Fatal Myocardial Infarction Associated with Bromocriptine for Postpartum Lactation Suppression

Summary: Bromocriptine (Parlodel®) has attracted widespread controversy for its use for postpartum lactation suppression because of recent reports of cerebral and cardiovascular complications. This case describes a maternal death in which bromocriptine therapy may have triggered myocardial infarction in a patient with asymptomatic coronary artery disease. We suggest its use with caution, especially in patients with identifiable risk factors of coronary artery disease or arteriovascular disease.     

Estrogen use and cardiovascular disease

In general, epidemiologic data from case-control and cohort studies have suggested that postmenopausal estrogen use confers a moderate degree of protection from coronary artery disease. The authors report reductions in all-cause mortality rates and in mortality rates for acute myocardial infarction among estrogen replacement users in comparison with never-users. It is calculated that even a small decline in the mortality rate for coronary artery disease among estrogen users would have a major impact on the overall risk/benefit ratio associated with estrogen use.     

Variation in use of menopausal hormone treatment on risk of health outcomes

AIM: To determine the relative risk of selected serious outcomes with variations in use of menopausal hormone treatment (MHT). METHODS: A cohort of 489 women, randomly recruited at age 40-79 years, from a longitudinal study of urbanised population was a study group and was followed for 14 years. Four selected outcomes (coronary artery disease, stroke, peripheral artery disease, breast cancer) were tested. Each woman on entry to the study was interviewed by a dedicated medical practitioner, and data on menstrual and menopausal history and health status were obtained. Outcome information was ascertained by questionnaire and medical reports from attending medical practitioners. In case of death, cause of death was checked with the Registry of Births, Deaths, Marriages and Divorce. This information was available for all women. An ever-user of MHT was defined as use for 6 mo or more at any time during the study. A late start of MHT was defined as 3 years or more from onset of menopause. The generalised linear statistical package was used to examine the data; univariate logistic regression models were used to describe the relationship between patient characteristics and a disease outcome, followed by stepwise multi variate analysis, controlling for age, lifestyle factors and co-morbidities. RESULTS: The risk of ever-use of MHT was significantly increased only for peripheral artery disease (RR = 2.16; 0.99, 4.71; P = 0.05), and not for coronary artery disease, stroke and breast cancer. A late start of MHT (three years or more from onset of menopause) was associated with significantly increased risks for coronary artery disease (RR = 2.56; 1.15, 5.72; P = 0.02) and peripheral artery disease (RR = 4.42; 1.55, 12.64; P = 0.005), and use after age 60 years with significantly increased risks for coronary artery disease (RR = 4.98; 2.19, 11.55; P < 0.001), stroke (RR = 2.99; 1.11, 8.08; P = 0.03) and peripheral artery disease (RR = 4.18; 1.24, 14.14; P = 0.02). Use up to 10 years was not associated with significant risk for all outcomes. These risks were confirmed by stepwise multi variate analysis, adjusting for age at recruitment, body mass index, smoking, physical activity and alcohol use, and existing diabetes, mellitus, hypertension and hypercholesterolaemia. Regardless of variations in use, risk for breast cancer was not found. CONCLUSION: The study confirms ever-use of MHT affected only risk of peripheral artery disease; but some use variations could have adverse effects.     

Clinical signs of androgen excess as risk factors for coronary artery disease

Women with androgen excess have been found to have higher triglycerides and lower high-density lipoprotein cholesterol concentrations than nonhirsute women and are presumed to be at increased risk of coronary artery disease. However, definitive data linking androgen excess with coronary artery disease is lacking. We evaluated 102 women coming to coronary artery catheterization for signs and symptoms of androgen excess. Hirsutism was found more commonly in those women with confirmed coronary artery disease (chi 2 = 10.11). Waist:hip ratio (an index of android fat distribution) was associated with hirsutism (by ANOVA, F-test) and with coronary artery disease (t-test). The strongest associations were found in older women (aged greater than or equal to 60). Androgen excess in women may signal risk for coronary artery disease.     

Preserved microcirculatory response to acute estrogen not reflected by exercise capacity

BACKGROUND: To assess the acute effect of a single dose of 10 mg oral micronized 17beta-estradiol on microcirculation in postmenopausal women with and without coronary artery disease and its potential influence on exercise capacity. METHODS: Postmenopausal women (n=11) with coronary artery disease had symptoms of ischemic heart disease and at least 1 mm ST depression at exercise. Microcirculation was examined by vital microscopy, with and without the acute administration of estrogen in a placebo-controlled cross-over design. Exercise test was performed on bicycle. The microcirculatory findings were contrasted to those in 14 healthy postmenopausal women. RESULTS: 17Beta-estradiol in serum and blood flow velocity increased significantly after acute oral estrogen administration both in women with coronary artery disease (p<0.001) and in healthy women (p<0.0001), with no significant difference between the two groups. No effect on exercise capacity or ST depression at exercise was detected. CONCLUSIONS: Previously reported data that a single dose of estrogen administered to postmenopausal women results in positive effects on exercise was not reproduced. An increased peripheral microvascular flow velocity was detected in women with coronary artery disease and this increase was not accompanied by an increased exercise capacity.     

Unstable angina during pregnancy in two patients with premature coronary atherosclerosis and aortic stenosis in association with familial hypercholesterolemia

Obstructive atherosclerotic coronary artery disease is uncommon in women during childbearing age, and the occurrence of myocardial ischemia during pregnancy has therefore been anecdotal. Two young patients with premature coronary artery disease in association with familial hypercholestrolemia had unstable angina in the second trimester of pregnancy. Workup revealed coronary artery disease and aortic stenosis. One patient opted for abortion at the twentieth week of gestation, and the other decided to continue pregnancy and was delivered by cesarean at 28 weeks' gestation. Coronary artery bypass grafting was performed after pregnancy in both patients. In addition, one of the patients underwent aortic valve replacement, and other had replacement of the narrowed ascending aorta with uneventful recovery. Our report describes an uncommon presentation of unstable angina during pregnancy in 2 young women with premature coronary artery disease and aortic valvular and supravalvular stenosis as a result of familial hypercholesterolemia. The management of these conditions during pregnancy is influenced by the effects of available therapeutic modalities on both maternal and fetal outcome.     

Complete myocardial revascularization using only pedicled arterial conduits in Kawasaki disease.

A 16-year-old boy with Kawasaki disease suffered from progressive angina and exercise intolerance for 1 year. Coronary angiography showed 60% stenosis of the left main coronary artery, a calcified aneurysm with total occlusion at the proximal left anterior descending artery (LAD), and another aneurysm with total occlusion at the middle portion of the right coronary artery. Aortocoronary bypass was done with the left internal mammary artery (IMA) anastomosed to the first obtuse marginal branch, the right IMA to the distal LAD, and the right gastroepiploic artery to the posterior descending artery. Graft patency was documented by follow-up coronary angiography 1 month after surgery. During follow-up, his rapid improvement led to an upgrade from New York Heart Association functional class III to class I. The results of the present case suggest that complete myocardial revascularization using arterial conduits in patients with Kawasaki disease with coronary artery occlusion is safe and effective.     

Feasibility and short-term results of total arterial coronary artery bypass in Taiwanese.

BACKGROUND AND PURPOSE: Long-term results of coronary artery bypass are limited by progressive atherosclerosis in venous conduits. Arterial conduits are believed to have a better patency rate. A radial artery in composite graft with the left internal thoracic artery makes total arterial revascularization possible in almost all patients. We sought to evaluate the feasibility and short-term results of this grafting strategy. METHODS: A total of 381 consecutive patients received elective coronary artery bypass grafting between 1 May 2000 and 31 August 2002. Patients with associated procedures were also included. There were 333 patients without venous conduits. Patients with left ventricular dysfunction were not excluded from total arterial revascularization. Follow-up time was 13.7 +/- 7.6 months. RESULTS: Total arterial revascularization was achieved in 88% of the patients. Arterial harvest was easy and simple and complete revascularization could be achieved. The 30-day overall mortality rate was 3.29%. In the patients with left ventricle ejection fraction greater than 0.4, the mortality rate was 2.32%. There were 6 late deaths: heart failure in 2, sepsis in 2, respiratory failure in 1, and pneumonia in 1. CONCLUSIONS: It is feasible to use total arterial grafts for coronary artery bypass graft in patients with coronary artery disease. Myocardial revascularization can be complete and the early mortality rate is acceptable.     

川崎病合并冠状动脉瘤63例临床分析

目的分析川崎病(KD)合并冠状动脉(以下简称冠脉)瘤患儿的临床特点。方法对首都医科大学附属北京儿童医院2000—2007年收治的63例超声心动图诊断为冠脉瘤的KD患儿临床资料、实验室检查、超声及心电图检查结果、治疗情况及随诊资料进行回顾性分析。结果(1)冠脉瘤患儿男性明显多于女性，男∶女为5.3∶1；冠脉巨大瘤男女比例为8.3∶1；<1岁患儿多发，占28.6%。(2)本组患儿中不完全KD、静脉注射丙种球蛋白(IVIG)抵抗以及KD复发的发生率均较高，分别为36.5%、30.2%和7.9%；急性期57例(90.5%)患儿使用IVIG冲击治疗，3例未用，3例使用情况不详；36例(57.1%)患儿发病至丙种球蛋白应用的时间间隔大于10 d。(3)超声检查发现小冠脉瘤患儿7例，中等冠脉瘤19例，巨大瘤37例，左冠脉受累者占76.2%，其中58.3%发生在前降支；右冠脉受累者达87.3%，其中47.3%发生在右冠Ⅱ段；双侧冠脉同时受累者占63.5%。(4)随诊发现71.4%冠脉瘤呈现回缩趋势，45.2%的受累分支冠脉瘤消退，平均消退时间为(2.1±1.5)年。结论对于男性、发病年龄<1岁、不完全KD、发生IVIG抵抗、复发患儿及应用IVIG治疗较晚患儿要警惕冠脉瘤的发生；左冠前降支及右冠脉瘤样病变最多见，多数冠脉瘤在恢复期发生回缩。     

Clinical alternative bypass conduits and methods for surgical coronary revascularization.

Poor quality or inadequate length of venous and mammary conduits, or both, a severely calcified or atherosclerotic aorta, or diffuse coronary atherosclerosis are situations cardiovascular surgeons will be facing with increasing frequency. These conditions are more common to the increasing number of patients requiring reoperation for advancing disease and to the growing number of older patients requiring operation. Decisions will be made preoperatively or intraoperatively about the technique to be used. Extensive use of the internal mammary arterial graft, such as bilateral internal mammary artery bypass, sequential use of the mammary artery and use of a free internal mammary artery graft, are excellent choices. These methods can overcome some of the difficult situations of the severely calcified atherosclerotic aorta or the absence of adequate venous conduits. Coronary arterial bypass using the inverted internal mammary conduit has too low a flow to be considered. Composite conduits will help gain the length needed to solve both the inadequate length problem and the severely diseased aorta. Little clinical experience is reported to date. These methods should only be used when nothing else is available. The innominate to coronary arterial bypass and the left subclavian to coronary arterial bypass can help solve the problem of the severely atherosclerotic aorta. The coronary to coronary arterial bypass has been used to solve both the severely diseased aorta and the short conduit situation. These methods, while ingenious, are supported only by occasional isolated clinical experiences. A large number of researchers have done extensive work on the selective retrograde coronary venous bypass grafting, but the last published article of any clinical importance dates back to 1979 and this suggests that other alternatives may be better. This technique should be used as a last resort. The surgical arteriovenous fistula has been clinically applied during the coronary artery bypass procedure. The nonconduit revascularization technique of coronary artery endarterectomy is needed in the armamentarium of the surgeon. This technique is not ideal but presently has better results than intraoperative transluminal coronary angioplasty and far better results than laser angioplasty. These methods may be useful to solve the diffuse coronary arterial problem, but sequential grafting techniques should be considered first.     

Open heart surgery in geriatric patients.

With the progress of medical science, the scope of open heart surgery has expanded. From 1975 through 1987, we operated on 114 consecutive patients aged 65 years and over with the aid of a cardiopulmonary bypass in the Department of Surgery, National Taiwan University Hospital. The annual number of these elderly patients has increased gradually, reaching 6.4% of the annual open heart cases in 1987. Eighty-six of our 114 patients were males and 28 were females. Their ages ranged from 65 to 88 years with an average of 68.5 years. Overall, 65 patients (57%) were operated on for coronary artery disease and/or its associated lesions; 41 (36%), for valvular heart disease; six, for aortic dissection; two, for cardiac tumor; and one, for congenital pulmonary stenosis. One patient had combined coronary artery disease and aortic dissection. The mortality for isolated coronary artery bypass surgery was 12%; for single valvular surgery it was 11%. The complexity of the surgical procedure increased the operative mortality. The overall mortality was 23.6% (27/114), with subsequent death in 5.7% during an average of 25 months of follow-up. Because of the degeneration of organ-systems in elderly patients, and its frequent association with poor cardiac reserve and other medical problems, these elderly cardiac patients should be checked thoroughly before they are considered for open heart surgery. Our experience suggests that open heart surgery can be done in selected patients aged 65 years or older with acceptable risks. Age alone should not be an absolute contraindication to surgery, and clinical improvement is to be expected after surgery.     

血浆前白蛋白和白细胞计数对川崎病患儿冠状动脉病变预测的意义

目的探讨血浆前白蛋白(PA)和白细胞计数(TLC)对川崎病患儿冠状动脉病变预测的意义。方法分析2013年1月至2016年1月江门市中心医院院收治的川崎病患儿83例,分析其病例资料,包括血浆中PA水平、TLC和冠状动脉超声检查结果等。采用t检验、χ~2检验以及ROC曲线下面积(AUC)与截断值计算等统计方法,对PA和TLC与冠状动脉病变进行相关性分析。结果在川崎病患儿的急性期,血浆PA水平为(72.39±46.81)mg/L,较正常参考值显著下降,TLC计数为(16.47±6.49)×10~9/L,较正常参考值显著升高,差异均有统计学意义(P0.05)。PA的AUC为0.699,具有诊断意义,PA水平选择界限值为48.5mg/L时,预测冠状动脉扩张的敏感度为73.3%,特异度为64.5%。结论 PA和TLC在川崎病急性期有显著变化,联合分析PA和TLC变化,对于预测冠状动脉病变可能具有重要意义,但不能据此判断冠状动脉病变类型与程度。     

Coronary stent graft for hypertrophic obstructive cardiomyopathy combined with coronary artery disease.

Percutaneous transluminal coronary angioplasty and stenting are established therapeutic modalities for coronary artery disease (CAD). Percutaneous transluminal septal myocardial ablation has become increasingly important for the treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We report a case of HOCM combined with CAD involving the left anterior descending coronary artery. Coronary stent graft implantation was performed with uneventful recovery. Coronary stent graft implantation may be beneficial in selected cases of symptomatic HOCM combined with CAD.     

Operative risk of general surgical procedures in patients with previous myocardial revascularization

Eighty general surgical procedures with general anesthesia were performed upon 73 patients who had undergone previous myocardial revascularization for significant coronary artery disease. No deaths occurred in this group of patients. Cardiac complications occurred in two patients. A silent myocardial infarction occurred in one patient while another required a permanent cardiac pacemaker for complete heart block. Six noncardiac complications developed in four patients. We concluded that patients with significant coronary artery disease who have undergone previous myocardial revascularization can tolerate subsequent general surgical procedures with limited risk.     

心型脂肪酸结合蛋白及冠状动脉Z值在川崎病早期诊断的临床意义

目的 观察川崎病患儿心型脂肪酸结合蛋白(h-FABP)、冠状动脉Z值的变化情况对小儿川崎病早期诊断的临床意义.方法 选择2018年10月至2020年8月于内蒙古自治区包头市中心医院收治并确诊为川崎病患儿50例为观察组,同期收治并确诊为上呼吸道感染患儿55例为对照组,收集入选川崎病患儿急性期、恢复期及上呼吸道感染患儿入院...     

Exploring the scientific basis of surgery: transmyocardial revascularization.

Transmyocardial revascularization (TMR) is a new surgical procedure aimed at increasing blood flow to the ischemic myocardium. It has been used for treatment of patients with end-stage coronary artery disease who are not candidates for conventional measures such as medication, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting. TMR involves creating transmural channels in the myocardium using lasers, in areas shown to be ischemic during preoperative testing. This procedure has shown promising results in clinical trials, but the mechanism of its efficacy remains largely unknown. TMR was originally developed as a means of supplying blood to the ventricular myocardium, directly through channels made in the wall of the ventricle. This was in an attempt to recreate the situation that exists in the reptilian heart, in which the myocardium is perfused directly from the ventricular chamber through a rich network of sinusoids that bathe the myocardial cells. However, the existence of a significant sinusoidal network in the human heart is doubtful. Whether the myocardium can be perfused directly via the TMR channels is controversial; it is becoming clear that other mechanisms such as angiogenesis are also at work. This review will use TMR as an example to illustrate how surgical practice and thinking can be based on theories that have little or no sound experimental evidence to support them. The importance of elucidating the valid scientific basis of surgical procedures in this modern era of evidence-based medicine will be emphasized.     

Clinical efficacy of transluminal extraction coronary atherectomy.

Mechanical revascularization has revolutionized the treatment of coronary artery disease. The transluminal extraction-endarterectomy catheter (TEC) system was developed recently and permits the excision and extraction of atherosclerotic lesions of the coronary artery and the bypass graft. The system includes a motor-driven flexible torque catheter with rotating conical shaped stainless steel blades distally. The proximal end of the TEC system consists of a mechanical housing which controls the vacuum, the rotating cutter (750 RPM) and the cutter excursion (4 cm). After safety testing of the TEC system in dogs and human peripheral arterial disease, percutaneous transluminal coronary atherectomies employing the TEC have been performed in 25 patients (six women, 19 men, mean age, 64 +/- 12 years) with the diameter of the stenosis greater than or equal to 75% in one or more coronary arteries. Twenty-eight atherosclerotic lesions were treated in 26 native coronary arteries. The overall success rate (less than 50% residual stenosis in all lesions) was 92%. There was one instance of hematoma proximal to the excised target lesion, and one instance of atherectomized debris embolization. There were no instances of dissection, perforation, coronary spasms or death related to the procedure. The results indicate that the TEC system can be used safely and effectively to treat coronary artery disease with a high success rate.     

Acute myocardial infarction in a young woman taking oral contraceptives. A case report

Acute myocardial infarction occurred in a 25-year-old woman. Coronary angiography performed one month after the acute illness was normal. An ergonovine test was negative. The patient's acute myocardial infarction most probably was induced by the use of oral contraceptives in combination with heavy smoking. Oral contraceptives, with their known influence on the blood coagulation system, must be considered a risk factor in precipitating coronary artery disease.     

Coronary artery disease in diabetic pregnancies

Severe vascular complications of diabetes mellitus include myocardial infarction and when this occurs during pregnancy it is associated with a high risk of maternal mortality. In the absence of myocardial infarction, information is unavailable on pregnancy outcome in diabetic patients with severe coronary artery disease or with prior coronary artery bypass graft. Such a case is presented together with a review of the literature.     

Pericardial fluid and serum levels of vascular endothelial growth factor and endostatin in patients with or without coronary artery disease.

BACKGROUND/PURPOSE: Vascular endothelial growth factor (VEGF) and endostatin are related to ischemic heart disease. This study investigated pericardial fluid and serum levels of VEGF and endostatin in patients with or without ischemic heart disease. METHODS: A total of 39 patients (24 patients in the CAD group with significant coronary artery disease; 15 patients in the non-CAD group without coronary artery disease) undergoing open heart surgery were enrolled. In the CAD group, patients were classified according to good coronary collateralization (Group A; n = 11) or poor coronary collateralization (Group B; n = 13). Pericardial fluid and serum samples were obtained at the time of surgery. VEGF and endostatin were measured by enzyme-linked immunosorbent assay. RESULTS: The levels of endostatin in both serum and pericardial fluid were significantly lower in the CAD group than in the non-CAD group (130.5 +/- 37.3 ng/mL vs. 172.4 +/- 37.8 ng/mL and 119.0 +/- 25.0 ng/mL vs. 143.0 +/- 23.5 ng/mL). The concentration of serum VEGF in the CAD group (92.6 +/- 18.2 pg/mL) was significantly higher than that in the non-CAD group (75.2 +/- 22.3 pg/mL). The concentration of serum VEGF in Group A (100.1 +/- 20.7 pg/mL) was significantly higher than that in Group B (84.3 +/- 12.4 pg/mL). The levels of pericardial fluid VEGF, serum and pericardial fluid endostatin were not significantly different between Groups A and B. CONCLUSION: Patients with coronary artery disease have lower serum and pericardial fluid levels of endostatin and higher serum levels of VEGF. Serum level VEGF, but not endostatin, is associated with good or poor collateralization in patients with coronary artery disease.