Resuscitation from cardiogenic shock by direct angioplasty and 23-hour balloon inflation using a coronary perfusion balloon.

Direct angioplasty is an accepted treatment for acute myocardial infarction and has resulted in stabilization and improvement in the clinical, electrocardiographic, and hemodynamic consequences of acute myocardial infarction. This case demonstrates the effectiveness of coronary perfusion as a method of resuscitation during cardiogenic shock and asystole in a patient with massive acute diaphragmatic and right ventricular infarction. Utilization of prolonged balloon inflation in this case obviated the need for emergency coronary bypass surgery and provided the patient with remarkable and almost complete recovery of left and right ventricular function.

Lipid management program: results of applying national guidelines in a private practice.

In our large single-specialty cardiology practice, we implemented a lipid management program based on the recommendations of the Expert Panel of the National Cholesterol Education Program and the Helsinki Heart Study. This program used allied health professionals and customized computer software to deliver efficient, comprehensive care to the 1214 patients enrolled in the program after 33 months. Data are reported for the 543 patients enrolled for more than 1 year. Cholesterol data were analyzed for all patients whose initial triglyceride values were less than 400 mg/dL. For this group of patients, the mean cholesterol level decreased from 242.7 to 217.4 mg/dL, triglycerides fell from 170.0 to 144.7 mg/dL, HDL cholesterol increased from 41.6 to 42.9 mg/dL, and LDL cholesterol fell from 167.2 to 145.7 mg/dL. Using guidelines modified from the National Cholesterol Education Program, a significant number of patients were able to achieve desirable LDL and HDL goals. Modified national guidelines can be used effectively in a private practice setting.

Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia.

A survey of the rural community in Evans County, Georgia, revealed cervical arterial bruits in 72 (4.4 per cent) of 1620 persons 45 years of age of older without previous stroke, transient ischemic attacks, or overt ischemic heart disease. The prevalence of such asymptomatic bruits increased with age and was greater in women and persons with hypertension. We estimated the risk of stroke associated with cervical bruits during a six-year follow-up period, taking age and blood pressure into account. The presence of asymptomatic bruits was associated with a significantly higher risk of stroke in men but not in women, with odds ratios of 7.5 and 1.6, respectively. Despite the high risk of stroke among men with bruits, the correlation between the location of the bruits and the type of subsequent stroke was poor. Moreover, cervical bruits in men were a risk factor for death from ischemic heart disease. We suggest that asymptomatic cervical bruits are an indication of systemic vascular disease and do not themselves justify invasive diagnostic procedures or surgical correction of underlying extracranial arterial lesions.

The combined effect of smoking and coffee drinking on LDL and HDL cholesterol.

Conflicting reports on the effect of smoking and coffee drinking on lipoproteins prompted us to study the combined effect of these two associated, widely prevalent habits in 361 persons randomly sampled from the Evans County cohort. Low-density lipoprotein (LDL) cholesterol levels were significantly higher among persons who smoked cigarettes and consumed five or more cups of coffee per day than among nonsmokers who abstained from coffee. Conversely, high-density lipoprotein (HDL) cholesterol was higher in persons who did not smoke or drink coffee than in coffee-consuming smokers. However, this trend was not statistically significant. Triglycerides and very low-density lipoprotein (VLDL) cholesterol were highest among smokers who drank five or more cups of coffee per day, but these differences did not reach statistical significance. Lipoprotein cholesterol levels were adjusted for age, sex and body mass. Smoking and coffee drinking interact in affecting LDL and total cholesterol, but coffee drinking alone did not appear to affect blood lipids.

Pericardial fluid gas analysis in hemorrhagic pericardial tamponade.

Nine patients with hemorrhagic pericardial tamponade were studied to determine the localizing value of gas analysis of pericardial fluid in therapeutic pericardiocentesis. The aspirate and the central venous blood was analyzed simultaneously for partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and hematocrit at the time of pericardiocentesis. In all 9 patients the difference in hematocrit between the pericardial fluid and the central venous blood was not significant. The PCO2 of pericardial fluid was significantly higher than that of central venous blood (p less than 0.025). The PO2 of pericardial fluid was consistently and significantly lower than that of central venous blood (p less than 0.005). We conclude that in patients with hemorrhagic pericardial tamponade, the simultaneous measurement of PO2 and PCO2 of central venous blood and pericardial fluid is a useful rapid bedside method to confirm the site of aspiration during pericardiocentesis. The PO2 determination is statistically the best discriminator between the two fluids in this setting.

Exercise stress testing--current status.

This paper is a review of the stress testing literature applying current methods of evaluation and analysis of exercise stress testing data to modern practice. Advantages and disadvantages of various methods for stress testing are discussed. Interpretation of the exercise stress test and an extensive discussion of 'false positive tests' as well as 'false negative tests' and correlation of stress testing results with other parameters of coronary heart disease provide the reader with material which is particularly relevant to frequently encountered clinical situations. The implications of a negative and adequate stress test as well as various degrees of positivity of results are reviewed. Emphasis is placed on subgrouping patients with coronary artery disease by exercise stress testing results into reasonably homogeneous and clinically relevant subgroups. The usefulness of exercise stress testing in other conditions such as valvular heart disease, cardiac rehabilitation, postoperative coronary bypass evaluation and application of radionucleotide scanning are reviewed.

Prophylactic use of intra-aortic ballon pump in aortocoronary bypass for patients with left main coronary artery disease.

Aortocoronary bypass surgery in patients with left main coronary artery disease is reported to have an operative mortality of between 1.4 and 39%. It is generally accepted that the operative mortality in this group of patients is considerably greater than in routine bypass candidates, presumably due to the large amount of myocardium threatened by a single lesion. In an effort to preserve threatened left ventricular myocardium, intra-aortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty per cent of these patients had New York Heart Association Class IV angina, 25% had Class III, and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina. Operative patients requiring left ventricular aneurysmectomy and/or valve replacement, were excluded. No operative deaths have been encountered in 20 consecutive patients managed in this manner. One patient displayed signs of myocardial infarction in the postoperative period. Correctable peripheral vascular ischemic complications of pump insertion were encountered in three patients. Preliminary results from this ongoing study support the hypothesis that prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized routinely in aortocoronary bypass surgery for left main coronary artery disease.

Comparison of angiographic and postmortem findings in patients with coronary artery disease.

The accuracy of coronary cineangiography in predicting the degree of stenosis in coronary arteries was evaluated by comparing autopsy and premortem cineangiographic findings in 25 patients. Coronary cineangiograms and autopsy specimens were reviewed independently by two cardiologists and two pathologists. Identical diagrams dividing the cononary arteries into 12 segments were used by both groups to record the location and degree of stenosis observed. Cineangiographic findings were in agreement with pathologic findings (less than 25 percent difference in cross-sectional luminal area) in 178 (79 percent) of the 226 segments examined, but overestimated the degree of stenosis in 13 (6 percent) and underestimated it in 34 (15 percent). Thus, cineangiography appears to be a reliable tool in evaluating coronary artery disease. When diagnostic errors are made, they are usually underestimations of the degree of disease; common causes of error are circumferential stenosis, eccentric lesions, obstruction of view by artifical valves and poor opacification due to severe proximal stenosis.