Nonrheumatic atrial fibrillation: a brief overview.

OBJECTIVE: To review the effectiveness of current approaches in the treatment of patients with nonrheumatic atrial fibrillation (NRAF). DESIGN: Review of the available English-language articles on the epidemiology, clinical consequences, management and prevention of stroke in patients with NRAF. RESULTS: The incidence of atrial fibrillation increases steadily in both sexes in relation to age. The clinical independent risk factors for NRAF are diabetes mellitus, hypertension, recent heart failure, valvular heart disease and myocardial infarction. The echocardiographic predictors are left atrial enlargement, reduced left ventricular function and left ventricular wall thickness. The clinical consequences of NRAF are increased risk of stroke, mortality and left ventricular dysfunction. The management of NRAF includes correction of cause, termination of acute episode, maintenance of sinus rhythm, ventricular rate control and prevention of systemic embolism. CONCLUSION: NRAF is a common cardiac arrhythmia that is associated with high incidence of mortality and systemic embolism. Anticoagulation is effective in preventing embolism with acceptable risk of major bleeding. Acetylsalicylic acid is less effective but a reasonable alternative when anticoagulation is contraindicated.

Undergoing cardiac catheterization: the effects of informational preparation and coping style on patient anxiety during the procedure.

OBJECTIVE: To examine the effects of coping styles and preparatory informational treatments on patient anxiety during cardiac catheterization. DESIGN: Prospective, experimental, random assignment, repeated measures design. SETTING: Canadian, university-affiliated, large urban hospital. SUBJECTS: 145 adult patients (107 men and 38 women) scheduled for their first cardiac catheterization. Age range was from 34 to 78 years. Mean educational level was 10.72 years. OUTCOME MEASURES: Subject's coping style, "monitoring" (information seeking) or "blunting" (information avoiding) was assessed by means of Miller's Behavioral Style Scale. Subjects' anxiety was assessed using three measures: (1) a self-report measure, the Subjective Units of Distress (SUDS) Scale; (2) a behavioral measure, the Cardiac Catheterization Adjustment (CA) Scale; and (3) physiologic measures, heart rate and systolic and diastolic blood pressure. INTERVENTION: After coping style assessment, monitors and blunters were randomly assigned to receive one of three preparatory informational treatments: (1) videotaped procedural modeling information, (2) videotaped procedural-sensory modeling information, and (3) procedural-sensory information booklet. RESULTS: Analysis of variance techniques applied to the anxiety data revealed the following: (1) significant changes in self-reported patient anxiety occurred as a function of occasion rather than preparatory informational treatment or coping style, (2) subjects receiving the three preparatory informational treatments demonstrated significantly different behavioral adjustments during cardiac catheterization, and (3) most subjects demonstrated heart rate and blood pressure readings in the normal range; however, significant changes in cardiovascular reactivity were found to be associated with contrast dye insertion. CONCLUSIONS: Subjects who received the videotaped modeling treatments demonstrated greater behavioral adjustment than patients who received the information booklet. Questions remain as to whether the procedural modeling treatment is more efficacious than the procedural-sensory modeling treatment. Increases in subjects' SUDS levels were found to be associated with changes in ideational content. Changes in blood pressure and heart rate were attributed to physiologic and psychologic factors. Coping style did not appear to significantly influence any of the measures of patient anxiety.

Preparing adult patients for cardiac catheterization: informational treatment and coping style interactions.

OBJECTIVE: To examine the interacting effects of coping style and type of preparatory informational treatment on cardiac catheterization patient anxiety. DESIGN: Pretest-posttest randomized control group design. SETTING: Canadian, university-affiliated, large urban hospital. SUBJECTS: 145 adult patients (107 men and 38 women) scheduled for their first cardiac catheterization. Age range was from 34 to 78 years. Mean educational level was 10.72 years. OUTCOME MEASURES: Subject's coping style (monitoring [information seeking] or blunting [information avoiding]) was assessed by means of Miller's Behavioral Style Scale. Subject's anxiety was assessed by means of Speilberger's A-Trait and A-State Inventory. INTERVENTION: After coping style assessment, monitors and blunters were randomly assigned to receive one of three preparatory informational treatments: (1) videotaped procedural modeling information; (2) videotaped procedural-sensory modeling information; and (3) procedural-sensory information booklet. RESULTS: Subjects' anxiety was assessed before and after intervention (Time 1 and Time 2) and before and after catheterization (Time 3 and Time 4). Analysis of variance techniques applied to the anxiety data largely confirmed the hypothesized interaction between subjects' coping style and type of preparatory informational treatment. Monitors who received the procedural-sensory modeling video treatment and blunters who received the procedural modeling video treatment reported significant reductions in A-state anxiety at Time 2 and maintained that decrease at Time 3. In contrast, monitors and blunters who received the other preparatory informational treatments reported a significant increase in A-state anxiety or a nonsignificant change in A-state anxiety at Time 2 and Time 3. At Time 4 monitors and blunters in each of the treatment groups reported a significant decrease in A-state anxiety. CONCLUSIONS: Two unexpected findings emerged from the study: (1) female monitors and blunters reported significantly higher A-state anxiety levels than their male counter-parts at preintervention, and (2) significant differences were observed among the preintervention A-state anxiety means of male monitors in the three preparatory treatment groups. These findings limit the conclusions that can be drawn from the study but provide direction for future research in the preparatory area.

The changing clinical profile of coronary artery bypass graft patients, 1970-89.

OBJECTIVE: To review the changing clinical profile of isolated coronary artery bypass graft (CABG) surgery patients at the University of Alberta Hospitals during the past two decades. DESIGN: Data were obtained retrospectively by review of patients' hospital charts and cardiologists' charts. The three patient cohorts consisted of the first 411 consecutive patients who underwent isolated CABG surgery between 1970 and 1974, 302 consecutive patients who had CABG surgery in 1984 and 346 consecutive patients who had the operation in 1989. RESULTS: Patients who underwent CABG surgery in 1984 and 1989 were older than patients undergoing the same operation in the 1970s. Emergency and/or urgent operations and the number of patients with prior myocardial infarct were increased significantly in 1984 and 1989. The incidence of patients with multiple vessel disease and left main stem stenosis increased significantly over the two decades. The number of bypass grafts per patient and the use of internal mammary grafts have increased since 1970. The endarterectomy procedure was performed less frequently in 1984 and 1989. The use of radial artery grafts has been discontinued. Perioperative mortality remained stable throughout the study period despite an increasing incidence of high risk patients. The major cause of death was pump failure. The incidence of peripostoperative myocardial infarct was higher in the 1970s. A multivariate analysis of the 1984 and 1989 cohorts was performed to identify temporal trends in risk factors. Emergency surgery, preoperative heart failure, age (older than 65 years), prior CABG surgery and preoperative renal failure are significant predictors of operative motility. CONCLUSIONS: The clinical profile of patients for isolated CABG surgery has changed over the years. The mortality rate has been stable over two decades despite the advancement of medical and surgical practices, representing a balance of increasingly high risk patients presenting for CABG surgery.

Long term clinical outcomes following isolated mitral valve replacement.

OBJECTIVE: This study reviews the short and long term outcomes of patients who underwent isolated mitral valve replacement at the University of Alberta Hospitals during the past decade. DESIGN: Data were obtained retrospectively by review of patients' hospital charts, cardiologists' follow-up charts, contact with patients' physicians, and direct telephone or mail contact with patients and/or their surviving relatives. RESULTS: The clinical outcomes of 198 consecutive patients (124 women and 74 men) who underwent isolated mitral valve replacement from January 1981 to December 1990 at the University of Alberta Hospital were reviewed. Overall early operative mortality was 11%. Deaths were mainly related to pump failure and previous mitral valve replacement. Late mortality was 17%. Follow-up data were available except in five patients. Average follow-up was 6.3 years. Overall cumulative survival was 72.9 +/- 3.4% at five years and 63.1 +/- 4.8% at 10 years. The cumulative freedom from complications was 64.3 +/- 3.9% and 36.4 +/- 4.9% at five and 10 years, respectively. Long term survival rates obtained after isolated mitral valve replacement are higher than those reported in series of medically treated patients with mitral valve disease. CONCLUSIONS: Mitral valve replacement can prolong survival as well as improve symptoms in patients with symptomatic mitral valve disease.

Long term follow-up after isolated aortic valve replacement.

Between January 1982 and June 1989, 102 consecutive patients (25 women and 77 men) who had isolated aortic valve replacements were reviewed. The overall early operative mortality was 5%. The deaths were related mainly to pump failure and endocarditis. The early operative mortality in younger patients (less than 70 years old) was 3.5% and in the elderly (70 or older) 11%. The overall late mortality was 4%. All of the survivors except three (follow-up by telephone) were seen in follow-up by cardiologists. The mean follow-up was 40 +/- 26 months (range four to 89). Eighty-seven per cent of all patients or 92% of the survivors in the younger population did well following the operation. In the elderly patients, the results were less favorable (P less than 0.025). The overall cumulative survival was 92% at one year and 89% at five years. The actuarial event-free percentage of survivors was 86% at one year and 74% at five years. Aortic valve replacement can be accomplished in symptomatic patients with an acceptable operative mortality. Long term follow-up of these patients showed functional improvement and low mortality.

Clinical efficacy of emergency bypass surgery for failed coronary angioplasty.

The clinical and angiographic variables of 26 coronary artery disease patients at the University of Alberta Hospitals requiring emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) were reviewed. Emergency CABG was judged necessary in 2% of 1300 consecutive patients undergoing PTCA. The most frequent indication for an emergency operation was dissection and acute closure of eccentric bend point target lesions associated with clinically severe, unremitting chest pain and ST-T abnormalities suggestive of impending myocardial infarction. The mortality rate for the combined procedures of failed PTCA and CABG was low (3.8%). The incidence of periprocedural infarction was high (61%); it was, however, associated with a benign clinical course and electrocardiographic evidence of significant reversibility of acute phase damage. Thus, overall, emergency CABG appears to be a clinically efficacious treatment for patients with threatened or impending infarction as a consequence of failed PTCA.

Risk stratification after percutaneous transluminal coronary angioplasty.

Approximately 20-30% of patients who undergo elective percutaneous transluminal coronary angioplasty (PTCA) require a second angioplasty within 12 months. A significant proportion of patients develop clinical cardiac events during the first year following the initial procedure. The present investigation was undertaken to establish a statistical model for predicting such events. The study group consisted of 100 patients who underwent elective PTCA at the University of Alberta Hospital. All patients were prescribed nifedipine (10 mg tid) and aspirin (325 mg daily) in addition to other medications determined by the attending cardiologist. The patients were reviewed 10 weeks after the procedure and again at the end of 1 year. The follow-up was completed on 96 patients. Within the first year, forty-five experienced cardiac events (1 death, 5 myocardial infarctions, 4 bypass surgeries, 22 repeat PTCAs). These events occurred in 29 patients. An additional 16 patients experienced significant anginal symptoms. A statistical model based upon the patients' perception of symptoms immediately after the procedure, history of hypertension, vessel subjected to PTCA, ejection fraction pre-PTCA, and occurrence of intimal dissection during PTCA was used to identify patients likely to develop cardiac events. Overall, the model classified 72% of the patients (with and without events). Such a statistical model could be used to identify patients who should be subjected to an enhanced degree of cardiologic surveillance in a rehabilitation program.

Isolated unruptured sinus of Valsalva aneurysm producing right ventricular outflow obstruction.

An unusual case of right ventricular outflow obstruction and right heart failure due to an isolated unruptured congenital sinus of Valsalva aneurysm originating from the right coronary sinus in a 75-year-old-man is described. The diagnosis was made by two-dimensional echocardiography and cardiac catheterization. Successful surgical resection of the aneurysm resulted in dramatic symptomatic improvement.

Large air embolus complicating coronary angioplasty.

With the substantial advances in technology and further refinements in the technique of coronary angioplasty, the potential for and manifestations of complications may have changed from those observed in populations studied previously. We describe a rare complication of percutaneous transluminal coronary angioplasty (PTCA), a large air embolus obstructing coronary flow, which is related to the newer technology. The air embolus was successfully extracted by aspiration through the balloon angioplasty catheter.

A simple and economical equipment arrangement for percutaneous transluminal coronary angioplasty.

A simple and economical equipment arrangement for percutaneous transluminal coronary angioplasty (PTCA) for USCI system is described. The arrangement will provide for immediate deflation when required with a short deflation time. Cardiac catheterization laboratories performing a large number of angioplasties could benefit from its low cost and convenience.

Unidirectional coronary collateral blood flow in a patient with congenital anomaly of a coronary artery: an angiographic artefact.

A 53-year-old female underwent coronary arteriography for evaluation of chest discomfort. A congenital anomaly of a large interconnecting vessel between the right coronary and circumflex arteries was documented. Selective injection of the right coronary artery resulted in visualization of the circumflex branch of the left coronary through a large interconnecting vessel. Through careful analysis of the left ventriculogram and coronary arteriograms, it appears that retrograde filling of the circumflex artery during right coronary injection is an angiographic artefact.

Coronary angioplasty at the time of initial diagnostic coronary angiography in patients with unstable angina.

Of the last 200 consecutive patients undergoing PTCA procedures at our institution, 29 (15%) had unstable angina; and angioplasty was performed at the time of diagnostic coronary arteriography. There were 26 males and three females with an age range of 31-82 (mean 57) years. Factors favoring PTCA at the time of initial coronary arteriography included clinical indications for revascularization, appropriate anatomy based on high-quality fluoroscopy, and availability of emergency surgery if required. Of 34 coronary lesions in 29 patients, 19 involved the anterior branch of the left anterior descending coronary artery (LAD), eight the circumflex branch (Cx); and seven the right coronary artery (RCA). Five patients had two vessels dilated (one LAD + RCA, two LAD + Cx, and two RCA + Cx). Of the coronary artery lesions, 19 were concentric, seven were eccentric, 20 were single and discrete, six were long or multiple in the same vessel; eight vessels were totally occluded, and in nine patients there was good collateral circulation. Twenty-nine (85%) arteries were successfully dilated. Of the unsuccessful cases, one was from failure to cross a totally occluded lesion, and three residual lesions and/or postdilatation pressure gradients remained significant. One patient required emergency aortocoronary bypass surgery because of total occlusion of the LAD immediately post-PTCA. There were no postprocedural myocardial infarcts or deaths. It is concluded that, in selected patients with unstable angina, PTCA can be performed successfully and with low risk at the time of initial diagnostic coronary arteriography. This approach offers certain clinical financial advantages.

Subacute left main coronary stenosis following percutaneous transluminal coronary angioplasty.

Subacute left main coronary stenosis following percutaneous transluminal coronary angioplasty (PTCA) is an uncommon but recognized complication of the procedure. This report describes a case of left main coronary stenosis, which occurred 6 months following PTCA of an angulated, eccentric, proximal (adjacent to the left main stem) left anterior descending artery stenosis. Angiographically demonstrated morphology of complicated coronary stenosis adjacent to the left main coronary artery may represent a risk factor threatening major complications of PTCA. Detailed evaluation of angiographic coronary anatomy may improve patient selection and reduce the likelihood of such complications.

The value of sum of ST segment depression in 12-lead electrocardiogram in relation to change in heart rate during exercise to predict the extent of coronary artery disease.

The present study was planned to investigate whether the sum of ST segment depression in 12-lead electrocardiogram (sigma STD) in relation to change in heart rate (delta HR) during exercise, sigma STD/delta HR index, could be utilized to predict the extent of underlying coronary artery disease. Two hundred and twenty-six consecutive patients were included in this study, 191 men and 35 women, aged 28-74 years (mean 56). Patients were classified into two groups. Group I consisted of 165 patients with either no coronary disease, single or double vessel disease. Group II included 61 patients with triple vessel or left main stem stenosis. It was found that the sigma STD/delta HR index at 25 mm. beat-1 X min. 10(2) provided the best separation between Groups I and II patients. All but 3 of the 61 patients in Group II had a sigma STD/delta HR index greater than 25. In contrast, all but 4 of the 165 patients in Group I had an index less than 25. The sensitivity, specificity and positive predictive value in the identification of Group II patients by using the index were 95%, 98% and 94% respectively. Utilization of ST segment depression of greater than or equal to 2 mm in a VF alone as a test criterion for the recognition of Group II patients had a low sensitivity (41%), specificity (88%) and positive predictive value (56%).(ABSTRACT TRUNCATED AT 250 WORDS)

Implication of transstenotic coronary pressure gradient measurement during coronary angioplasty.

The aim of this study was to establish a criterion for the success of an angioplasty based upon pressure gradients across coronary lesions. Sixty-two percutaneous transluminal coronary angioplasties (PTCA) in 56 patients with isolated left anterior descending artery disease were examined. Pressure gradients measured before and after PTCA were expressed as normalized mean pressure gradients (NMPG) computed by dividing mean pressure gradient by mean aortic or proximal coronary artery pressure. Angiographic severity was expressed as percentage area stenosis (AS) calculated from diastolic caliper measurements of diameter of each lesion and the nearest normal adjacent segment in at least two projections. The relationship between AS and NMPG was nonlinear with a steep increase in gradients beyond a critical value of AS of about 60%. This relationship was unaffected by angiographically visualized collaterals. All except one of 65 coronary stenotic lesions with NMPG of more than 0.32 had an AS of more than 60%. Only three of 57 coronary stenoses with NMPG of less than 0.32 had severe AS (p less than 0.001). The results indicate that NMPG is a reliable, practical guide to the severity of coronary stenosis and is therefore a useful measurement for assessing either the success or the residual stenosis during PTCA.

Cardiac amyloidosis: combined use of two-dimensional echocardiography and electrocardiography in noninvasive screening before biopsy.

Cardiac amyloidosis (CA) presenting with intractable congestive heart failure, electrocardiographic (ECG) normal or low voltage, and conduction or rhythm disturbances, is rapidly fatal. During life, CA often mimics other cardiomyopathies so that definitive diagnosis depends on demonstration of amyloid on myocardial biopsy. On two-dimensional echocardiography (2-D echo), nonspecific features, such as increased ventricular wall thicknesses, predominant diastolic dysfunction, and diffuse myocardial "sparkling," are consistently found in CA. The combined presence of these 2-D echo features and normal or low voltage on ECG is highly suggestive of CA, allows differentiation from other cardiomyopathies, and might be useful in noninvasive screening before myocardial biopsy.

Localization of coronary artery disease with exercise induced ST segment depression: coronary angiographic correlation.

Abnormalities of the 12 lead electrocardiogram (ECG) are often used to localize the anatomic site of myocardial ischemia and vessel involvement in patients (pts) with coronary artery disease. This study is to determine if ischemia of specific vascular segments can be identified by exercise induced ST segment depression (STD) on 12-lead ECG. One hundred and forty three pts with a positive treadmill stress testing (TST) who had coronary arteriography within one month of TST were reviewed. There were 114 men and 29 women, aged 34-74 years (mean 55 years). The Bruce protocol was used for TST. Significant coronary stenosis was defined as obstruction of 70% or greater of the luminal diameter. The pattern of STD on 12 lead ECG during exercise was similar in pts with single vessel disease involving the left anterior descending artery (LAD), right coronary artery (RCA) or circumflex artery (Cx). This pattern of STD in single vessel disease was also comparable to 2-vessel, 3-vessel or left main stem disease. Twenty-two percent of pts with LAD disease had isolated STD in inferior leads. Twenty-five and 29% of pts with RCA and Cx disease respectively had STD in the anterior leads alone during exercise testing. It is concluded that exercise induced STD in 12 lead ECG can not predict ischemia of specific vascular segments or specific vessel involvement.

Incremental value of the exercise treadmill test in determining the extent of coronary artery disease: a discriminant function analysis.

This study was undertaken to determine whether it was possible to use a multivariate discriminant function analysis to assess the severity of coronary artery disease in patients with angina pectoris. One hundred and forty-three patients diagnosed as having angina pectoris who formed a 'learning group' were subjected to an exercise test on a treadmill using a Bruce protocol. The items of data from the test least likely to be influenced by beta blockade were considered for the analysis along with two discrete variables (the gender and the use of beta blockers). All the patients subsequently underwent coronary angiography and the severity of the coronary artery disease was graded according to a scoring system. In addition, patients in 'learning group' were classified into two 'Groups', (I) those with normal vessels or with disease in one or two of the major arteries, (II) those with disease in the left main stem or in all three major arteries. The multivariate analysis yielded a score based upon 4 factors: (i) gender, (ii) percentage increase in double product at the highest level of exercise achieved, (iii) duration of ST depression in the recovery period and (iv) the summation of the ST depression in the standard electrocardiogram excluding lead aVR. There was a significant overall correlation between the discriminant function score and the coronary artery score for severity of the disease. In addition, it was found that, of patients having discriminant function score below 0, 96% (69/72) were in Group I. The post-test risk of a positive test was 0.005.(ABSTRACT TRUNCATED AT 250 WORDS)

Diaphragmatic coronary lesion mimics significant coronary stenosis: a report of four cases.

Diaphragmatic coronary stenosis is a rare coronary angiographic finding. It gives rise to an appearance of relatively severe obstruction and can lead to unnecessary surgical intervention or PTCA. We described four patients with this type of stenosis in whom the lesions proved to be hemodynamically insignificant as judged by the presence of only minor pressure gradients across them.