Cause of death and sudden cardiac death after heart transplantation. An autopsy study

Postmortem findings in 39 patients following cardiac transplantation are presented. Causes of death were right-sided heart failure after transplantation (6 [15%]), infection (5 [13%]), multisystem organ failure (4[10%]), complications of noncardiac surgery (3 [8%]), acute rejection (3 [8%]), malignant neoplasm (3 [8%]), graft vascular disease (3 [8%]), preservation procurement injury (3 [8%]), cardiac arrhythmia (2 [5%]), other (4 [10%]), and unclear (3 [8%]). Seven patients in medically stable condition died after a sudden cardiac arrest, and these constituted 27% (7/26) of deaths more than 1 month after transplant. The 7 sudden cardiac arrests were due to graft vascular disease (2 [29%]), acute rejection (2 [29%]), cardiac arrhythmias (2 [29%]), and hyperkalemia during an exacerbation of acute renal failure (1 [14%]). In 3 of the 5 patients who died of sudden cardiac arrest not due to acute rejection, hemodialysis and plasmapheresis were triggers of the event. Pulmonary hypertensive arteriopathy was associated with early death and right-sided heart failure, and 6 of 8 patients with these changes died perioperatively or postoperatively.     

Clinical choroidal thrombosis, hypertension, and diabetes mellitus: an electron microscopic study

Changes in the choroidal artery were examined at autopsy in 16 Japanese patients with hypertension and insulin-dependent diabetes mellitus. These changes could be divided into 1) arteriosclerotic ones consisting of intimal thickening due to migration of smooth muscle cells, 2) hyaline deposits in the subendothelium, 3) extensive degeneration (moth-eaten atrophy and necrosis) of medial smooth muscle cells, and 4) changes resulting from fibrinoplatelet thrombi and their organization (recanalization and obstruction). The intimal thickening and medial damage correlated with aging, were accelerated by hypertension, and were remarkable in arterioles less than 60 micron in diameter. Diabetes mellitus apparently did not enhance these vascular changes. Thrombotic occlusion or narrowing of the choroidal artery was frequently observed in the arterioles of patients with hypertension and diabetes mellitus who had chronic azotemia or renal insufficiency. Subendothelial hyaline deposits were increased in patients with diabetes. The narrowing or obstructive changes in the choroidal artery were extensive in the intraocular blood vessels. These changes may be secondary and induce damage to other intraocular blood vessels and tissues, including the retina.     

Hypertensive-diabetic cardiomyopathy in the rat: an experimental model of human disease.

The authors recently described a group of diabetic patients with severe congestive heart failure, hypertension, and minimal coronary artery disease, who had significant myocardial degeneration apparently secondary to the combined effects of high blood pressure and diabetes on the heart. To evaluate the effects of hypertension and diabetes mellitus more fully, the authors studied four groups of rats with either no disease, streptozotocin-induced diabetes mellitus, renovascular hypertension, or a combination of hypertension and diabetes. They employed semiquantitative light microscopy, which revealed significantly greater replacement fibrosis in the hypertensive-diabetic rats when compared with the other three groups. Interstitial fibrosis was increased in the hypertensive-diabetic animals, though it was just below the 5% level of significance when compared with the hypertensives. Further analysis, however, revealed that those hypertensive-diabetic animals with the greatest relative cardiac hypertrophy, as measured by the heart weight/body weight ratio, had significantly increased interstitial fibrosis. Surprisingly, diabetes mellitus alone produced no morphologic light-microscopic alterations; yet 8 weeks of combined hypertension and diabetes mellitus led to myocardial degeneration similar to the human disease. These changes do not appear to be secondary to abnormalities of intramyocardial muscular vessels. Measurement of 3 parameters of vascular disease revealed that hypertensive animals with less myocardial damage had greater vascular changes than the more severely affected hypertensive-diabetics. This study provides evidence that the combination of diabetes mellitus and hypertension produces significantly greater myocardial lesions than either disease alone. The similarity of the lesions with those observed in human patients suggests that the hypertensive-diabetic rat is a useful model for elucidating the pathogenesis of clinical myocardial disease in patients with hypertension and diabetes mellitus.     

Mechanisms of development of diabetic macroangiopathy

Pieces of the aorta and heart coronary arteries taken at autopsy of 100 patients who had died of insulin-dependent and non-insulin-dependent diabetes mellitus were studied histologically and immunohistologically. Atherosclerosis was more pronounced in diabetes mellitus patients than in patients with normal glycemic indices. Atherosclerosis was most severe in non-insulin-dependent diabetes. Diabetic microangiopathy of the vasa vasorum of large arteries promotes development of atherosclerosis.     

Association of eosinophils with cardiac rupture

Cardiac rupture occurs in 10 per cent of patients who die with acute myocardial infarction, but the pathogenesis remains unclear. Twenty randomly selected patients with cardiac rupture were reviewed retrospectively at autopsy, and the findings were compared with those of 20 age- and sex-matched control subjects who had died of acute transmural myocardial infarction without rupture. The times from the onset of chest pain to death were similar in the two groups (5.7 +/- 5.8 days for patients with rupture versus 4.2 +/- 4.9 days for control subjects), and there were no differences in the incidences of systemic hypertension, diabetes mellitus, hypercholesterolemia, history of myocardial infarction, or angina pectoris. The severity of coronary atherosclerosis was different in the two groups, with 55 per cent of the patients with cardiac rupture having single-vessel disease and 70 per cent of the patients without cardiac rupture having disease in three vessels. Additionally, the incidence of thrombosis was greater in patients with cardiac rupture than in those without. The inflammatory cell response in each patient was quantitated microscopically (number and type of leukocytes) in ten high-power fields. The inflammatory response was greater in patients with cardiac rupture. The number of eosinophils in the inflammatory response was significantly (P less than 0.01) greater in hearts associated with cardiac rupture (29.5 +/- 4 per cent) than in control hearts (11.7 +/- 3.1 per cent). It is postulated that eosinophils rich in arylsulfatase B, peroxidase, glucuronidase, beta-glycerophosphatase, major basic protein, and eosinophilic cationic protein may further weaken the necrotic myocardium and, in part, determine whether acute myocardial infarction will eventually result in cardiac rupture.     

Pulmonary thrombotic arteriopathy in patients with sickle cell disease.

BACKGROUND: Shortened life expectancy due to pulmonary hypertension (PH) is seen in 5% to 10% of patients with sickle cell disease. The principal factors suspected of causing PH are pulmonary thromboemboli (PE) and in situ arterial thrombosis. OBJECTIVE: To investigate the possible role that PE or in situ arterial thrombosis play in the development of PH in sickle cell disease. METHODS: Autopsies of 12 patients with sickle cell disease were correlated with clinical data from medical records. RESULTS: Right ventricular hypertrophy was present in 9 of 12 patients. Six patients with right ventricular hypertrophy had thrombi in large elastic pulmonary arteries. All patients with elastic artery thrombi had fresh or organized thrombi in small muscular pulmonary arteries. Hypertensive small arterial changes were present in 5 of these 6 patients. Six patients showed no thrombi in elastic arteries. Among these 6 patients, 3 had right ventricular hypertrophy and recent and organized thrombi, as well as hypertensive changes in small arteries. One of these 3 patients demonstrated plexiform-like lesions and fibrinoid necrosis of small arteries. Three patients without right ventricular hypertrophy had pneumonia or pulmonary edema with no identifiable pulmonary artery pathology. CONCLUSIONS: Arterial thrombosis with PH and cor pulmonale was regarded as the cause of death among most of these patients. Elastic artery thrombi are pulmonary thromboemboli, but pulmonary thromboemboli are always associated with widespread thrombosis of small arteries. Widespread thrombosis of small arteries alone was associated with PH in some cases. This finding suggests that pulmonary thromboemboli may be a late complication of PH and cor pulmonale and that an in situ thrombotic arteriopathy underlies the development of PH in most patients with sickle cell disease.     

The long-term results of coronary artery bypass grafting in patients with type II diabetes

A three-year follow-up of patients with coronary heart disease (CHD) and type II diabetes after coronary artery bypass grafting, shows that the following pathologic conditions are significantly more frequent: arterial hypertension, visceral obesity, marked disturbances of blood lipid spectrum, an increases CHD duration, and an increased rate of myocardial reinfarction and revascularizations. The study shows that the presence of diabetes mellitus in CHD patients undergoing coronary artery bypass grafting, is associated with pronounced disturbances in blood lipid spectrum, and is an important risk factor of coronary event progression.     

Psychologic predictors of psychosocial and medical outcomes in patients undergoing coronary angioplasty

The relationship between psychologic variables (the match between repressive style and level of cardiac information, and anxiety level) and medical complications, re-stenosis (renarrowing), and psychosocial adjustment was studied in 97 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for treatment of narrowed coronary arteries. Three major findings emerged for outcomes measured 6 months after PTCA: repressors with a high level of cardiac information (coping style-information level mismatch) and no history of heart attack were at higher risk for late medical complications (p less than 0.001); sensitizers with a low level of cardiac information (coping style-information level mismatch) and whose PTCA was only moderately successful were at higher risk for re-stenosis of the artery previously widened during PTCA (p less than 0.01); and patients who were more anxious during hospitalization had poorer social functioning and more mood disturbance 6 months after PTCA (p less than 0.05). Thus, psychologic, information, and medical factors are important in predicting 6-month outcomes in patients undergoing PTCA.     

Regurgitation of fat and marrow emboli into coronary veins during resuscitation

Three groups of patients were examined at autopsy for the presence of fat and marrow emboli in the lungs, heart, and other organs. Group 1 was composed of patients with massive pulmonary thromboembolism and attempted cardiopulmonary resuscitation; group 2, patients with pulmonary thromboembolism and without attempted cardiopulmonary resuscitation; and group 3, patients without pulmonary thromboembolism and with attempted cardiopulmonary resuscitation. The results confirm that pulmonary fat and marrow emboli are frequent in those patients who are resuscitated. A novel observation is the finding of multiple coexistent cardiac venous emboli in those resuscitated patients who have pulmonary artery obstruction with pulmonary thromboemboli. These findings suggest that these emboli regurgitate from the right side of the heart to the coronary sinus and cardiac veins in cases of pulmonary artery hypertension.     

Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsy.

Thrombi in the fetal circulation of the placenta cause a pattern of clustered fibrotic villi called fetal thrombotic vasculopathy (FTV), which has been associated with serious injuries to neonates, especially brain injuries. Correlation of FTV with visceral thrombi in autopsy specimens might lead to a more accurate estimate of the prevalence of somatic thrombi as a significant and underrecognized cause of prenatal injury or perinatal death, and show the potential validity of placental FTV as an indicator of thrombotic lesions in the fetus and newborns who survive. Clinicopathologic correlation was used to perform a 3-year retrospective autopsy review. We identified 16 cases (19%) among 84 perinatal autopsy specimens in which placental FTV was associated with stillbirth, intrapartum, or neonatal death. Two liveborn neonates survived 2.5 hours, and one for 24 hours; there was one intrapartum death, and the rest were stillborn. Clinical evidence of severe central nervous system (CNS) injury to two of the liveborn infants was evident at birth. Twelve stillborns died from 12 to 48 hours before delivery. Placental FTV had features of organization that clearly antedated the fetal death. Autopsy findings confirmed somatic thrombi in six cases (37.5%) of the 16 with FTV, including cerebral thrombi or infarcts (three cases), renal thromboemboli (three cases), and pulmonary thromboemboli (two cases). One mother had history of deep vein thrombosis, and four of eight tested had abnormal coagulation test results. Placental FTV indicates a significant probability of thrombi in the fetus and represents an important, possibly underrecognized cause of perinatal mortality and neonatal injury. Parental coagulopathy as a significant factor in prenatal injury and death deserves more comprehensive study. The placenta remains an undervalued and underutilized surgical specimen in the evaluation of perinatal injury, especially cerebral palsy.     

Prevalence of diabetes mellitus, hypertension and cardiac complaints in a follow-up study of a Dutch PCOS population

The aim of this study was to investigate the prevalence of diabetes mellitus, hypertension and cardiac complaints in a Dutch population with polycystic ovarian syndrome (PCOS) and to compare the results with the prevalence of these conditions in the Dutch female population, as retrieved from the Netherlands Health Interview Survey of Statistics Netherlands. A total of 346 PCOS patients were interviewed by telephone, with a mean age of 38.7 years (range 30.3--55.7) and a mean body mass index of 24.4 (range 17.5--55.8). Diabetes occurred in eight (2.3%), hypertension in 31 (9%) and cardiac complaints in three (0.9%) of the women. The prevalence of diabetes and hypertension differed significantly from the prevalence of these conditions in the Dutch female population (both P < 0.05). In PCOS women aged 45--54 years (n = 32) the prevalence of diabetes was four times higher (P < 0.05) and of hypertension 2.5 times higher (P < 0.01) than the prevalence of these conditions in the corresponding age group of the Dutch female population. Hypertension also occurred significantly (P < 0.05) more in the younger (35--44 years) PCOS group (n = 233), but this age group was significantly more obese (P < 0.01) when compared with figures of obesity of the Dutch female population. In conclusion, our data show that in a follow-up study of a relatively lean PCOS population, the prevalence of diabetes mellitus and hypertension was increased when compared with the Dutch female population, especially in women aged 45--54 years.     

Intracardiac thrombi in extracardiac disorders: an autopsy study

IntroductionIntracardiac thrombi (ICT), more commonly encountered at autopsy, are well documented with underlying cardiovascular disease. Occurrence of ICT in systemic diseases without an intrinsic cardiac disorder is rare. The aim of this autopsy study was to highlight such an occurrence.MethodsFrom 1996 to 2010, cases with ICT unrelated to primary cardiac disorders were selected at autopsy and analyzed. Clinical and investigational data were obtained from the medical records. The location, morphology, size, and histological appearance of the thrombi were noted. The thrombi were then classified on the basis of their location, nature, and histology (fresh and/or organized); this was correlated with the clinical setting.ResultsAmong a total of 11,724 autopsies performed in 15 years, 276 patients (2.4%) had ICT. Of these, 45 patients (0.4%) had ICT that were unrelated to primary cardiac diseases. There were 25 men and 20 women with a mean age of 46.1 years. Antemortem diagnosis was not made in any of these patients. Eight patients each (35.6%) showed isolated left-sided and multichambered involvement, while the rest of the hearts (64.4%) had thrombi in the right-sided chamber(s). The recognizable risk factors were underlying cancers (24.4%), prolonged immobilization (20%), systemic lupus erythematosus (6.7%), pregnancy (4.4%), nephropathy (4.4%), primary antiphospholipid antibody syndrome (2.2%), and ulcerative colitis (2.2%). However, 16 patients (35.7%) had no obvious predisposing factor, although investigations for prothrombotic markers had not been done. Diabetes mellitus, chronic alcoholism, and deep vein thrombosis of the lower limbs had been clinically documented in some of them. The cause of death in most patients (73.3%) had been related to pulmonary and/or systemic thromboembolism.ConclusionsThis autopsy study emphasizes the great need for a higher index of suspicion of in situ thrombosis in the heart in hypercoagulable states so as to curtail the morbidity and mortality of the primary disease process.     

Analysis of multiple primary cancer autopsy cases associated with breast cancer: 2002–2010

Breast cancer patients have a generally increased risk of developing second cancers. The object of this study was to clarify the increased as well as decreased incidence of cancers in breast cancer patients using autopsy cases. 164 211 autopsy cases in the Annual of Pathological Autopsy Cases in Japan from 2002 to 2010 were analyzed for multiple primary cancer (MPC). Female MPC cases (4222 cases) were selected. We investigated the cancer incidence observed in breast cancer associated MPC. The Chi‐squared test was used for analysis. All P‐values were two‐sided, and differences at P < 0.05 were considered significant. Breast cancer associated MPC showed a significantly increased incidence of ovarian, pancreatic, and skin cancer (Odds Ratio [95 % confidence interval (CI)]) = 1.464 [1.03, 2.08], 1.414 [1.08, 1.85] and 2.092 [1.28, 3.41]), and a decreased incidence of colorectal and cervical cancer (OR [95 % CI]) = 0.732 [0.60, 0.90], 0.605 [0.38, 0.96]). Our findings of an increased incidence of malignancies in breast cancer associated MPC cases were consistent with the results of previous population‐based studies. This study is the first study to analyze massive autopsy data on MPC which provide new evidence clinically and pathologically.     

Morphological changes in small vessels on endomyocardial biopsy

Small vessel disease has been described in various cardiac conditions including diabetes mellitus, amyloidosis, and connective tissue disease. Less well understood is the incidence and morphological features of small vessel disease in patients with myocardial disease of unknown etiology. This study examines the incidence, clinical presentation, and pathological changes of small vessel disease in patients with normal epicardial coronary arteries undergoing endomyocardial biopsy. Biopsy specimens in 110 consecutive patients were analyzed by light and electron microscopy. Small vessel abnormalities were present in 16 patients (14.6 percent) of whom five patients had associated hypertension and 11 patients had idiopathic small vessel disease. There were six males and 10 females with a mean age of 53 (26 to 76) years. Clinical presentations were arrhythmias, heart failure, or chest pain. The left ventricular ejection fraction was reduced (less than 50 percent) in 12 of these 16 patients. The morphological features of small vessel disease included marked thickening of the arterial wall owing to subendothelial deposits of heterogeneous electron dense materials consisting of microfibrils, collagen and elastic fibers, cellular debris, and other amorphous substances. Subendothelial deposits comprised a mean 60 percent (40 to 76 percent) of the arterial wall thickness.     

Pulmonary vasculitis with hypereosinophilia and episodic pulmonary hypertension: Report of three siblings

Three siblings with eosinophilia who developed pulmonary hypertension are reported. They consisted of a 3 year old boy (case I), a 9 year old boy (case 2) and a 13 year old girl (case 31, all of whom died within an 18 month period of severe episodic attacks of pulmonary hypertension and the resultant low cardiac output. Marked peripheral eosinophilia was found in cases 1 and 2, and mild eosinophilia in case 3. Open lung biopsy of case 1 revealed pulmonary arteritis with massive eosinophilic infiltration and intimal thickening of muscular arteries of 300–1500μm in diameter. At autopsy, caws 2 and 3 showed almost similar findings, comprising widespread obliteration of the pulmonary arteries by concentric intimal thickening, medial hypertrophy and recanalized thrombi of arterioles. Rarely, there were foci of granulomas in the thickened intima surrounding birefringent foreign bodies. There were small areas of infarction in the lungs and heart due to arterial thrombi. Vascular lesions other than those in the lungs were mild and almost limited to the branches of the coronary arteries. Therefore, the present cases appear to be a single disease of pulmonary hypertension secondary to endothelial injury and the resultant intimal fibrosis probably evoked by toxic substances, although such agents were not confirmed.     

Relationship between C peptide and chronic complications in type-2 diabetes mellitus

OBJECTIVE: The relationship between C peptide and micro- and macrovascular complications is poorly known in type-2 diabetes mellitus. The aim of the study was to evaluatethe relationship between serum C-peptide level and chronic complications in patients with type-2 diabetes mellitus. PATIENTS AND METHODS: Three-hundred-eighteen patients (138 male, 180 female) with type-2 diabetes mellitus were included in the study. Microvascular (nephropathy, retinopathy and neuropathy) and macrovascular complications (coronary artery disease and peripheral vascular disease) were determined in all patients. In addition, presence of hypertension and smoking habit was recorded. Fasting serum glucose, lipid levels, HbA1c and C-peptide levels were measured in all patients. RESULTS: There were 90 (28.3%) patients with sensorial neuropathy, 48 (15.1%) with autonomic neuropathy, 72 (22.7%) with nephropathy, 84 (26.4%) with retinopathy, 135 (42.5%) with hypertension, 270 (84.9%) with dyslipidemia, 33 (10.4%) with coronary artery disease and 18 (5.7%) with peripheral vascular disease. Serum C-peptide level was higher in patients with dyslipidemia (p = 0.045), hypertension (p = 0.001), coronary artery disease (p = 0.001), peripheral vascular disease (p = 0.001) and autonomic neuropathy (p = 0.001). Serum C-peptide level was not significantly different in patients with and without sensorial neuropathy, nephropathy and retinopathy. Serum C-peptide level was significantly associated with the presence of coronary artery disease (p = 0.001), peripheral vascular disease (p = 0.001) and autonomic neuropathy (p = 0.001). There was no relationship between C peptide and sensorial neuropathy, nephropathy and retinopathy. CONCLUSION: Our findings indicate a relationship between C peptide and macrovascular but not microvascular compli cations in patients with type-2 diabetes mellitus.     

Major Primary Congenital Coronary Artery Anomalies: An Angiographic Study

Congenital Coronary artery anomalies are found in about 1 % population (0.6% to 1.5% in different geographic studies). Angiographic recognition of these anomalies is important because of their clinical significance (sudden death) and importance in patients undergoing coronary interventions or cardiac surgery. Our study included 3215 patients who underwent diagnostic coronary angiography during the 2 years period from 2008 to 2010. Twenty nine (0.90%) patients (22 male and 7 female) had major congenital coronary anomalies of which twenty seven (93.10%) patients had anomalies of origin and distribution while two (6.89%) had coronary artery fistulae. Right coronary artery was the commonest anomalous vessel, involved in 14 (48.27%) patients. It was originating from the left sinus of Valsalva in 10, from the non-facing aortic sinus in 2 and from left anterior descending artery in 2 patients. Anomalous origin of left circumflex artery was the second commonest anomaly, seen in 10 (34.48%) patients. Anomalous left anterior descending artery was found to be originating from right coronary artery in 2 (6.89%) and anomalous left coronary artery from right coronary artery was seen in one (3.4%) patient. Among patients with coronary fistulae, one (3.4%) had fistulae between the left anterior descending artery and the main pulmonary artery, one (3.4%) between the conal artery and the right atrium. The fistulae in our series were small & without significant shunt circulation. Atherosclerotic plaques in anomalous arteries were seen in only 8 (27.58%) patients, significantly less than the incidence (51.5%) of overall coronary artery disease in 3215 patients studied in this series. In two (6.89%) patients only the anomalous vessels were involved in coronary artery disease. Congenital coronary artery anornalies do not appear to be associated with an increased risk for development of coronary atherosclerosis. Recognition of coronary anomalies is important in patients undergoing coronary angiography, coronary interventions and cardiac surgery. Variations in the frequency of major congenital coronary anomalies may have a genetic background.     

Percutaneous transluminal coronary angioplasty of focal coronary lesions after cardiac transplantation

Summary Transplant coronary artery disease is the greatest impediment to long-term survival beyond the first year after cardiac transplantation. Transplant coronary artery disease shows a heterogeneous angiographic appearance, but focal stenoses can occur alone or at least predominate. Based on an angiographic indication 35 critical focal lesions causing narrowing by 75% or more were treated by PTCA during 23 procedures in seven patients 18–84 months after cardiac transplantation. Three patients each underwent only one procedure and four underwent repeated procedures [2, 3, 4 and 11, respectively]. Primary success was achieved without any complication in 35 of 35 lesions (100%). The mean degree of stenosis was reduced from 86±9% to 28±17% (P<0.001). The rate of restenosis was 18/29 (62%) at a mean of 4 months after angioplasty. Four patients are alive and free of adverse effects (symptoms, myocardial infarction, repeated percutaneous transluminal coronary angioplasty, retransplantation) 16±10 months after their last angioplasty. One patient underwent a successful second heart transplantation 26 months after the first angioplasty. Two patients died, 1 and 31 months after the last angioplasty. In conclusion, percutaneous transluminal coronary angioplasty can be performed safely with an excellent primary success rate in critical focal transplant coronary artery disease. The rate of restenosis is higher than in native coronary artery disease. Long-term follow-up depends on the individually variable accelerated nature of graft atherosclerosis.Abbreviations PTCA percutaneous transluminal coronary angioplasty - TxCAD transplant coronary artery disease - HTX heart transplantation - LAD left anterior decending artery - CFX circumflex artery - RCA right coronary artery     

Cognitive adaptation as a predictor of new coronary events after percutaneous transluminal coronary angioplasty.

OBJECTIVE: We tested whether the psychological components of cognitive adaptation theory would predict new coronary events after a first percutaneous transluminal coronary angioplasty (PTCA). METHODS: A consecutive sample of patients treated successfully with PTCA were enrolled in the study. Of 343 patients approached, 303 (88%) agreed to participate and were interviewed shortly before hospital discharge. We measured the components of cognitive adaptation theory (optimism, self-esteem, and mastery) during the interview. Five patients were excluded from the analysis because of early, in-hospital reocclusion. New cardiac events (coronary artery bypass grafting, PTCA, myocardial infarction, or disease progression) were examined within 6 months of the first PTCA. We obtained 6-month follow-up data on 98% of patients. RESULTS: The cognitive adaptation index predicted new cardiac events, even when demographic variables and medical variables thought to predict restenosis were statistically controlled (p = .02). CONCLUSIONS: These results suggest that persons who respond to their illness by perceiving control over their futures, by having positive expectations about their futures, and by holding a positive view of themselves seem to be at less risk for a new cardiac event after a first PTCA.