Combination use of a TandemHeart with an extracorporeal oxygenator in the treatment of five patients with refractory cardiogenic shock after acute myocardial infarction.

Cardiogenic shock remains the leading cause of in-hospital death for patients admitted with acute myocardial infarction. For patients with refractory cardiogenic shock, early revascularization and intra-aortic balloon pump support are often inadequate to reverse the persistent circulatory collapse. We report 5 cases in which an extracorporeal oxygenator in series with the TandemHeart system was instituted emergently in patients with refractory cardiogenic shock from acute myocardial infarction. From our experience, we showed that the device can be safely and easily inserted and that it is able to reverse circulatory collapse and provide hemodynamic stability in patients who otherwise have a high mortality rate.

Prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention treated with heparin 5000 IU administered systemically versus 500 age-matched and sex-matched patients treated with heparin 70 IU/kg administered systemically.

We investigated the prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention (PCI) treated with heparin 5000 IU administered systemically (group 1) at the time of PCI versus in 500 age-matched and sex-matched patients undergoing PCI treated with heparin 70 IU/kg administered systemically (group 2) at the time of PCI. There was no significant difference in baseline characteristics, indications for PCI, cardiovascular drug therapy at the time of PCI, prevalence of 1-vessel, 2-vessel, and 3-vessel obstructive coronary artery disease, and in-hospital complications between the 2 groups. In-hospital death occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Non-ST-segment elevation myocardial infarction occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. Stroke occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Stent thrombosis occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Occlusion of a side branch occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. A hematoma needing intervention occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Regression analysis showed that none of the differences between the 2 groups were significant. The sample size was adequate to conclude that a fixed low dose of heparin 5000 IU administered systemically at the time of PCI is noninferior to standard therapy with heparin.

Major adverse cardiac events at long-term follow-up in patients treated with single versus multiple stents during single-vessel percutaneous coronary intervention.

BACKGROUND: Although insertion of multiple stents into a single coronary vessel during single-vessel percutaneous coronary intervention (PCI) is common, there are no data on long-term occurrence of major adverse cardiac events (MACE) in patients treated with multiple stents versus a single stent. METHODS: The incidence of MACE (death, myocardial infarction, or target vessel revascularization) during long-term follow-up was investigated in 634 patients who underwent single-vessel PCI. Of the 634 patients, 319 (50%) had a single stent, and 315 (50%) had multiple stents inserted. Stepwise Cox regression analyses were performed to identify significant independent prognostic factors for MACE. RESULTS: At 47-month follow-up, MACE occurred in 61 of 319 patients (19%) who had a single stent versus in 57 of 315 patients (18%) who had multiple stents (P not significant). Significant independent predictors of MACE were use of vein grafts (hazard ratio = 1.94; 95% CI, 1.24-3.03; P = 0.0038) and use of drug-eluting stents (hazard ratio = 0.49; 95% CI, 0.34-0.72; P = 0.0002). CONCLUSIONS: At long-term follow-up of single-vessel PCI, the incidence of MACE was similar in patients with multiple or single stents inserted even after controlling for the length of stents.

Incidence of new stroke or new myocardial infarction or death at 39-month follow up in patients with diabetes mellitus, hypertension, or both treated with and without angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

We investigated in 306 patients, mean age 57 ± 10 years, with diabetes mellitus (202 patients) or hypertension (179 patients), whether treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ARBs) reduced the incidence of new stroke or new myocardial infarction (MI) or death. At 39-month follow up, new stroke or new MI or death developed in 49 of 228 patients (21%) treated with ACE inhibitors or ARBs and in 33 of 78 patients (42%) treated without angiotensin-converting enzyme inhibitors or ARBs (P = 0.0001). Stepwise Cox regression analysis showed that significant independent predictors of the time to development of new stroke or new MI or death were 1) use of angiotensin-converting enzyme inhibitors or ARBs (risk ratio, 0.21), 2) diabetes (risk ratio, 4.01), 3) left ventricular hypertrophy (risk ratio, 6.71), 4) prior stroke (risk ratio, 4.00), and 5) prior MI (risk ratio, 3.69).

A planar QRS-T angle >90 degrees is associated with multivessel coronary artery disease in patients undergoing coronary angiography.

BACKGROUND: The aim of the study was to investigate the severity of coronary artery disease (CAD) in patients who had a planar QRS-T angle >90 degrees versus 50% obstruction of >or=1 major coronary artery. All QRS-T angle measurements were made from a 12-lead electrocardiogram by 2 authors who agreed on the measurement and who were blinded to the coronary angiographic findings. A QRS-T angle >90 degrees was considered abnormal. RESULTS: Obstructive CAD of 2 or 3 vessels was present in 309 of 495 patients (62%) with a planar QRS-T angle >90 degrees and in 250 of 734 patients (34%) with a planar QRS-T angle or=30 kg/m2 (odds ratio =1.5). CONCLUSIONS: The prevalence of 2- or 3-vessel obstructive CAD was significantly higher in patients with a planar QRS-T angle >90 degrees than in patients with a planar QRS-T angle

Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography.

The prevalence of an enlarged ascending thoracic aortic diameter (AAD) diagnosed by 2-dimensional echocardiography compared with 64-slice cardiac computed tomography (MSCT) was investigated in 97 women and 117 men (mean age 65 +/- 12 years). Enlarged AADs were diagnosed in 42 of 214 patients (20%) by echocardiography and in 45 of 214 patients (21%) by MSCT (p = NS). The sensitivity, specificity, positive predictive value, and negative predictive value of echocardiography in diagnosing an enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively. A Bland-Altman plot showed that the agreement for AAD measured by echocardiography and MSCT was 95% inside the 2-SD limits. In conclusion, the sensitivity, specificity, positive predictive value, and negative predictive value of 2-dimensional echocardiography in diagnosing enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively.

Relation of bone mineral density to frequency of coronary heart disease.

Coronary angiography was performed because of chest pain in 198 patients (146 women, 52 men; mean age 66 years) who had dual-energy x-ray absorptiometry scans of the spine and left hip because of suspected osteoporosis or osteopenia. Of the 198 patients, 53 (27%) had osteoporosis, 79 (40%) had osteopenia, and 66 (33%) had normal bone mineral density (BMD). Obstructive coronary artery disease with >50% narrowing of > or =1 major coronary artery was present in 40 of 53 patients (76%) with osteoporosis, in 54 of 79 patients (68%) with osteopenia, and in 31 of 66 patients (47%) with normal BMD (p <0.005 comparing osteoporosis with normal BMD, p <0.01 comparing osteopenia with normal BMD). In conclusion, in patients who undergo coronary angiography because of chest pain, patients with osteoporosis or osteopenia have a higher prevalence of obstructive coronary artery disease than those with normal BMD.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease.

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Pseudoaneurysm with thrombus and left ventricular inflow obstruction after left circumflex stenting.

A 61-year-old woman had stenting of the left circumflex coronary artery. She had a repeat coronary angiogram the day after stenting because of hypotension and orthopnea. The left circumflex stent was patent. A transesophageal echocardiogram showed a 2.5 cm x 3.0-cm mass in the atrioventricular groove compressing the left atrium. A pseudoaneurysm with thrombus and left ventricular inflow obstruction was diagnosed. The patient was observed for 48 hours to allow the pseudoaneurysm to seal and coagulate. She then had surgical evacuation of the thrombus, which had caused her hypotension and orthopnea by compression of the left atrium.

Incidence of new stroke or new myocardial infarction or death at 39-month follow-up in patients with diabetes mellitus, hypertension or both with and without microalbuminuria.

We investigated in 306 patients, mean age 57 +/- 10 years, with diabetes mellitus (202 patients) or hypertension (179 patients) whether microalbuminuria was a significant independent risk factor for the development of new stroke or new myocardial infarction (MI) or death. At 39-month follow-up, new stroke or new MI or death developed in 44 of 111 patients (40%) with microalbuminuria and in 38 of 195 patients (19%) without microalbuminuria (p = 0.0001). Stepwise Cox regression analysis showed that significant independent predictors of the time to development of new stroke or new MI or death were (1) diabetes (risk ratio = 1.76), (2) left ventricular (LV) mass index (risk ratio = 1.020 for each 1 g/m(2) increase), (3) prior stroke (risk ratio = 5.39), and (4) prior MI (risk ratio = 3.29). Microalbuminuria was not a significant independent predictor of new stroke or new MI or death, but LV mass index, diabetes mellitus, prior stroke, and prior MI were significant independent predictors.

Relation of increased hemoglobin A(1c) levels to severity of peripheral arterial disease in patients with diabetes mellitus.

The association between hemoglobin A(1c) levels and the severity of peripheral arterial disease (PAD) was investigated in 224 patients with diabetes mellitus and PAD. The mean hemoglobin A(1c) levels were 9.1 +/- 2.1% in patients with diabetes with ankle-brachial indexes (ABIs) <0.60 and 7.1 +/- 0.9% in those with ABIs of 0.60 to 0.89 (p <0.0001). Hemoglobin A(1c) levels <6.5% were present in 2 of 89 patients with diabetes (2%) with ABIs <0.60 and in 24 of 135 (18%) with ABIs of 0.60 to 0.89 (p = 0.0004). Hemoglobin A(1c) levels <7.0% were present in 24 of 89 patients with diabetes (27%) with ABIs <0.60 and in 63 of 135 (47%) with ABIs of 0.60 to 0.89 (p = 0.003). Hemoglobin A(1c) levels <7.5% were present in 30 of 89 patients with diabetes (34%) with ABIs <0.60 and in 92 of 135 (68%) with ABIs of 0.60 to 0.89 (p <0.0001). In conclusion, the higher the hemoglobin A(1c) levels in patients with diabetes with PAD, the higher the prevalence of severe PAD.

Comparison of age, body mass index, and frequency of systemic hypertension and diabetes mellitus in patients having coronary angioplasty in 1996 versus in 2006.

The data submitted to the New York State Department of Health Coronary Angioplasty Reporting System Database on coronary angioplasties performed at Westchester Medical Center/New York Medical College from 1996 to 2005 were analyzed. Compared with 1996, during 2005, more coronary angioplasties were performed (1,624 vs 1,122), and the patients were older (mean age 64.5 vs 61.0 years, p <0.001), weighed more (84.2 vs 82.0 kg, p <0.001), had a higher mean body mass index (28.8 vs 28.3 kg/m(2), p <0.001), and had a higher prevalence of diabetes mellitus (27% vs 17%, p <0.001). The prevalence of systemic hypertension was significantly higher in 2005 (76%) than in 1996 (54%) (p <0.001). In conclusion, in 2005 compared with 1996, patients who underwent coronary angioplasty at Westchester Medical Center/New York Medical College were older, had higher body mass indexes, and had higher prevalences of diabetes mellitus and systemic hypertension.

Prevalence of an increased ascending and descending thoracic aorta diameter diagnosed by multislice cardiac computed tomography in men versus women and in persons aged 23 to 50 years, 51 to 65 years, 66 to 80 years, and 81 to 88 years.

The prevalence of increased ascending thoracic aortic diameter (AAD) and increased descending thoracic aortic diameter (DAD) diagnosed using multislice cardiac computed tomography was investigated in 624 consecutive patients at an academic cardiology practice in 2006. Increased AAD (>3.7 cm) was present in 71 of 361 men (20%) and in 23 of 263 women (9%) (p <0.001). Increased DAD (>3.0 cm) was present in 26 of 339 men (8%) and in 8 of 258 women (3%) (p <0.02). Increased AAD was present in (1) 7 of 96 patients (7%) aged 23 to 50 years, (2) 22 of 234 patients (9%) aged 51 to 65 years, (3) 53 of 263 patients (20%) aged 66 to 80 years, and (4) 12 of 31 patients (39%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1; p <0.001 comparing groups 4 and 1, groups 4 and 2, and groups 3 and 2; p <0.02 comparing groups 4 and 3). Increased DAD was present in (1) 0 of 96 patients (0%) aged 23 to 50 years, (2) 5 of 227 patients (2%) aged 51 to 65 years, (3) 21 of 244 patients (9%) aged 66 to 80 years, and (4) 8 of 30 patients (27%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1, groups 3 and 2, and groups 4 and 3; p <0.001 comparing groups 4 and 1 and groups 4 and 2). In conclusion, men have a higher prevalence of increased AAD and DAD than women, and increasing age increases the prevalence of increased AAD and DAD.

In-hospital mortality and time from onset of symptoms of acute myocardial infarction in 540 patients undergoing primary coronary angioplasty. Comparison between blacks, whites and patients of other races, and between men and women.

The time from the onset of symptoms of acute myocardial infarction to primary coronary angioplasty was 18 +/- 23 h in 386 men and 19 +/- 24 h in 154 women (p not significant) and 14 +/- 19 h in 27 blacks, 19 +/- 23 h in 493 whites, and 13 +/- 11 h in 20 patients of different races (p not significant). In-hospital mortality was 6% in 144 patients aged > or =70 years and 1% in 396 patients <70 years (p < 0.005). In-hospital mortality was 2% in 386 men and 4% in 154 women (p not significant). In-hospital mortality was 2% in 493 whites, 4% in 27 blacks, and 0% in 20 patients of other races (p not significant). In-hospital mortality was 6% in 143 patients with a left ventricular ejection fraction (LVEF) <40% and 1% in 397 patients with a LVEF > or =40% (p < 0.005). In-hospital mortality was 5% in 223 patients with a glomerular filtration rate (GFR) <90 ml/min and 1% in 317 patients with a GFR > or =90 ml/min (p < 0.005).

Association of hemoglobin A(1c) level with the severity of coronary artery disease in patients with diabetes mellitus.

Coronary angiography was performed in 152 men and 163 women with diabetes mellitus (mean age 55 +/- 8 years) because of chest pain. The mean hemoglobin A(1c) level was 6.66 +/- 0.58% in 132 patients with 0-vessel coronary artery disease (CAD), 8.00 +/- 0.84% in 40 patients with 1-vessel CAD, 8.83 +/- 1.45% in 76 patients with 2-vessel CAD, and 10.40 +/- 2.28% in 67 patients with 3- or 4-vessel CAD. There was a significant increasing trend of hemoglobin A(1c) levels over the increasing number of vessels with CAD (p <0.0001).

Comparison of prevalence of unrecognized myocardial infarction and of silent myocardial ischemia detected by a treadmill exercise sestamibi stress test in patients with versus without diabetes mellitus.

We investigated, in 287 patients with diabetes (71% men; mean age 63 +/- 8 years) and 292 age- and gender-matched patients with diabetes, the prevalence of unrecognized myocardial infarction (MI) and silent myocardial ischemia (SMI) detected by a treadmill exercise sestamibi stress test. In the patients without a history of MI, MI was diagnosed by treadmill exercise sestamibi stress test in 40 of 217 patients (18%) with diabetes and 16 of 224 patients (7%) without diabetes (p <0.001). In patients with a history of angina, SMI was diagnosed in 35 of 98 patients (36%) with diabetes and 30 of 101 patients (30%) without diabetes (p = NS). In patients without a history of angina, SMI was diagnosed in 62 of 189 patients (33%) with diabetes and 35 of 191 patients (15%) without diabetes (p <0.001). In patients with 2 or 3 risk factors, SMI was diagnosed in 58 of 144 patients (40%) with diabetes and 41 of 142 patients (29%) without diabetes (p <0.005). In patients with 0 or 1 risk factor, SMI was diagnosed in 39 of 143 patients (27%) with diabetes and 24 of 150 patients (16%) without diabetes (p <0.02). In conclusion, patients with diabetes have a higher prevalence of unrecognized MI and a higher prevalence of SMI without a history of angina than patients without diabetes.

Prevalence of silent myocardial ischemia in persons with diabetes mellitus or impaired glucose tolerance and association of hemoglobin A1c with prevalence of silent myocardial ischemia.

Silent myocardial ischemia detected by exercise treadmill or pharmacologic sestamibi stress testing was present in 67 of 196 patients (34%) who had diabetes mellitus or impaired glucose tolerance and in 89 of 640 patients (14%) who had normal glucose tolerance (p <0.001). Among those who had diabetes mellitus or impaired glucose tolerance, silent myocardial ischemia was present in 27 of 54 patients (50%) who had a hemoglobin A1c level > or =7.6% and in 39 of 137 patients (28%) with a hemoglobin A1c level <7.6% (p <0.005).

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure.

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Increased fasting plasma insulin concentrations are associated with the severity of angiographic coronary artery disease.

Fasting plasma insulin concentrations were obtained in 82 patients (51 men and 31 women), mean age 60 +/- 11 years, with a body mass index >25 kg/m(2) who had coronary angiography because of suspected symptomatic coronary artery disease (CAD). Obstructive CAD was diagnosed if there was >50% obstruction of > or =1 vessel. Of 82 patients, 37 (45%) had left main or 3-vessel CAD, 22 (27%) had 2-vessel CAD, 9 (11%) had 1-vessel CAD, and 14 (17%) had no obstructive CAD. Among the 4 groups, there was no significant difference in gender, age, dyslipidemia, and smoking. Hypertension (p = 0.0003), diabetes mellitus (p = 0.035), and increased fasting plasma insulin concentration (p < 0.0001) were significantly associated with the severity of CAD. Stepwise ordinal logistic regression analysis identified increased fasting plasma insulin concentrations in these obese subjects as a significant independent risk factor for the severity of angiographic CAD (p < 0.0001).