Advances in interventional cardiology

The field of interventional cardiology is growing widely. This growth is the result of improvements in existing technology, development of new technology, and expansion of criteria for the selection of patients. Percutaneous transluminal coronary angioplasty (PTCA) remains the mainstay and is used to treat an increasing number of patients with coronary artery disease that manifests as stable or unstable angina or acute myocardial infarction. Atherectomy is being used to "debulk" lesions and remove atheromatous plaque as well as to remove intimal flaps after PTCA. The insertion of an intracoronary stent is a strategy designed to treat intimal dissections and acute closure as well as to attempt to decrease the incidence of restenosis. Finally, intracoronary laser therapy--independently or in combination with PTCA--is being evaluated as a treatment approach for more diffuse disease, acute occlusion, and prevention of restenosis.     

Drug-coated balloons in interventional cardiology

Over the last few years, drug-coated balloon (DCB) therapy has emerged as a promising therapeutic intervention for the management of obstructive cardiovascular disease. The dictum of this novel technology is that effective prevention of restenosis can be achieved by the short-term transfer of antiproliferative drug to local arterial tissue by means of a single prolonged balloon angioplasty dilatation. Its main attraction is that no foreign body is implanted eliminating thus the risk of late inflammatory response to device components without preventing positive remodeling. Here, we discuss the evidence regarding the effectiveness of DCB in different lesion types and clinical settings as well as the types of DCB commercially available or under development.     

New interventional technologies in cardiology

If atherectomy procedures are found to be safe and effective for removal of plaque in human coronary arteries, they can be expected to provide an important alternative to balloon angioplasty for the treatment of many types of coronary lesions. In addition, many patients who are candidates for coronary artery bypass procedures could likely benefit from these less invasive procedures. Although atherectomy has a theoretic potential for reducing the rate of restenosis by removing the plaque rather than pushing it to the side, it is unlikely to eliminate the restenosis problem completely. A more important advantage of atherectomy may be the potential for successful treatment of lesions that are anatomically unsuitable for PTCA. Even though balloon catheter technology has evolved to the point that almost all lesions in the coronary anatomy can be successfully negotiated, approximately half the coronary patients who require invasive therapy in the United States are still undergoing open-heart bypass procedures. Thus, if atherectomy can expand the indications for interventional therapy to the types of lesions that are currently considered unsuitable for PTCA, the large number of patients who are currently unable to benefit from interventional catheterization techniques could be treated. With all the new devices under investigation, carefully controlled prospective randomized trials must be conducted once the developmental phases have been completed. Each new technology must be compared with the current state-of-the-art techniques of balloon angioplasty and coronary artery bypass operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Factor Xa-inhibition in interventional cardiology

The recently established correlation between bleeding events and clinical outcomes in patients with coronary artery disease undergoing either non-invasive or invasive treatment for acute coronary syndromes (ACS) highlights the unmet need for safer anticoagulants that can be used in conjunction with dual or triple antiplatelet therapy. The central position of the coagulation factors IIa and Xa within the coagulation system account for their prominent role as targets for anticoagulants. Unfractionated heparin (UFH) achieves a variable indirect inhibition of both factors. The low molecular weight heparins (LMWH) show favourable pharmacokinetics over UFH and have a more pronounced activity against factor Xa as opposed to thrombin which may partially account for the benefits observed with LMWH in clinical trials. New agents that have been developed allow for a selective inhibition of factor Xa. Recently, exciting results have been reported with an indirect selective inhibitor of factor Xa in patients with ST-elevation myocardial infarction (STEMI) -acute coronary syndromes (ACS) and non-STEMI-ACS. In this article the pharmacology of the indirect selective factor Xa inhibitors Fondaparinux and Idraparinux will be discussed along with the direct selective factor Xa inhibitors DX-9065a and Otamixaban in the setting of interventional cardiology.     

Evidence-based clinical outcome management in interventional cardiology

In conclusion, through the use of pathways and case management, evidence-based clinical outcome management has occurred. The author's institution now has a process that enables it to accomplish three objectives: (1) the ability to track outcomes, (2) the ability to obtain information about opportunities for improvement and develop action plans for this, and (3) the ability to judge through continued variance analysis whether the actions taken made a difference or whether more changes are necessary. Based on this evidence, supported by the literature, the author's institution has been able to offer quality patient care at a reasonable cost.     

超声心动图在介入心脏病学中应用进展和前景

介入心脏病学是以心导管术为基础，在影像技术的引导下进行心脏病诊断和治疗的学科，为过去20年临床医学领域中发展最快的学科之一。其突出特点是大量新概念与新技术、新器械不断涌现，并迅速、广泛和成功地应用于临床，使冠心病、先天性心脏病（先心病）、心瓣膜病和心律失常等主要病种的治疗发生了革命性的变化。介入治疗是否能成功达到预期的治疗效果，与超声心动图学有着密切的关系。从术前对临床病例的选择、术中对介入手术监护到术后的疗效评价和病情随访，超声心动图都发挥着其他影像学方法无法比拟的重要作用。本文就超声心动图在介入心脏病学中应用进展和前景进行介绍。     

Advances in interventional cardiology: beyond the balloon

The world of interventional cardiology has changed dramatically since the advent of balloon angioplasty. New therapies have evolved over the past decade as knowledge of the pathophysiology of heart disease has increased. Nurses who have an understanding of this pathophysiology will be better equipped to manage and educate their patients, teaching them about current and future interventional therapies. This article reviews the pathophysiology of heart disease, current interventional therapies, and the future directions for interventional cardiology nursing practice.     

Highlights from the past decade of interventional device research

The last decade of research and implementation in the interventional device arena has brought about an unprecedented improvement in the ability to safely and effectively treat coronary artery disease. This explosion of technology is not over; there remain questions to be answered and patient subsets whose care can be improved upon. Our understanding of the restenosis process has helped guide research in the appropriate directions, and by 2010 restenosis after a coronary intervention will most likely be of historic interest only. With the addition of thrombus removal catheters and protection devices, treatment of problematic high-risk lesions will also be improved upon. The effect of these devices on acute patient care and long-term outcomes, including quality of life, will be profound.     

Direct thrombin inhibition in interventional cardiology. The ACUITY trial

The direct thrombin inhibitor bivalirudin was tested in the ACUITY Trial 13 819 patients with acute non-ST-segment elevation coronary syndrome in a prospective and randomized design. Three therapeutic regimens were compared in the context of an early invasive strategy: heparin plus glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus GPI, or bivalirudin alone. Concerning the rate of ischaemic events bivalirudin alone was comparable to heparin plus GPI at a significantly lower rate of bleeding complications.     

Overall information needs of early-stage prostate cancer patients over a decade: highly variable and remarkably stable

PURPOSE: To assess the stability of information needs of early-stage prostate cancer patients by comparing needs in the same location, at two time points, almost 10 years apart. METHOD: Two groups of patients were surveyed (first, 1996; second, 2005) to identify retrospectively their information needs in the diagnosis-to-treatment-decision time interval. Both sampling cohorts were men diagnosed in one location in Canada within the previous 2 years. Participants rated the importance of getting answers to each of 92 questions (organized in eight categories) using four options: essential, desired, no opinion, or avoid. For each essential and desired question, respondents also indicated the reason(s) they wanted the question addressed: to understand, decide, plan, or other. RESULTS: The two groups had similar response rates: 38 (68%) in 1996 and 130 (70%) in 2005. They also had similar ages, marital status, or education. Both groups rated means of: 49 questions "essential" with wide ranges across respondents (12-90 vs 0-92 questions); 73 questions as "essential"/"desired"; and two questions to "avoid". At both times, every question was essential to some participants but only six (in 1996) and 12 (in 2005) questions were essential to over 80% of participants. In both groups, the most frequent reason for essential questions was for understanding (mean number of questions 34 vs 36), followed by decision making (means 13 vs 19), and then planning (means 10 vs 15). CONCLUSIONS: We have demonstrated reliably that, although many patients want a lot of information, the range in amount and in exact details varies considerably across individuals. Systematic patient education is needed, therefore, but it must be individualized.     

Progression of diabetic autonomic neuropathy over a decade in insulin-dependent diabetics

The prognosis for diabetics with autonomic neuropathy is little known. We therefore studied the progress of young insulin-dependent diabetics, first identified as having abnormal autonomic function 10-15 years ago. We have shown that the mortality of diabetics with symptomatic autonomic neuropathy is increased, but is less than previously reported. Mortality in asymptomatic diabetics with an isolated abnormality in autonomic function tests is not increased. The heart rate variability declines at 1.02 +/- 0.47 (SD) per annum in diabetics with an initially normal heart rate variability. While symptoms of autonomic neuropathy do not usually remit even over a decade, they do not commonly progress. Three groups of young insulin-dependent diabetics had heart rate variability tested between 1972 and 1977 and have been reviewed 10-15 years later. Group A (n = 49) had symptomatic autonomic neuropathy and an abnormal heart rate variability (less than 12), Group B (n = 24) were asymptomatic yet had an abnormal heart rate variability and Group C (n = 38) were asymptomatic and had a normal heart rate variability (16-26). The 10-year survival in Group A (73.4 per cent) was less (P less than 0.05) than in Groups B (91.7 per cent) or C (89.5 per cent) which did not differ from each other. The 18 Group A deaths were due predominantly to renal failure (n = 4), myocardial infarction in patients with nephropathy (n = 3) and sudden unexpected death (n = 3). The chief symptoms of autonomic neuropathy--diarrhoea, postural hypotension and gustatory sweating, were very persistent but did not necessarily deteriorate or become disabling in the majority of patients. The development of autonomic symptoms in asymptomatic patients with abnormal heart rate variability was uncommon over a decade.     

Risk stratification and interventional cardiology: Robert L. Frye Lecture

Risk stratification and risk-benefit ratios are extremely important in guiding patient-physician interactions as well as patient and family counseling. Risks associated with percutaneous transluminal coronary angioplasty are (1) compromise of the vessel lumen or vessel integrity, (2) unsuccessful procedure, and (3) restenosis. Predicting mortality risk depends on the specific patient population to be treated and on the specific mortality model used. The most common models are those from New York State, the American College of Cardiology, the Northern New England Cooperative Group, the University of Michigan, and The Cleveland Clinic Foundation. As more data and sophisticated analyses become available, risk stratification will become more accurate as long as the approach used is straightforward, makes intuitive sense, and is easy and efficient to apply.     

Patient radiation dose during diagnostic and interventional cardiology procedures: A study in a tertiary hospital

BackgroundFluoroscopy-guided diagnostic and interventional cardiology (IC) procedures help to identify and treat several problems associated with the heart. However, these procedures expose patients, cardiologists, radiographers, and nurses to radiation doses. Due to the risk that ionizing radiation poses, concerns have been raised and studies are continually being done to ensure that optimization is achieved during such procedures. This study assessed patient radiation dose during diagnostic and interventional cardiology procedures as well as right heart studies at a tertiary hospital in Ghana to formulate the facility's diagnostic reference levels (DRLs) for optimization purposes. As this study was the first of its kind in Ghana, it was a vital step towards dose optimization within the local department, as well as contributing to future DRLs in Ghana.MethodsThe study collected dose (air kerma, and kerma area product (KAP) and procedural data, and assessed any correlation between parameters such as fluoroscopy time and KAP, and between body mass index (BMI) and KAP. The DRL values were determined as the 75th percentile level for the dose distribution for the various IC procedures including percutaneous coronary interventions (PCI), coronary angiography (CA), and right heart catheterization (RHC). Data were analyzed using SPSS version 23.ResultsCA was the most frequently performed IC procedure (77.3%), while RHC was the least recorded (3.3%). The highest mean KAP was observed during the PCI procedure. The proposed diagnostic reference levels (DRLs) were 162.0 Gy.cm² (PCI), 69.4 Gy.cm² (CA), 39.8 Gy.cm² (RHC) and 159.9 Gy.cm² (CA+PCI). Patients who presented for the CA+PCI and RHC procedures received the highest and lowest mean KAP of 159.9 Gy.cm² and 39.8 Gy.cm² of radiation respectively.ConclusionThis study, therefore, concludes that there is a need for dose optimization of radiation exposures for IC procedures at the cardiothoracic center in Ghana.     

Clinical outcomes of point-of-care testing in the interventional radiology and invasive cardiology setting

BACKGROUND: Point-of-care testing (POCT) can provide rapid test results, but its impact on patient care is not well documented. We investigated the ability of POCT to decrease inpatient and outpatient waiting times for cardiovascular procedures. METHODS: We prospectively studied, over a 7-month period, 216 patients requiring diagnostic laboratory testing for coagulation (prothrombin time/activated partial thromboplastin time) and/or renal function (urea nitrogen, creatinine, sodium, and potassium) before elective invasive cardiac and radiologic procedures. Overall patient management and workflow were examined in the initial phase. In phase 2, we implemented POCT but utilized central laboratory results for patient management. In phase 3, therapeutic decisions were based on POCT results. The final phase, phase 4, sought to optimize workflow around the availability of POCT. Patient wait and timing of phlebotomy, availability of laboratory results, and therapeutic action were monitored. Split sampling allowed comparability of POCT and central laboratory results throughout the study. RESULTS: In phase 1, 44% of central laboratory results were not available before the scheduled time for procedure (n = 135). Mean waiting times (arrival to procedure) were 188 +/- 54 min for patients who needed renal testing (phase 2; n = 14) and 171 +/- 76 min for those needing coagulation testing (n = 24). For patients needing renal testing, POCT decreased patient wait times (phases 3 and 4 combined, 141 +/- 52 min; n = 18; P = 0.02). For patients needing coagulation testing, wait times improved only when systematic changes were made in workflow (phase 4, 109 +/- 41 min; n = 12; P = 0.01). CONCLUSIONS: Although POCT has the potential to provide beneficial patient outcomes, merely moving testing from a central laboratory to the medical unit does not guarantee improved outcomes. Systematic changes in patient management may be required.