RESUMO
OBJECTIVES: Lipoprotein(a) [Lp(a)] is an independent risk factor for aortic valve stenosis and aortic valve calcification (AVC) in the general population. In this study, we determined the association between AVC and both plasma Lp(a) levels and apolipoprotein(a) [apo(a)] kringle IV repeat polymorphisms in asymptomatic statin-treated patients with heterozygous familial hypercholesterolaemia (FH). METHODS: A total of 129 asymptomatic heterozygous FH patients (age 40-69 years) were included in this study. AVC was detected using computed tomography scanning. Lp(a) concentration and apo(a) kringle IV repeat number were measured using immunoturbidimetry and immunoblotting, respectively. Univariate and multivariate logistic regression were used to assess the association between Lp(a) concentration and the presence of AVC. RESULTS: Aortic valve calcification was present in 38.2% of patients, including three with extensive AVC (>400 Agatston units). Lp(a) concentration was significantly correlated with gender, number of apo(a) kringle IV repeats and the presence and severity of AVC, but not with coronary artery calcification (CAC). AVC was significantly associated with plasma Lp(a) level, age, body mass index, blood pressure, duration of statin use, cholesterol-year score and CAC score. After adjustment for all significant covariables, plasma Lp(a) concentration remained a significant predictor of AVC, with an odds ratio per 10-mg dL(-1) increase in Lp(a) concentration of 1.11 (95% confidence interval 1.01-1.20, P = 0.03). CONCLUSION: In asymptomatic statin-treated FH patients, plasma Lp(a) concentration is an independent risk indicator for AVC.
Assuntos
Estenose da Valva Aórtica/sangue , Valva Aórtica/patologia , Calcinose/sangue , Hiperlipoproteinemia Tipo II/complicações , Lipoproteína(a)/sangue , Adulto , Idoso , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/etiologia , Calcinose/epidemiologia , Calcinose/etiologia , Feminino , Humanos , Hiperlipoproteinemia Tipo II/sangue , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: The authors investigated the prognostic value of computed tomography coronary angiography (CTCA) for major adverse cardiac events (MACE) in patients with suspected or known coronary artery disease (CAD), with particular focus on left main (LM) disease and obstructive vs. nonobstructive disease. MATERIALS AND METHODS: A total of 727 consecutive patients (485 men, age 62 ± 11 years) with suspected (514; 70.1%) or known (213; 29.9%) CAD underwent CTCA. Patients were followed up for the occurrence of MACE (i.e. cardiac death, nonfatal myocardial infarction, unstable angina, percutaneous/surgical revascularisation). RESULTS: A total of 117 MACE [five cardiac deaths, 11 acute myocardial infarctions (AMI), five unstable angina, 86 percutaneous coronary interventions, ten coronary artery bypass grafts] occurred during a mean follow-up of 20 months. Severity and extension of CAD was associated with a progressively worse prognosis. The event rate was 0% among patients with normal coronary arteries at CTCA. The presence of LM disease was not associated with a worse prognosis either in patients with no history of CAD or in those with a history of CAD. At multivariate analysis, presence of obstructive CAD and diabetes were the only independent predictors of MACE. CONCLUSIONS: Evaluation of atherosclerotic burden by CTCA provides an independent prognostic value for prediction of MACE. Patients with normal CTCA findings have an excellent prognosis at follow-up.
Assuntos
Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Idoso , Meios de Contraste , Doença da Artéria Coronariana/complicações , Feminino , Seguimentos , Humanos , Iopamidol/análogos & derivados , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
PURPOSE: We evaluated the multislice computed tomography (MSCT) coronary plaque burden in patients with stable and unstable angina pectoris. MATERIALS AND METHODS: Twenty-one patients with stable and 20 with unstable angina pectoris scheduled for conventional coronary angiography (CCA) underwent MSCT-CA using a 64-slice scanner offering a fast rotation time (330 ms) and higher X-ray tube output (900 mAs). To determine the MSCT coronary plaque burden, we assessed the extent (number of diseased segments), size (small or large), type (calcific, noncalcific, mixed) of plaque, its anatomic distribution and angiographic appearance in all available ≥2-mm segments. In a subset of 15 (seven stable, eight unstable) patients, the detection and classification of coronary plaques by MSCT was verified by intracoronary ultrasound (ICUS). RESULTS: Sensitivity and specificity of MSCT compared with ICUS to detect significant plaques (defined as ≥1-mm plaque thickness on ICUS) was 83% and 87%. Overall, 473 segments were examined, resulting in 11.6±1.5 segments per patient. Plaques were present in 62% of segments and classified as large in 47% of diseased segments. Thirty-two percent were noncalcific, 25% calcific and 43% mixed. Plaques were most frequently located in the proximal and mid segments. Plaque was found in 33% of segments classified as normal on CCA. Unstable patients had significantly more noncalcific plaques when compared with stable patients (45% vs. 21%, p<0.05). CONCLUSIONS: MSCT-CA provides important information regarding the coronary plaque burden in patients with stable and unstable angina.
Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Placa Aterosclerótica/diagnóstico por imagem , Idoso , Angina Estável/diagnóstico por imagem , Angina Instável/diagnóstico por imagem , Angiografia Coronária , Doença da Artéria Coronariana/patologia , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Índice de Gravidade de Doença , UltrassonografiaRESUMO
AIM: The aim of this study was to investigate long-term graft outcome in patients with left internal mammary artery to left anterior descending coronary artery (LIMA-LAD) and T-grafts by ultrasonography and dual source computed tomography (DSCT) and to analyse if ultrasonography can determine graft patency. METHODS: Thirty-two patients, 28 males, 50.8+/-8.8 years at operation, were studied. Fifteen patients with single LIMA-LAD and additional vein grafts (group I) and 17 patients with LIMA-free right internal mammary artery (FRIMA) T-grafts (group II) underwent DSCT, transthoracic ultrasonography of the LIMA and an electrocardiogram. Differences were tested with unpaired and paired t tests. RESULTS: In group I, 4.1+/-1.1 and in group II, 4.5+/-1.1 anastomoses/patients were performed. DSCT showed three string sign LIMA (20%) grafts and six occluded venous anastomoses (13%) in group I and three (distal) string sign LIMA grafts (18%), seven occluded LIMA anastomoses (23%) and nine occluded FRIMA anastomoses (23%) in group II. Ultrasonographic variables in the proximal part of the LIMA graft did not differ between the groups. No effect was found for proximal string sign LIMA grafts in ultrasonographic graft performance. CONCLUSION: Ultrasonography cannot distinguish between string sign and patent single LIMA or T-grafts nor demonstrate distal anastomosis patency in T-grafts 12 years after surgery.
Assuntos
Angiografia Coronária/métodos , Ponte de Artéria Coronária , Oclusão de Enxerto Vascular/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler Dupla , Grau de Desobstrução Vascular , Adulto , Ponte de Artéria Coronária/efeitos adversos , Estudos Transversais , Eletrocardiografia , Feminino , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Valor Preditivo dos Testes , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Our purpose in this study was to compare the impact of contrast material volume in delayed-enhancement computer tomography (CT) imaging for assessing acute reperfused myocardial infarction. MATERIALS AND METHODS: In five domestic pigs (20-30 kg), the circumflex coronary artery (CX) was balloon-occluded for 2 h followed by reperfusion. After 5 days, CT imaging was performed after intravenous administration of iodinated contrast material (Iomeprol 400 mgI/ml; Bracco, Italy). A 64-slice multidetector CT (MDCT) (Sensation 64, Siemens) scanner was used for imaging, with standard angiography characteristics. Three scans were performed: first, coronary angiography at first pass with 1.25 gI/kg of contrast material (ART); and remaining delayed-enhancement (DE(1)-DE(2)) 15 min after administration of 1.25 (DE(1)) and 15 min after additional administration of 2.50 gI/kg (=total 3.75 gI/kg - DE(2)). Mean heart rate decreased to 51+/-9 bpm after intravenous administration of Zatebradine (10 mg/kg). Data sets were reconstructed during the end-diastolic phase of the cardiac cycle. Areas of infarction-enhanced (DE), no-reflow (no-reflow) and remote myocardial [remote left ventricle (LV)] were manually contoured. CT attenuation values (Hounsfield units) were measured using five regions of interest: DE, no-reflow, remote LV, left ventricular cavity (lumen LV) and in air. Differences, correlations, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. RESULTS: We found significant differences between the attenuation of DE, no-reflow and remote LV (p<0.001). DE and no-reflow size were assessed accurately with DEMDCT. In particular, SNR and CNR showed higher values in DE(2) (approximately 6.0 and 3.5, respectively; r(2)=0.90) vs. DE(1) (approximately 4.0 and 2.2, respectively; r(2)=0.85). CONCLUSIONS: The increase of contrast material volume determines a significant improvement in myocardial infarction image quality with DE-MDCT.
Assuntos
Meios de Contraste/administração & dosagem , Iopamidol/análogos & derivados , Infarto do Miocárdio/diagnóstico por imagem , Reperfusão Miocárdica , Tomografia Computadorizada por Raios X , Animais , Modelos Animais de Doenças , Iopamidol/administração & dosagem , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Sus scrofaRESUMO
PURPOSE: This study evaluated the impact of tube current (mAs) in delayed-enhancement computed tomography (CT) imaging for assessing acute reperfused myocardial infarction in a porcine model. MATERIALS AND METHODS: In five domestic pigs (mean weight 24 kg), the circumflex coronary artery was balloon-occluded for 2 h and then reperfused. After 5 days, CT imaging was performed following administration of iodinated contrast material. A 64-slice CT system was used to perform first-pass coronary angiography with a tube current of 15 mAs/kg [Arterial Phase (ART)] followed by two delayed-enhancement (DE) scans 15 min after contrast material administration, with a tube current of 15 mAs/kg and 37.5 mAs/kg, respectively (DE(1) and DE(2)). The mean heart rate decreased to 51±9 beats/min after administration of zatebradine (10 mg/kg IV). The data set was reconstructed during the end-diastolic phase of the cardiac cycle. Areas with DE, no reflow and remote myocardium [remote left ventricular (LV)] were calculated. CT values expressed in Hounsfield units (HU) were measured using five regions of interest (ROI): DE, no reflow, remote LV, LV cavity (LV lumen) and in air, respectively. Differences, correlations, image quality [signal-to-noise ratio (SNR)] and contrast resolution [contrast-to-noise ratio (CNR)] were calculated. RESULTS: Significant differences were found between attenuation of areas of DE, no reflow and remote LV (p<0.001) within the different scans. There was a fair correlation between DE and no-reflow attenuation (r=0.6; p<0.001). In DE(1) vs. DE(2), areas of DE and no reflow were not significantly different (p>0.05). The SNR and CNR were not significantly different in DE(1) vs. DE(2) (p>0.05). CONCLUSIONS: Tube current does not significantly affect infarction area, image quality or contrast resolution of DE imaging with CT.
Assuntos
Meios de Contraste , Coração/diagnóstico por imagem , Infarto do Miocárdio/diagnóstico por imagem , Reperfusão Miocárdica , Tomografia Computadorizada por Raios X , Animais , Angiografia Coronária , Circulação Coronária , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/terapia , Sus scrofa , Tomografia Computadorizada por Raios X/métodosRESUMO
CT coronary angiography (CTCA) allows accurate noninvasive imaging of the coronary arteries. As illustrated by this case report, the threedimensional information provided by this technique might be of value to resolve complex coronary pathology encountered in the cathlab. However, the limitations inherent to an anatomical test also apply for CTCA, and bring in the need for functional information to ensure adequate patient management. (Neth Heart J 2009;17:292-4.).
RESUMO
BACKGROUND: Before coronary evaluation by modern imaging techniques was feasible, premorbid diagnoses of coronary artery anomalies (CAAs) were usually made fortuitously by invasive coronary angiography (ICA). However, this technique is limited by its invasive and projectional nature. Coronary magnetic resonance angiography (CMRA) and multi-slice computed tomography (MSCT) broadened clinical information by enabling visualisation of the coronary arteries in their anatomical environment. METHODS: This case series visualises and reviews anomalous coronary artery from the opposite sinus (ACAOS) and coronary artery fistulae. All CAAs were detected by means of 64-slice dual source computed tomography after 1000 cardiac scans at the Erasmus MC, Rotterdam, the Netherlands. RESULTS: Eight ACAOS cases, one anomalous left coronary artery from the pulmonary artery (ALCAPA) and one congenital aneurysm of an aortic sinus were found. Seven out often detected CAAs were considered malignant whereas three CAAs of the ACAOS type (retroaortic path) were considered benign. Significant coronary artery disease was found in three out of eight ACAOS cases. In one of the ACAOS cases complete evaluation of the anomalous coronary artery was limited by motion artifacts. All five cases of right ACAOS were referred for MSCT because the right coronary artery could not be located by invasive angiography. CONCLUSION: All CAAs were easy to diagnose because of 3D imaging and high temporal and spatial resolution. High resolution made it possible to not only depict coronary artery abnormalities, but also to quantify luminal and vessel properties such as stenosis grade, aspects of plaque, anomalous vessel length, luminal area ratio and the asymmetry ratio. Because of its comprehensiveness, MSCT can be an effective imaging modality in patients suspected of coronary artery abnormalities caused by coronary artery disease, CAAs, or a combination of both. (Neth Heart J 2008;16:369-75.).
RESUMO
Multislice computed tomography coronary angiography (MSCT-CA) has emerged as a powerful noninvasive diagnostic modality to visualize the coronary arteries and to detect significant coronary stenoses. The latest generation 64-slice computed tomography (CT) scanners is a robust technique which allows high-resolution, isotropic, nearly motion-free coronary imaging. Coronary stenoses are detected with high sensitivity and a normal scan accurately rules out the presence of a coronary stenosis. With the introduction of further novel concepts in CT-technology one may expect that MSCT-CA will become a clinically used diagnostic tool.
Assuntos
Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Tomografia Computadorizada Espiral/métodos , Humanos , Valor Preditivo dos TestesRESUMO
Cardiac and coronary computed tomography (CT) is becoming increasingly common in clinical practice. Even if there is no well-established evidence, this diagnostic modality is so strong and effective and, in skilled hand, it can be readily used in clinical practice. After learning its potential and the technical limits, this tool could be used for risk stratification as well as for revascularization evaluation. In this review, we will describe the results of present literature, clinical applications at present considered suitable to CT technology (i.e. 64-slice and dual-source scanners) and future applications and innovations.
Assuntos
Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Tomógrafos Computadorizados , Doença da Artéria Coronariana/diagnóstico , Humanos , Valor Preditivo dos Testes , Tomografia Computadorizada Espiral/métodosRESUMO
Multi-slice CT coronary angiography is a rapidly developing noninvasive diagnostic technique that can be used to detect coronary stenosis. Detection of coronary stenosis by coronary angiography is usually hindered by limited image quality, motion artefacts caused by heart contractions, and artefacts caused by extensive calcification. In addition, the radiation exposure is relatively great. Multi-slice CT coronary angiography, however, can reliably rule out coronary stenosis. At this time, multi-slice CT coronary angiography is not a routine part of the diagnosis of coronary artery disease. In the future, the target population for this technique may include asymptomatic high-risk patients and symptomatic low- or intermediate-risk patients for severe coronary artery disease.
Assuntos
Angiografia Coronária/métodos , Doença das Coronárias/diagnóstico , Estenose Coronária/diagnóstico , Tomografia Computadorizada por Raios X , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância MagnéticaRESUMO
BACKGROUND: Intravascular ultrasound (IVUS)-guided stent implantation and the availability of a reference chart to predict the expected in-stent restenosis rate based on operator-dependent IVUS parameters may interactively facilitate optimal stent placement. The use of IVUS guidance protects against undue risks of dissection or rupture. METHODS AND RESULTS: IVUS-determined post-stent-implantation predictors of 6-month in-stent restenosis on quantitative coronary angiography (QCA) were identified by logistic regression analysis. These predictors were used to construct a reference chart that predicts the expected 6-month QCA restenosis rate. IVUS and QCA data were obtained from 3 registries (MUSIC [Multicenter Ultrasound Stenting in Coronaries study], WEST-II [West European Stent Trial II], and ESSEX [European Scimed Stent EXperience]) and 2 randomized in-stent restenosis trials (ERASER [Evaluation of ReoPro And Stenting to Eliminate Restenosis] and TRAPIST [TRApidil vs placebo to Prevent In-STent intimal hyperplasia]). In-stent restenosis was defined as luminal diameter stenosis >50% by QCA. IVUS predictors were minimum and mean in-stent area, stent length, and in-stent diameter. Multiple models were constructed with multivariate logistic regression analysis. The model containing minimum in-stent area and stent length best fit the Hosmer-Lemeshow goodness-of-fit test. This model was used to construct a reference chart to calculate the expected 6-month restenosis rate. CONCLUSIONS: The expected 6-month in-stent restenosis rate after stent implantation for short lesions in relatively large vessels can be predicted by use of in-stent minimal area (which is inversely related to restenosis) and stent length (which is directly related to restenosis), both of which can be read from a simple reference chart.
Assuntos
Angiografia Coronária/normas , Stents/normas , Ultrassonografia de Intervenção/normas , Ensaios Clínicos como Assunto , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Recidiva , Valores de Referência , Sistema de RegistrosRESUMO
BACKGROUND: Virtual reality techniques have recently been introduced into clinical medicine. This study examines the possibility of coronary artery fly-through using a dataset obtained by noninvasive coronary angiography with contrast-enhanced electron-beam computed tomography. METHODS AND RESULTS: Ten patients were examined, and 40 to 60 transaxial tomograms (thickness, 1.5 mm; in-plane pixel dimensions, approximately 0.5x0.5 mm) were obtained after intravenous contrast injection. The datasets were processed on a graphics workstation using volume-rendering software. For fly-throughs, the contrast-enhanced lumen was made transparent and other tissue was made opaque. Then, key frames were selected in a path through the vessel, with software interpolation of frames between key frames. A typical movie contained 150 to 300 frames (10 to 15 key frames). Fly-throughs of coronary bypass grafts (n=3), left anterior descending arteries (LAD; n=6), and the intermediate branch (n=1) were reconstructed. Coronary calcifications were seen in 3 patients. The fly-through of the intermediate branch, the bypass grafts, and one of the LADs did not show any irregularities. In 2 cases, a stenosis was visible in the LAD; its presence was confirmed by conventional coronary angiography. CONCLUSIONS: Recent developments in fast-volume rendering using special-purpose hardware in combination with noninvasive coronary angiography with electron beam computed tomography have provided the possibility of performing coronary artery fly-throughs.
Assuntos
Angiografia Coronária/métodos , Calcinose , Cardiomiopatias/patologia , Ponte de Artéria Coronária , Vasos Coronários/patologia , Humanos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: True 3D reconstruction of coronary arteries in patients based on intravascular ultrasound (IVUS) may be achieved by fusing angiographic and IVUS information (ANGUS). The clinical applicability of ANGUS was tested, and its accuracy was evaluated quantitatively. METHODS AND REUSLTS: In 16 patients who were investigated 6 months after stent implantation, a sheath-based catheter was used to acquire IVUS images during an R-wave-triggered, motorized stepped pullback. First, a single set of end-diastolic biplane angiographic images documented the 3D location of the catheter at the beginning of pullback. From this set, the 3D pullback trajectory was predicted. Second, contours of the lumen or stent obtained from IVUS were fused with the 3D trajectory. Third, the angular rotation of the reconstruction was optimized by quantitative matching of the silhouettes of the 3D reconstruction with the actual biplane images. Reconstructions were obtained in 12 patients. The number of pullback steps, which determines the pullback length, closely agreed with the reconstructed path length (r=0.99). Geometric measurements in silhouette images of the 3D reconstructions showed high correlation (0.84 to 0.97) with corresponding measurements in the actual biplane angiographic images. CONCLUSIONS: With ANGUS, 3D reconstructions of coronary arteries can be successfully and accurately obtained in the majority of patients.
Assuntos
Angiografia Coronária/métodos , Doença das Coronárias/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Processamento de Imagem Assistida por Computador/métodos , Ultrassonografia de Intervenção/métodos , Vasos Coronários/anatomia & histologia , Humanos , Modelos Cardiovasculares , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Earlier reports have shown that the outcome of balloon angioplasty or bypass surgery in unstable angina is less favorable than in stable angina. Recent improvements in percutaneous treatment (stent implantation) and bypass surgery (arterial grafts) warrant reevaluation of the relative merits of either technique in treatment of unstable angina. Methods and Results- Seven hundred fifty-five patients with stable angina were randomly assigned to coronary stenting (374) or bypass surgery (381), and 450 patients with unstable angina were randomly assigned to coronary stenting (226) or bypass surgery (224). All patients had multivessel disease considered to be equally treatable by either technique. Freedom from major adverse events, including death, myocardial infarction, and cerebrovascular events, at 1 year was not different in unstable patients (91.2% versus 88.9%) and stable patients (90.4% versus 92.6%) treated, respectively, with coronary stenting or bypass surgery. Freedom from repeat revascularization at 1 year was similar in unstable and stable angina treated with stenting (79.2% versus 78.9%) or bypass surgery (96.3% versus 96%) but was significantly higher in both unstable and stable patients treated with stenting (16.8% versus 16.9%) compared with bypass surgery (3.6% versus 3.5%). Neither the difference in costs between stented or bypassed stable or unstable angina ($2594 versus $3627) nor the cost-effectiveness was significantly different at 1 year. CONCLUSIONS: There was no difference in rates of death, myocardial infarction, and cerebrovascular event at 1 year in patients with unstable angina and multivessel disease treated with either stented angioplasty or bypass surgery compared with patients with stable angina. The rate of repeat revascularization of both unstable and stable angina was significantly higher in patients with stents.
Assuntos
Angina Pectoris/cirurgia , Implante de Prótese Vascular , Ponte de Artéria Coronária , Stents , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Instável/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Intervalo Livre de Doença , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/economia , Revascularização Miocárdica/métodos , Reoperação , Stents/efeitos adversos , Stents/economia , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Management of unstable angina has evolved progressively, and coronary angioplasty has recently been shown to be an effective treatment strategy for unstable angina. However, the procedure-related major complication rate is higher when compared with that for angioplasty in stable angina. The underlying pathophysiology may explain this higher complication rate. Rupture of an atherosclerotic plaque associated with thrombus formation is frequent in the pathogenesis of unstable angina. These processes lead to a critical reduction in myocardial blood supply, and coronary angioplasty may effectively interrupt this process. In contrast, coronary angioplasty itself may cause further injury of the already ulcerated intima, have the potential to intensify the ongoing thrombogenic process and lead to an increased frequency of abrupt closure of the artery during the procedure. Therefore, intracoronary streptokinase was used in the procedure in those patients with abrupt closure of the artery immediately after dilation to attempt to improve the immediate result. Coronary angioplasty was attempted in 200 consecutive patients with unstable angina. Initial success in crossing the obstructed artery was achieved in 196 patients; however, an abrupt closure immediately after dilation occurred in 21 of these patients. Of these 21 patients, 12 were also treated with intracoronary streptokinase, and successful dilation was achieved in 9 patients without evidence of necrosis or the need for emergency bypass surgery. Of the remaining nine patients, four successfully underwent redilation with a larger-sized balloon, four underwent urgent surgery (one death postoperatively) and one was treated conventionally. Final success was achieved in 188 patients (94%) without death, the need for emergency surgery or evidence of myocardial necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Angina Pectoris/terapia , Angina Instável/terapia , Angioplastia com Balão , Doença das Coronárias/tratamento farmacológico , Trombose Coronária/tratamento farmacológico , Estreptoquinase/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Instável/tratamento farmacológico , Angioplastia com Balão/efeitos adversos , Ponte de Artéria Coronária , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/enzimologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Radiografia , RecidivaRESUMO
OBJECTIVES: The aim of this study was to determine which quantitative angiographic variable best describes functional status 6 months after coronary balloon angioplasty. BACKGROUND: Several angiographic restenosis criteria have been developed. These can be divided into those that describe the change in lesion severity and those that merely describe lesion severity at follow-up angiography. The functional significance of these criteria is unknown. METHODS: We studied 350 patients with single-vessel coronary artery disease who underwent a single-site balloon dilation. Sensitivity and specificity curves were constructed for the prediction of anginal status and exercise electrocardiography of four quantitative angiographic variables that describe restenosis. The point of highest diagnostic accuracy for the variables was determined at the intersection of the sensitivity and specificity curves. Results of exercise electrocardiography were considered indicative for ischemia 6 months after angioplasty if horizontal or downsloping ST segment depression > or = 1 mm occurred. RESULTS: The points of highest diagnostic accuracy of the angiographic variables were similar for both anginal status and exercise electrocardiography: 1.45 and 1.46 mm for the minimal lumen diameter measurements, 45.5% and 46.5% for the percent diameter stenosis measurements at follow-up, -0.30 and -0.32 mm for change in minimal lumen diameter and -10% and -10% for the change in percent diameter stenosis at follow-up. CONCLUSIONS: Angiographic variables reflecting a change in lesion severity at follow-up angiography were only slightly less accurate than variables that describe lesion severity at follow-up. The large study group and the fact that the same optimal values for diagnostic accuracy of the various quantitative angiographic variables were obtained for the prediction of two different markers of ischemia suggests that these values reflect the lesion severity or increase in lesion severity in major epicardial vessels at which coronary flow reserve is unable to meet myocardial demands.
Assuntos
Angioplastia Coronária com Balão , Angiografia Coronária , Doença das Coronárias/terapia , Angina Pectoris/diagnóstico , Doença das Coronárias/diagnóstico , Doença das Coronárias/epidemiologia , Eletrocardiografia , Teste de Esforço , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Sensibilidade e Especificidade , Fatores de TempoRESUMO
OBJECTIVES: We aimed to identify periprocedural quantitative coronary angiographic (QCA) variables that have predictive value on long-term angiographic results and to construct multivariate models using these variables for postprocedural prognosis. BACKGROUND: Coronary stent implantation has reduced the restenosis rate significantly as compared with balloon angioplasty in short de novo lesions in coronary arteries >3 mm in size. Although the postprocedural minimal luminal diameter (MLD) is known to have significant bearing on long-term angiographic results, no practically useful model exists for prediction of angiographic outcome based on the periprocedural QCA variables. METHODS: The QCA data from patients who underwent Palmaz-Schatz stent implantation for short (<15 mm) de novo lesions in coronary arteries >3 mm and completed six months of angiographic follow-up in the four prospective clinical trials (BENESTENT I, BENESTENT II pilot, BENESTENT II and MUSIC) were pooled. Multiple models were constructed using multivariate analysis. The Hosmer-Lemeshow goodness-of-fit test was used to identify the model of best fit, and this model was used to construct a reference chart for prediction of angiographic outcome on the basis of periprocedural QCA variables. RESULTS: Univariate analysis performed using QCA variables revealed that vessel size, MLD before and after the procedure, reference area before and after the procedure, minimal luminal cross-sectional area before and after the procedure, diameter stenosis after the procedure, area of plaque after the procedure and area stenosis after the procedure were significant predictors of angiographic outcome. Using multivariate analysis, the Hosmer-Lemeshow goodness-of-fit test showed that the model containing percent diameter stenosis after the procedure and vessel size best fit the data. A reference chart was then developed to calculate the expected restenosis rate. CONCLUSIONS: Restenosis rate after stent implantation for short lesions can be predicted using the variables percent diameter stenosis after the procedure and vessel size. This meta-analysis indicates that the concept of "the bigger the better" holds true for coronary stent implantation. Applicability of the model beyond short lesions should be tested.
Assuntos
Angioplastia Coronária com Balão , Angiografia Coronária , Doença das Coronárias/terapia , Processamento de Imagem Assistida por Computador , Stents , Adulto , Idoso , Angiografia Coronária/instrumentação , Doença das Coronárias/diagnóstico por imagem , Feminino , Humanos , Processamento de Imagem Assistida por Computador/instrumentação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Projetos Piloto , Prognóstico , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Resultado do TratamentoRESUMO
To determine the changes in stenotic and nonstenotic segments of a dilated coronary artery, detailed quantitative angiographic measurements were performed in 342 patients (398 lesions) immediately after angioplasty and at a predetermined follow-up time of 30, 60, 90 or 120 days after the dilation. Measurements of the stenotic segments were expressed as minimal luminal diameter, and the adjacent nonstenotic segments were expressed as interpolated reference diameter (both in millimeters). A follow-up rate of 86% was achieved. In the patients followed up at 30 and 60 days, there was no significant change in either the mean minimal luminal diameter or the mean reference diameter. However, at 90 and 120 days, there was significant deterioration in both the mean minimal luminal diameter (-0.37 and -0.42 mm, respectively) and the mean reference diameter (-0.17 and -0.26 mm, respectively), all of the changes being highly significant (p less than 0.00001). The reference diameter is involved in the dilation process and may be subject to the same restenosis process that takes place in initially stenotic segments. Percent diameter stenosis measurements, which are conventionally used to express the change in the severity of a stenosis after angioplasty, will tend to underestimate the change when there is a simultaneous reduction in the reference diameter.