Telephone reporting of the results of cardiac procedures: feasibility and primary care physician preferences.

PURPOSE: We evaluated the feasibility and time required for routine telephone communication with primary care physicians after cardiac procedures and surveyed primary care physicians as to their preferences for the method and content of reports of cardiac procedures. SUBJECTS AND METHODS: A phone call was made within 1 day of the procedure during normal working hours to the primary care physician for all 414 patients who underwent cardiac catheterizations or interventions during a 1-year period. Subsequently, all 211 primary care physicians were mailed a questionnaire on the effectiveness of phone calls as compared with other communication methods. RESULTS: The primary care physician was reached with one call for 51% of patients and could not be contacted with up to five calls to office, clinic, or hospital for 32% of patients. Mean (+/- SD) phone time per patient was 4.1 (+/- 2.0) minutes. Surveys were returned by 119 (56%) of 211 referring physicians. Telephone communication was rated as "very helpful" by 69%. Most primary care physicians (86%) were "very" or "a little pleased" to receive phone calls. Survey respondents identified the summary of the results and the recommendations for treatment as the most important parts of the report. Respondents preferred personal phone calls or faxed reports to phone messages left with office staff, reports sent by electronic mail, or mailed written reports. CONCLUSIONS: Most primary care physicians find personal phone calls helpful and desirable, but the effectiveness of routine phone calls is limited by the availability of primary care physicians during working hours and the time required for phonereporting.

Incidence of intracranial hemorrhage complicating treatment with glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis of major clinical trials.

PURPOSE: The major risk of therapy with platelet glycoprotein IIb/IIIa receptor inhibitors is bleeding. We reviewed trials using these agents to determine if bleeding risks include an increased incidence of intracranial hemorrhage. METHODS: A Medline search identified 14 randomized trials of intravenous platelet glycoprotein IIb/IIIa receptor inhibitors for patients undergoing percutaneous coronary intervention or who had an acute coronary syndrome. We compared the incidence of intracranial hemorrhage among 15,850 patients treated with glycoprotein IIb/IIIa inhibitors with that among 12,039 patients treated with placebo. RESULTS: The incidence of intracranial hemorrhage with heparin plus any IIb/IIIa inhibitor was similar to placebo with heparin (0.12% vs 0.09%, odds ratio = 1.3, 95% confidence interval: 0.6 to 3.1, P = 0.59). The incidence of intracranial hemorrhage with glycoprotein IIb/IIIa drugs alone was similar to that with heparin alone (0.07% vs 0.06%), albeit with a wide confidence interval (odds ratio = 1.2, 95% confidence interval: 0.1 to 16, P = 1.0). CONCLUSIONS: Intravenous glycoprotein IIb/IIIa receptor inhibitors alone or in combination with heparin do not cause a statistically significant excess of intracranial hemorrhage as compared with heparin alone. Because of small numbers, the data do not exclude the possibility of an excess of intracranial hemorrhage in some groups of patients treated with glycoprotein IIb/IIIa receptor inhibitors.

Telephone reporting of cardiac procedure results to primary care physicians.

We attempted telephone communication of the results of cardiac catheterization and/or intervention to primary care physicians for 100 patients in a health maintenance organization. Phone calls during work-day office hours required 3.5 minutes per patient and provided personal contact with the primary care physician for only 65% of the patients.

Physical working capacity after acute myocardial infarction in patients with low ejection fraction and effect of captopril.

Previous studies after acute myocardial infarction (AMI) have reported conflicting results on the effects of angiotensin-converting enzyme inhibition on physical working capacity. In an effort to provide more insight into this subject, we examined the effects of captopril on working capacity of patients who had low ejection fractions but no congestive heart failure after AMI. One hundred sixty-six participants were recruited from 5 centers after randomization to either captopril or placebo for the Survival and Ventricular Enlargement study. Upright cycle ergometer tests were performed with continuous measurements of respiratory gases at 4, 12, and 24 months after AMI. Our study concurs with 2 of 3 previous post-AMI studies and supports the conclusion that working capacity is not affected by angiotensin-converting enzyme inhibition at 4 or 12 months after AMI in patients without congestive heart failure. In addition, no significant effect of captopril was noted at 24 months after AMI. Peak oxygen uptake tended to decrease between 12 and 24 months in the placebo group by an average (+/- SD) of -22 +/- 322 ml/min (n = 66), but to increase in the captopril group (+62 +/- 289, n = 57), a difference that was significant (Mann-Whitney chi-square, p = 0.02). This post-hoc observation suggests that a late beneficial effect may have been masked by inadequate study duration. Known benefits of captopril appear not to include an increase in working capacity within the first 24 months after AMI.

Incidence and natural history of left ventricular thrombus following anterior wall acute myocardial infarction.

Previous studies have reported left ventricular (LV) thrombus in 20% to 56% of patients after anterior wall acute myocardial infarction (AMI). The Healing and Early Afterload Reducing Therapy (HEART) study was a prospective study comparing effects of early (24 hours) or delayed (14 days) initiation of ramipril, an angiotensin-converting enzyme inhibitor, on LV function after anterior wall AMI. This ancillary study assessed prevalence of LV thrombus. Two-dimensional echocardiography was performed on days 1, 14, and 90 after myocardial infarction. The cohort consisted of 309 patients. Q-wave anterior wall AMI occurred in 78%; 87% received reperfusion therapy. The prevalence of LV thrombus was 2 of 309 (0.6%) at day 1, 11 of 295 (3.7%) at day 14, and 7 of 283 (2.5%) at day 90. One patient had thrombus at 2 examinations. The day 1 echocardiogram was not correlated with thrombus development. LV size increased more in patients with thrombus than in those without thrombus. Patients with thrombus had more wall motion abnormality after day 1 than patients without thrombus (p = 0.03). Thus, the current prevalence of LV thrombus in anterior wall AMI is lower than previously reported, possibly due to changes in AMI management. Preservation of LV function is likely to be an important mechanism. Most thrombi are seen by 2 weeks after AMI. Resolution documented by echocardiography is frequent.

Captopril reduces the VE/VCO2 ratio in myocardial infarction patients with low ejection fraction.

STUDY OBJECTIVES: To determine whether captopril (CAP) therapy had an effect on the minute ventilation/carbon dioxide output (VE/VCO2) ratio at submaximal levels of exercise in asymptomatic patients with reduced left ventricular function after myocardial infarction. DESIGN: Double blinded, randomized, prospective, repeated measures. PATIENTS AND INTERVENTIONS: One hundred thirty-five patients with left ventricular ejection fractions of < 40% were randomly assigned to a treatment group (CAP; n = 62) or a placebo group (PLC; n = 73). Subjects had cycle ergometer exercise tests at 2 to 6 months (T1), 10 to 14 months (T2), and > 22 months (T3) postmyocardial infarction. MEASUREMENTS: Oxygen uptake (VO2), VCO2, and VE were measured throughout each exercise test. Dependent variables were peak VO2 (VO2peak), the ventilatory anaerobic threshold (VAT), and the VE/VCO2 ratio measured at 30 W and at 75% VO2peak. RESULTS: VO2peak and VAT did not differ as a result of treatment (CAP vs PLC; p = 0.92 and 0.80) or over time (T1 vs T2 vs T3; p = 0.51 and 0.07). VE/VCO2 was significantly lower for CAP at 30 W (p = 0.05) and, although lower at 75% VO2peak, did not obtain statistical significance (p = 0.22). The between group differences were larger at T2 and T3 when compared with T1. CONCLUSIONS: CAP resulted in a reduced VE/VCO2 ratio during submaximal exercise. The reduced ventilation may permit patients to perform their normal activities of daily living at a lower perception of difficulty, reduce symptoms, and provide an improved quality of life.

Abbreviated aortic insufficiency in aortic dissection caused by prolapse of the intimal flap.

Aortic insufficiency was identified in a patient with acute ascending aortic dissection. The aortic insufficiency was limited to the first half of diastole by prolapse of the intimal flap against the regurgitant orifice. This unusual pathophysiology was well demonstrated by two-dimensional and color flow Doppler echocardiography.

Dipyridamole thallium imaging: use in preoperative cardiac risk assessment in vascular surgical patients.

BACKGROUND: The objective of this study was to determine whether routine performance of dipyridamole thallium imaging adds to the power of a careful clinical evaluation in the risk stratification of patients undergoing major vascular surgery. METHODS: In this retrospective study, 115 cases evaluated by dipyridamole thallium imaging before major vascular surgery were reviewed. Patients were assigned to a high-risk cohort if they had a history of congestive heart failure or evidence of previous myocardial infarction. RESULTS: Six (8%) patients from the high-risk cohort developed major cardiovascular complications. Reversible perfusion defects, present in 67% of the high-risk patients, did not predict complications. None of the patients in the low-risk cohort developed complications despite the presence of reversible perfusion defects in 33%. Patients in the high-risk cohort who underwent cardiac catheterization and selective coronary bypass grafting were uniformly free of perioperative complications. The extent and severity of fixed or reversible thallium perfusion did not predict the occurrence of cardiovascular complications. However, three patients were denied surgery following an unacceptable cardiovascular risk assessment based on clinical findings and multiple reversible thallium perfusion defects. CONCLUSION: In low-risk patients, screening with dipyridamole thallium can identify patients with redistribution defects whose risk of perioperative ischemic events can be reduced by intensifying perioperative anti-ischemic management. If the patient is in the high-clinical-risk subgroup, screening with dipyridamole thallium does not identify a cohort with negligible perioperative risk; thus, further evaluation of these patients by cardiac catheterization should be considered.

Results of coronary artery bypass grafting using multiple arterial conduits.

Between January 1991 and June 1993, a total of 128 patients underwent coronary artery bypass grafting employing multiple autologous arterial conduits, including 157 internal mammary arteries, 69 inferior epigastric arteries, 44 gastroepiploic arteries, and 72 radial artery grafts. Their mean age was 61.4 years (range 29 to 82 years). The patients were divided into 2 groups: group A, consisted of 69 patients (mean age 60.3 years), in whom multiple arterial conduits were used exclusively (no vein grafts); group B, included 59 patients (mean age 62.7 years) in whom, in addition to multiple arterial conduits, 89 saphenous vein grafts were used concomitantly. The mean number of grafts was 3.1 and 3.7, for groups A and B, respectively. The preoperative left ventricular function, and the prevalence of unstable angina, a recent myocardial infarction, and diabetes, were not significantly different between both groups. Our series included 11 "redo" operations (8 in group A, and 3 in group B). There were 6 early deaths (4.7% mortality) (1 in group A, and 5 in group B), and 4 perioperative myocardial infarctions (1 in group A, 3 in group B). During a mean follow-up of 12.9 months (range 1 to 28 months) there were no late deaths or reoperations in any group. All patients in group A are free of symptoms. In group B, 2 patients have recurrent angina, and 1 had a late myocardial infarction, in the distribution of a vein graft. A myocardial SPECT scan with exercise revealed new perfusion defects in 4 of 49 patients (1 in group A, 3 in group B), studied 1 year after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial revascularization using the "no-touch" technique, with mild systemic hypothermia, in patients with a calcified ascending aorta.

Modifications in the standard technique for coronary artery bypass grafting are recommended in presence of a calcified ascending aorta, to avoid clamp injury or atheroembolism. Between January 1991 and August 1994, we used a "no-touch" technique in 18 patients undergoing myocardial revascularization, who had a heavily calcified and atherosclerotic ascending aorta. Their mean age was 76.1 years (range 63 to 82 years). Cardiopulmonary bypass with mild systemic hypothermia (32 degrees C) was employed in 16 patients; 2 other patients were operated upon without cardiopulmonary bypass. The "no-touch" technique avoids all types of clamps in the aorta. No cardioplegia was given, and no grafts were anastomosed to the aorta. Fifty-two distal anastomoses (mean: 2.9 per patient) were performed, using 37 pedicled arterial grafts (22 internal mammary and 15 gastroepiploic arteries), and 15 free grafts, which were anastomosed proximally to the internal mammary artery. There were no postoperative cerebrovascular accidents. Three patients died (16.7% overall mortality): 1 died of pneumonia, one patient with a large left ventricular aneurysm died in congestive heart failure, and one patient with associated aortic insufficiency died in low cardiac output. Our experience suggests that using pedicled arterial grafts for myocardial revascularization is safe and effective to avoid clamp injury or atheroembolism in patients with a calcified aorta. Deep hypothermia is not necessary when using the "no-touch" technique.

Attention versus avoidance: attributional search and denial after myocardial infarction.

OBJECTIVE: In this study the focus was on two strategies: denial (an avoidant strategy) and causal thinking (an attention strategy) and their relationships to affect after myocardial infarction. DESIGN: Descriptive, correlational. SETTING: Large rural medical center. SAMPLE: The sample comprised 152 recently hospitalized patients with first-time myocardial infarction. MEASURES: A denial scale, a question about causal thinking, and an affect adjective checklist measuring anxiety, hostility, and depression. RESULTS: Denial had a weak but significant negative correlation with anxiety (r = -0.18, p < 0.05). However, denial was not significantly related to either depression or hostility. Regression analysis indicated that both denial (F = 4.84, p = 0.02) and the interaction of denial with causal search (f = 4.77, p = 0.009) were predictors of affect. The interaction indicated that those with high denial who had not searched for a cause were least anxious. A large number of subjects used both attention and avoidant strategies. CONCLUSIONS: The main effect for denial suggests that avoidance is a more effective strategy for reducing anxiety after myocardial infarction than causal search, an attention strategy. However, the fact that many subjects used both strategies suggests that they are not mutually exclusive in the process of adaptation after a heart attack.

Ruptured aortic valve cusp: a complication of the Heimlich maneuver.

A case of traumatic rupture of the aortic valve as a complication of the Heimlich maneuver is presented. Conformation was made by comparative echocardiographic studies available from three months before and immediately following the incident. The patient refused surgical intervention and died one month later with severe congestive heart failure despite vigorous medical therapy.

Polyarteritis nodosa presenting as acute myocardial infarction with coronary dissection.

Coronary manifestations of polyarteritis nodosa (PAN) are rarely identified pre-mortem. We report a 51-year-old female with PAN causing a coronary dissection and new lesions developing over the next 5 days. PAN should be added to the list of differential diagnoses for spontaneous coronary dissections.

Oxygen uptake and cardiac output during progressive and constant load work in patients after acute myocardial infarction.

PURPOSE: Simultaneously measured oxygen uptake (VO2) and Doppler echocardiography could verify if an alteration in the VO2 response to progressive and constant load work is due to reduced cardiac output. METHODS: The study group consisted of nine patients after acute myocardial infarction (MI), five age-matched healthy subjects (HE), and five young well-trained subjects (WT). Each subject performed a progressive exercise test and two bouts of constant load work at power outputs equated to 10% below (W1) and 10% above (W2) their ventilatory thresholds. VO2 and cardiac output were measured continuously and simultaneously during the tests. RESULTS: VO2 was significantly reduced for the MI group during the initial stages of the progressive exercise test (P < .02) and remained lower throughout the entire test. During the first 60 seconds of constant load work (W2), VO2 was lower for MI (P < .05). At steady state exercise during W2, cardiac output was significantly less for MI (P < .05). VO2 for the MI group was more reliant on cardiac output during lower power outputs and differences in the arterial and venous O2 content (a-VO2 difference) during greater power outputs. CONCLUSIONS: Cardiac rehabilitation programs must be aware of this delayed VO2 and cardiac output response when setting training workloads or selecting the magnitude of the workload increments during progressive exercise tests.

Physiologic responses of coronary care patients to visiting.

The authors examined physiologic changes in myocardial infarction patients during a family visit in the cardiac intensive care unit (CICU) and the relationship of these changes to illness variables, patient preference for visits, and patients' perceptions of the supportiveness of the visit. Forty-eight patients were studied for changes in heart rate, blood pressure, ST segment, and oxygen saturation. Patients who had the greatest physiologic changes were among those who had had more severe infarcts. However, many patients in the severe category did not show such changes. Examination of the reactive group revealed that, in addition to having more severe infarcts, it included a greater percentage of smokers than did the nonreactive group. Visit preferences were relatively low, but as visit preferences increased, so did cardiovascular changes. Supportiveness scores were quite high, and these were positively correlated with cardiovascular changes. Clinical and research implications are discussed.