Drug-eluting stents: a critique.

Despite advances in the design of balloons and stents, restenosis remains a major drawback of coronary angioplasty. Multiple randomised trials have demonstrated that drug-eluting stents (DES) can significantly reduce rates of restenosis by 60-75% across both lesion and patient subsets. In recent years there has been an exponential increase in the worldwide use of DES. This expansion has occurred as a result of an enthusiastic extrapolation of results from randomised trials leading to "off-label" use of DES in anatomical or clinical high-risk scenarios, or both. However, emerging medium- to long-term follow-up data have raised concerns about the safety of DES. A number of analyses have recently shown increased rates of late stent thrombosis in patients with DES. The exact mechanisms leading to stent thrombosis remain unclear. This article critically reviews the available efficacy and safety data on DES and discusses the factors influencing our current practice and perception of the net value of DES.

Can the published cost analysis data for delivery of an efficient primary angioplasty service be applied to the modern National Health Service?

Despite the clinical benefits and safety profile of primary percutaneous coronary intervention (PCI), the health care system in the UK has been slow to adopt this strategy as first line management for ST segment elevation myocardial infarction. The cost implications of a 24 hour a day, seven days per week primary PCI service and the absence of an existing efficient working model within the National Health Service (NHS) framework are two of the major deterrents for provision of such a service. The existent cost effectiveness data for primary PCI is critically reviewed, with particular reference to the NHS.

Coronary bifurcation stenting. Current techniques, outcome and possible future developments.

Percutaneous treatment of coronary bifurcation lesions remained challenging in the stent era, with restenosis rates greater than 30% and no advantage from the routine use of kissing stents. Drug eluting stents (DES) have dramatically reduced the restenosis rates (RR) in the main vessel, but with conventional T-stenting double digits figures are still reported for the side-branch because of poor ostial coverage. The techniques of kissing stenting able to provide full lesion coverage (Culotte, V-stenting, Crush) have the potential to improve these results but the development of dedicated DES is probably needed to obtain consistently high procedural and long-term success.

Learning on the Web. Case 7: recurrent pleural effusions, resistant atrial arrhythmias, and abnormal liver function tests: general medicine or cardiology?

A 65 year old man presented with recurrent pleural effusions. Repeated pleural fluid examination and pleural biopsy were unremarkable. Pericardial calcification was noted on admission and attributed to an uncomplicated episode of pericarditis 30 years previously. His symptoms and signs were not thought not to be associated with the heart. While awaiting an open pleural biopsy the patient was admitted with a further pleural effusion, jaundice, resistant atrial arrhythmias, and dyspnoea. Hepatic investigations including autoantibody screen and transjugular liver biopsy were normal. The significance of these signs and symptoms, the diagnosis, and the management of these problems are discussed in an interactive case presentation.

Antioxidant potential of intermediates in phenylpropanoid metabolism in higher plants.

In this study the antioxidant activities of the hydroxycinnamic acids, chlorogenic, caffeic, ferulic and p-coumaric, have been investigated in peroxidising lipid systems mediated by metmyoglobin. The results show that the order of effectiveness in increasing the resistance of LDL to peroxidation, in protecting LDL cholesterol from oxidation and preventing the oxidative modification of the LDL apoprotein B100 is caffeic = chlorogenic > ferulic > p-coumaric acid. Assessment of the rates of reaction of the hydroxycinnamates with ferrylmyoglobin, a product of the reductive decomposition of lipid hydroperoxides, reveals that the compounds are more effective as peroxyl radical scavengers than reductants of ferryl myoglobin in peroxidising LDL systems mediated by haem proteins.