Bilirubin in coronary artery disease: Cytotoxic or protective?

Bilirubin has traditionally been considered a cytotoxic waste product.However,recent studies have shown bilirubin to have anti-oxidant,anti-inflammatory,vasodilatory,anti-apoptotic and anti-proliferative functions.These properties potentially confer bilirubin a new role of protection especially in coronary artery disease(CAD),which is a low grade inflammatory process exacerbated by oxidative stress.In fact,recent literature reports an inverse relationship between serum concentration of bilirubin and the presence of CAD.In this article,we review the current literature exploring the association between levels of bilirubin and risk of CAD.We conclude that current evidence is inconclusive regarding the protective effect of bilirubin on CAD.A causal relationship between low serum bilirubin level and increased risk of CAD is not currently established.     

Surgical or interventional revascularization in diabetic patients with coronary artery disease?

The combination of diabetes mellitus and coronary artery disease (CAD) constitutes an aggressive disease characterized biologically by chronic inflammatory, proliferative and pro-thrombotic situation. In the "diabetic patient" the increased frequency and gravity of simultaneous myocardial infarction and the deterioration of congestive heart failure contribute to the inevitable unfavourable final result. Diabetes accelerates the natural course of atherosclerosis and involves a great number of coronary vessels with more diffuse atherosclerotic lesions. Moreover, the risks of plaque ulceration and thrombosis have been shown to be considerably higher in diabetic patients. The treatment should be also aggressive and be based on the combined treatment of CAD and the effective regulation of glucose levels. The decision of revascularization in the diabetic patient should be posed relatively earlier. The surgical choice of revascularization seems to be advantageous over the interventional, with better early and late results.     

Radionuclide viability testing: should it affect treatment strategy in patients with cardiomyopathy and significant coronary artery disease?

Background

Ischemic heart failure is a significant source of morbidity and mortality, yet it has an unclear treatment strategy. The assessment of viable myocardium by nuclear imaging studies has shown promise in predicting improvements in ejection fraction and symptoms. However, the relationship of viability to long-term mortality has not been fully established.

Methods

A number of studies have addressed long-term mortality with nuclear viability imaging in patients with impaired left ventricular function and significant coronary artery disease. These studies were analyzed to determine differences in design, results, trends, and limitations. They were then evaluated by use of qualitative criteria established for prognostic studies.

Results

Fourteen studies met our criteria. Although the conclusions differed, it appears that patients with viability who undergo revascularization have the highest survival rate, whereas patients with viability who are treated medically have a much lower survival rate. Patients without viability have an intermediate survival rate, regardless of treatment. Several limitations were identified, including a lack of randomization, small sample size, inadequate follow-up, and extensive study protocol and design differences.

Conclusions

The use of viability testing in patients with heart failure and significant coronary artery disease has shown promise in predicting the long-term mortality rate with treatment allocation. However, there is a need for further study involving larger cohorts with a randomized design, longer periods of follow-up, improved study designs, and identification of referral bias and viability prevalence.     

Current treatment of significant left main coronary artery disease: A review

Though infrequent, left main stenosis has a major prognostic impact. The management of left main disease has evolved over the last few decades with the growing evidence of the efficacy and safety of percutaneous interventions, as attested by the most recent trials.However, mastery of the technical aspects of left main bifurcation stenting is essential in ensuring optimal results. This review focuses on recent data concerning left main angioplasty results as well as the current technical approaches.     

Long-term prognosis in patients with single-vessel or double-vessel coronary artery disease: does successful revascularization achieved by coronary angioplasty improve late outcome?

OBJECTIVES: It is not clear whether revascularization by coronary angioplasty improves long-term prognosis in patients with stable angina, single- or double-vessel coronary artery disease. This study investigated the extent of late revascularization achieved by percutaneous transluminal coronary angioplasty(PTCA) and evaluated the long-term effect of revascularization in patients with coronary artery disease. METHODS: This study reviewed 178 patients with single-vessel or double-vessel disease and significant coronary diameter stenosis(American Heart Association classification, 75% or more stenosis), but excluded 35 patients with failed revascularization of the target vessels because of initial failed angioplasty(n = 14) or restenosis(n = 21). The remaining 143 patients were available for assessment. Revascularization was successful at follow-up angiography after the last angioplasty in 105 patients(Group A). The remaining 38 patients received conservative medical therapy(Group B). Kaplan-Meier survival curves were used to examine absolute survival difference. RESULTS: One hundred forty-three patients(mean age 64 +/- 9 years) were followed-up for 3.8 +/- 1 years. The patients were 70.6% male, 59.4% had myocardial infarction and 76.9% had single-vessel disease. Anatomical complete revascularization in the chronic phase was accomplished in 80 patients with single-vessel disease(97.6%) and 11 patients with double-vessel disease(47.8%). The event-free survival rate was not significantly different between Group A and Group B(88.6% vs 84.2%, p = NS). Cardiac survival rate decreased significantly in Group B compared to Group A(89.5% vs 99.0%, p < 0.01). This difference in survival rate was due to sudden cardiac death in Group B(7.9% vs 0%, p < 0.05). Non-fatal myocardial infarctions occurred in seven patients(6.7%) with revascularization and in one patient(2.6%) with conservative medical therapy, but with no significant difference. Late successful revascularization improved cardiac survival rate in patients with proximal left anterior descending coronary artery involvement or single-vessel disease. CONCLUSIONS: Cardiac events decreased and long-term prognosis appeared to be a good possibility in patients with single- or double-vessel coronary artery disease if late successful revascularization of target vessel was accomplished.