Diagnostic and therapeutic approach of congenital solitary coronary artery fistulas in adults: Dutch case series and review of literature.

BACKGROUND: Coronary artery fistulas (CAFs) are infrequent anomalies, coincidentally detected during coronary angiography (CAG). AIM: To elucidate the currently used diagnostic imaging modalities and applied therapeutic approaches. MATERIALS AND METHODS: Five Dutch patients were found to have CAFs. A total of 170 reviewed subjects were subdivided into two comparable groups of 85 each, treated with either percutaneous 'therapeutic' embolisation (PTE group) or surgical ligation (SL group). RESULTS: In our series, the fistulas were visualised with several diagnostic imaging tests using echocardiography, multidetector computed tomography, and CAG. Four fistulas were unilateral and one was bilateral; five originated from the left and one originated from the right coronary artery. Among the reviewed subjects, high success rates were found in both treatment groups (SL: 97% and PTE: 93%). Associated congenital or acquired cardiovascular disorders were frequently present in the SL group (23%). Bilateral fistulas were present in 11% of the SL group versus 1% of the PTE group. The fistula was ligated surgically in one and abolished percutaneously in another. Medical treatment including metoprolol was conducted in two, and watchful waiting follow-up was performed in one. CONCLUSIONS: Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs.

Which drug to choose for stable angina pectoris: a comparative study between bisoprolol and nitrates.

The choice between beta-blockade or nitrates as first line treatment for stable angina pectoris is based upon the different mechanisms of action and patient characteristics. We performed a clinical trial comparing the efficacy of the longacting beta-blocker bisoprolol once daily and the short acting nitrate, isosorbide dinitrate, three times daily in the reduction of anginal complaints in daily life and under stress. Thirty patients were enrolled in a double-blind randomised cross-over study. Both bisoprolol and isosorbide dinitrate were effective in reducing anginal attacks and nitroglycerin consumption significantly, but bisoprolol was significantly more effective than isosorbide dinitrate. Bisoprolol improved the workload during bicycle exercise testing significantly, but the improvement with isosorbide dinitrate was not significant. Despite the reduction in maximal rate pressure product, bisoprolol was significantly (P < 0.05) more effective at improving total workload and reducing the time to onset of angina than isosorbide dinitrate. The rate pressure product did not change significantly with isosorbide dinitrate. In this study, bisoprolol 10 mg once daily was more effective and caused less side effects than isosorbide dinitrate 20 mg three times a day. It seems questionable if monotherapy of isosorbide dinitrate 20 mg t.i.d is an adequate drug regime for stable angina pectoris.

Clinical setting and prognostic significance of high degree atrioventricular block in acute inferior myocardial infarction: a study of 144 patients.

High degree AV block occurred in 144 of 843 patients consecutively admitted because of acute inferior myocardial infarction and was associated with more extensive myocardial damage and a higher mortality rate, as compared to those without AV block. Patients with power failure at the time of appearance of high degree AV block and a ventricular rate of less than 50 per minute, seemed to profit from pacemaker therapy. By contrast in patients with power failure and a ventricular rate of more than 50 per minute, pacemaker insertion did not affect immediate prognosis.

Immediate prognosis in recurrent myocardial infarction.

Of 880 patients admitted consecutively to a coronary-care unit with acute myocardial infarction, 200 had had a previous infarction. The mortality-rate in the first twenty-eight days after infarction was higher in the group with recurrent infarction (26 per cent) than in the group with first infarctions (16.9 per cent). When the patients were matched for sex and age this difference in mortality-rate was only statistically significant in men aged less than seventy. In patients with previous infarctions the short-term prognosis was worse in those with two or more previous infarctions, in those in whom infarction had occurred less than three months before, and in those with a previous infarction in the anteroseptal wall.