily. Acquisition using a three-detector camera provides more data that can serve to minimize the effects of localized attenuation if incorporated into the final reconstruction set. In this article, a practical approach for interpreting SPECT cardiac perfusion images is outlined, demonstrating with an illustrative case how this approach can be clinically helpful.

Comparison of stress echocardiography and stress myocardial perfusion scintigraphy for diagnosing coronary artery disease and assessing its severity.

The cumulative published literature dealing with the most frequently utilized noninvasive cardiac stress imaging modalities (radionuclide myocardial perfusion scintigraphy and echocardiography) was reviewed to gain insight on their comparative diagnostic accuracies. To be included, studies had to be performed in conjunction with exercise or a commonly used intravenous pharmacologic stress agent (dipyridamole, adenosine or dobutamine) and had to report temporally related coronary angiography findings. A total of > 75 studies were included, involving > 7,000 patients. Exercise single-photon emitted computed tomographic (SPECT) scintigraphy was more sensitive than exercise echocardiography for detecting coronary artery disease (CAD), localizing it to the proper coronary artery distribution and correctly identifying the presence of multivessel CAD. Adenosine, dipyridamole, and dobutamine provided similar diagnostic accuracy when performed in conjunction with SPECT scintigraphy, and all were more accurate than dobutamine echocardiography. Clinical specificity was similarly high with adenosine SPECT, dipyridamole echocardiography, and exercise echocardiography, and lower with exercise SPECT. Normalcy rate was high for exercise SPECT and similar to clinical specificity for echocardiography.

Incidence and importance of thrombolysis in myocardial infarction grade 3 flow after primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.

We analyzed angiographic flow and myocardial salvage in 180 patients who underwent primary percutaneous transluminal coronary angioplasty (PTCA) without antecedent thrombolytic therapy for acute myocardial infarction. Thrombolysis in Myocardial Infarction (TIMI) flow grade was analyzed visually before and after PTCA. All patients underwent paired baseline (before angioplasty) and predischarge quantitative tomographic perfusion imaging with technetium-99m (Tc-99m) sestamibi techniques for assessment of the initial area at risk and final infarct size. The myocardial salvage index was defined as the proportion of jeopardized myocardium that was salvaged. After primary PTCA, TIMI grade 3 flow was obtained in 163 patients (91%), TIMI grade 2 flow in 13 patients (7%), and TIMI grade 0 or 1 flow in 4 patients (2%). There was a significant association between TIMI flow and both infarct size and salvage index. Infarct size was significantly smaller in patients with TIMI grade 3 flow than in those with TIMI grade 2 flow (15 +/- 16% vs 29 +/- 21% of left ventricular mass, p = 0.007). The salvage index was 55 +/- 41% of the area at risk in the TIMI 3 group and 27 +/- 38% of the area at risk in the TIMI 2 group (p = 0.04). After primary PTCA, restoration of TIMI grade 3 flow was necessary for optimal myocardial salvage. TIMI grade 2 flow was associated with a larger final infarct size and a lower salvage index.

Influence of left ventricular mass on coronary artery cross-sectional area.

Observations from cardiac catheterization suggest that coronary artery cross-sectional area (CSA) is increased in patients with left ventricular (LV) hypertrophy and is proportional to LV mass. This hypothesis was tested using computer-based quantitative analysis of LV mass and CSA from angiographic images of the left ventricle and proximal coronary arteries from 19 men and 21 women, aged 23 to 78 years (mean 56). Twenty-seven patients had valvular heart disease, 16 of whom had multivalvular involvement; diagnoses included aortic stenosis in 19, aortic regurgitation in 13 and mitral regurgitation in 12. Thirteen patients had normal valvular and ventricular function. All patients had normal coronary arteries. Significant differences between normal patients and those with valvular disease were noted in LV mass (88 +/- 7 vs 165 +/- 12 g/m2, p less than 0.001) and coronary CSA (26 +/- 2 vs 46 +/- 3 mm2, p less than 0.001). Furthermore, a linear relation between LV mass and coronary CSA was noted (r = 0.788, p less than 0.001). Thus, proximal coronary artery CSA is significantly larger in valvular heart disease patients with LV hypertrophy than in those with normal ventricles, and proximal coronary artery area increases in proportion to LV mass in hypertrophied ventricles.