Comparing attitudes of younger and older patients towards cancer clinical trials.

OBJECTIVES: To determine the attitudes of patients towards cancer clinical trials (CCTs) and assess the differences between older and younger patients. MATERIALS AND METHODS: Patients with cancer, receiving treatment or in follow-up in University Hospital Waterford, Ireland were eligible. Patients completed a self-administered questionnaire. To determine attitudes towards CCTs, patients indicated their preference if offered participation in three hypothetical studies (cancer prevention/screening trial; CCT comparing standard to new treatment; a trial of new drug where no standard exists). Patients' reasons to or not to participate in CCTs were explored. RESULTS: From May 2014 to March 2015, 219 patients were accrued, 119 <65years and 100 ≥65years. Twenty-two (18%) younger and 4 (4%) older patients had been/were actively enrolled on a CCT (p=0.0012). No older patient and 5 (4%) of younger patients had enquired about CCT availability. For the CCT questions, 85 (71%) younger vs 57 (57%) older patients would participate in a prevention/screening CCT (p=0.033); 60 (50%) vs 44 (44%) for standard vs new drug (p=0.415), and 83 (69%) vs 78 (78%) for a CCT where no standard exists (p=0.218). The most common reason to participate in a CCT was a recommendation from the oncologist -98% <65years vs 87% ≥65years (p=0.001), with health problems being the leading reason not to participate, 86% vs 72% (p=0.01), respectively. CONCLUSIONS: Older and younger patients in this study gave similar importance to reasons for and against participation in CCTs. Most patients did not actively seek out a CCT, which may reflect a lack of awareness and a need for better education.

Prevalence of significant peripheral artery disease in patients evaluated for percutaneous aortic valve insertion: Preprocedural assessment with multidetector computed tomography.

OBJECTIVES: Percutaneous aortic valve insertion is an emerging treatment option for selected patients with severe aortic stenosis and may be done from a transfemoral or transapical approach. Concomitant atherosclerotic peripheral artery disease limits transfemoral access. We evaluated the potential role of multidetector computed tomography in preoperative assessment of vascular anatomy. METHODS: Consecutive patients with severe aortic stenosis were included. Contrast-enhanced computed tomographic angiography of the thoracic and abdominal aorta and iliofemoral arteries was performed. Criteria of unfavorable iliofemoral anatomy were defined as a minimal luminal diameter of the common iliac, external iliac, or common femoral arteries of less than 8 mm, presence of greater than 60% circumferential calcification at the external-internal iliac bifurcation, and severe angulation between the common and external iliac arteries (< 90 degrees ). The prevalence of these criteria was evaluated and infrarenal aortic and iliofemoral arterial anatomy was compared in the groups with and without peripheral artery disease for any of these criteria. RESULTS: One hundred patients (79 +/- 9 years, 59% male) were included. A total of 35 (35%) patients had at least one criterion of unsuitable iliofemoral anatomy, including 27 patients with small minimal luminal diameter (<8 mm), 12 patients with severe circumferential calcification at the iliac bifurcation (>60%), and 4 with severe angulation of the iliac arteries (<90 degrees ). CONCLUSIONS: Significant atherosclerotic peripheral artery disease is common in the high-risk patient population currently evaluated for percutaneous aortic valve insertion. Computed tomography allows identification of patients with iliofemoral anatomy unfavorable for the transfemoral approach to percutaneous aortic valve insertion.

Aortic root morphology in patients undergoing percutaneous aortic valve replacement: evidence of aortic root remodeling.

OBJECTIVE: Percutaneous aortic valve replacement is an emerging therapy for selected patients with severe aortic stenosis. Preoperative imaging of the aortic root facilitates sizing and deployment of the percutaneous aortic valve replacement device. We compared morphologic characteristics of the aortic root in patients with aortic stenosis versus elderly gender-matched controls using multidetector computed tomography. METHODS: Twenty-five consecutive subjects with severe calcific aortic stenosis referred for percutaneous aortic valve replacement and 25 elderly gender-matched controls were scanned on a Siemens Definition Dual Source (Siemens Medical, Forchheim, Germany) multidetector computed tomography scanner. Distances from the valve annulus to the coronary artery ostia and sinotubular junction, dimensions of the aortic root, and characteristics of the valve cusps were determined. RESULTS: Subjects with aortic stenosis had reduced distance from the aortic valve annulus to the inferior margins of the left and right coronary artery ostium and sinotubular junction compared with controls. There were no significant differences in cross-sectional dimensions of the aortic root. CONCLUSION: The distance from the aortic valve annulus to the coronary artery ostia and sinotubular junction is reduced in patients with aortic stenosis compared with controls. This finding suggests that longitudinal remodeling of the aortic root occurs in calcific aortic stenosis and has implications for the design and deployment of percutaneous aortic valve replacement devices.

Effect of chronic sustained-release dipyridamole on myocardial blood flow and left ventricular function in patients with ischemic cardiomyopathy.

Dipyridamole increases adenosine levels and augments coronary collateralization in patients with coronary ischemia. This pilot study tested whether a 6-month course of sustained-release dipyridamole/aspirin improves coronary flow reserve and left ventricular systolic function in patients with ischemic cardiomyopathy. Six outpatients with coronary artery disease and left ventricular ejection fraction (LVEF) <40% were treated with sustained-release dipyridamole 200 mg/aspirin 25 mg twice daily for 6 months. Myocardial function and perfusion, including coronary sinus flow at rest and during intravenous dipyridamole-induced hyperemia, were measured using velocity-encoded cine magnetic resonance stress perfusion studies at baseline, 3 months, and 6 months. There was no change in heart failure or angina class at 6 months. LVEF increased by 39%+/-64% (31.0%+/-13.3% at baseline vs 38.3%+/-10.7% at 6 months; P=.01), hyperemic coronary sinus flow increased more than 2-fold (219.6+/-121.3 mL/min vs 509.4+/-349.3 mL/min; P=.01), and stress-induced relative myocardial perfusion increased by 35%+/-13% (9.4%+/-3.4% vs 13.9%+/-8.5%; P=.004). Sustained-release dipyridamole improved hyperemic myocardial blood flow and left ventricular systolic function in patients with ischemic cardiomyopathy.

Brugada electrocardiographic pattern due to tricyclic antidepressant overdose.

The Brugada syndrome is an arrhythmogenic disease with characteristic coved ST-segment elevation 2 mm or greater in the right precordial leads (type 1 Brugada electrocardiogram [ECG] pattern or "Brugada sign"] and is estimated to be responsible for at least 20% of sudden deaths in patients with structurally normal hearts [Circulation 2005;111(5):659-70]. The Brugada sign has been described in asymptomatic patients after exposure to various drugs. As published reports of the drug-induced Brugada sign have become increasingly prevalent, there is growing interest in the mechanisms responsible for this acquired ECG pattern and its clinical significance. We report a case of a patient who developed the type 1 Brugada ECG pattern after intentional overdose of a tricyclic antidepressant agent, review the literature concerning tricyclic antidepressant agent-induced Brugada sign, discuss potential mechanisms, and evaluate the clinical significance of this ECG abnormality.

Effect of external counterpulsation on plasma nitric oxide and endothelin-1 levels.

Enhanced external counterpulsation (EECP) significantly augments diastolic blood flow and has been postulated to improve endothelial function by increased shear stress. We examined the effects of EECP on plasma nitric oxide and endothelin-1 (ET-1) levels. Plasma nitrate and nitrite (NOx) and ET-1 levels were measured serially in 13 patients with coronary artery disease who received 1-hour daily treatments of EECP over 6 weeks. During the course of EECP therapy, plasma NOx progressively increased and plasma ET-1 progressively decreased. After 36 hours of EECP, there was a 62 +/- 17% increase in plasma NOx compared with baseline (43.6 +/- 4.3 vs 27.1 +/- 2.6 micromol/L, p <0.0001) and a 36 +/- 8% decrease in plasma ET-1 (76.7 +/- 9.5 vs 119.5 +/- 8.5 pg/L, p <0.0001). At 3 months after completion of EECP, NOx remained 12 +/- 11% above baseline (p = 0.002), and ET-1 remained 11 +/- 10% below baseline (p = 0.0068). Our data provides neurohormonal evidence to support the hypothesis that EECP improves endothelial function.

Randomized study of the safety and clinical utility of rotational vs. standard coronary angiography using a flat-panel detector.

The purpose of this study was to test the hypothesis that rotational angiography improves patient safety while maintaining diagnostic accuracy for patients undergoing coronary angiography. Despite advances in angiographic technique, patients remain at risk for complications of coronary angiography, including contrast-induced nephropathy and radiation exposure. Technology has been developed to perform coronary angiography with active rotation of the imaging system that may reduce the quantity of contrast and radiation to which the patient is exposed. Fifty patients undergoing diagnostic cardiac catheterization were randomized to either standard vs. rotational angiography of the coronary arteries using a prespecified protocol with a flat-panel single-plane imaging system. We measured the quantity of radiographic contrast utilized and radiation exposure. Using an intention-to-treat analysis, there was a 40% reduction (24 +/- 5 vs. 40 +/- 10 ml; P < 0.0001) in contrast utilization in the rotational group compared to the standard group. Neither radiation exposure (35 +/- 14 vs. 30 +/- 20 Gycm(2); P = 0.35), fluoroscopic time (44 +/- 33 vs. 44 +/- 40 sec; P = 0.99), nor procedure time (249 +/- 137 vs. 214 +/- 79 sec; P = 0.26) differed, although significant intraoperator variability was noted for both standard and rotational angiography. The radiation exposure using this flat-panel system is significantly lower than prior reports that used an image intensifier system. Rotational coronary angiography has the potential to improve patient safety by markedly reducing radiographic contrast exposure while maintaining comparable diagnostic accuracy, radiation exposure, and procedure time compared to standard coronary angiography.