Analysis of bleeding complications associated with glycoprotein IIb/IIIa receptors blockade in patients with high-risk acute coronary syndromes: insights from the PRISM-PLUS study

We aim to characterize the hemorrhagic complications and predictors of increased bleeding risk in a population of patients with high-risk acute coronary syndromes (ACS), enrolled in the PRISM-PLUS study. Patients treated with heparin plus tirofiban had more bleeding events compared to patients treated with heparin alone. No significant increase in major bleeding, thrombocytopenia, blood loss and blood products transfusions was observed among the patients who received the combination therapy. Several clinical variables were independently associated with increased risk of bleeding for both treatment groups: advanced age, lower body weight, female gender, decreased creatinine clearance (<30 ml/min). Females, patients with impaired renal function, patients requiring percutaneous coronary intervention (PCI), especially prolonged PCI (>100 min duration) or coronary artery bypass surgery (CABG) were at risk for increased major bleeding complications. Increased blood loss was also found in females, patients with elevated diastolic blood pressure, PCI, duration of PCI>100 min or CABG. No incremental risk was detected with the addition of tirofiban to heparin in patients at risk for major bleeding or increased blood loss. We concluded that identification of patients with high-risk ACS, at risk for bleeding complications and blood loss can be done with specific clinical variables. Tirofiban added to heparin increased minor hemorrhagic complications. Although there was no significant increase in major bleeding, thrombocytopenia and blood transfusions with the combination of tirofiban plus heparin, the power to detect a statistically significant difference in these endpoints was limited by the small number of events.     

Sickle cell trait and gender influence type 2 diabetic complications in African patients

BACKGROUND: Black and African patients with type 2 diabetes have a greater frequency and more severe vascular complications of the disease, even after correction for socioeconomic factors. Asymptomatic sickle cell trait (SCT; hemoglobin AS) is also common among black Africans and may independently cause endothelial damage, manifested as isolated target organ complication or infarction. We examined the possibility that patients with concurrent type 2 diabetes and SCT may be predisposed to more frequent or severe diabetic macro- or microvascular complications than those without SCT. METHODS: Fifty-two type 2 diabetic patients were divided into four groups, according to gender and hemoglobin genotype (normal: AA or SCT: AS). The groups were well matched for age and for clinical and demographic parameters. Diabetic complications were assessed in each patient and scored. Hemoglobin genotype was determined by hemoglobin-gel electrophoresis. Statistical comparisons were made between the groups. RESULTS: The composite complication score for vascular disease differed significantly according to gender and genotype (p<0.027 ANOVA). Male diabetics with SCT had a higher risk ratio (RR 1.6, p<0.02) for complications than those with normal hemoglobin; however, this was not the case with female diabetics. Among the male diabetics with SCT, there was a significantly greater proportion with proteinuria (p<0.02) or retinopathy (p<0.05) than among those with a normal hemoglobin genotype. Multiple regression analysis showed that gender and SCT were independent predictors of the vascular complication severity score and that exclusion of hemoglobin genotype weakened the predictability of the regression. A significantly higher proportion of male than female diabetics had at least one detectable complication. Systolic or diastolic blood pressure had no significant impact on the regressions. CONCLUSION: Male gender and SCT may adversely affect the expression of microvascular diabetic complications in Africans. Diabetic patients from populations predisposed to the sickle gene should be screened for the trait as part of their initial risk assessment. Large-scale studies on the impact of hemoglobin genotype on diabetic complications are clearly indicated.     

Randomized Evaluation of an Inflatable Femoral Artery Compression Device After Cardiac Catheterization

Mechanical femoral artery compression devices have several limitations. We compared a novel disposable beltheld pneumatic compression device to manual compression alone in 213 patients randomized into two equal groups. Both were comparable for age, gender, current therapy with aspirin (ASA) and warfarin, diameter of the arterial sheath, previous procedures via the same artery, procedure duration, and blood pressure. Manual compression time was 12 ± 3 minutes. Pneumatic compression was reduced during 60 minutes. Patient discomfort was assessed as none (82% vs 88%), mild (13% vs 8%), moderate (3% vs 4%), or severe (2% vs 0%) for the manual versus pneumatic group, respectively. Bleeding and hematoma occurred in 7.5% of patients with no difference between the treatment groups. However, manual compression was significantly more effective in the higher range of systolic blood pressure, and pneumatic in the lower range, with a cut point of approximately 170 mmHg. Predictors for bleeding were systolic blood pressure and dose of ASA. Among 113 patients with systolic blood pressure < 160 mmHg and low dose (75 mg) or no ASA, only / patient (0.9%) experienced bleeding while 31% of 16 patients with both elevated systolic blood pressure and high dose ASA (150–330 mg) bled. We conclude that pneumatic femoral artery compression does not reduce bleeding and hematoma compared with manual compression. The use of low dose (75 mg) or no ASA, as well as giving special attention to patients with elevated systolic blood pressure, may reduce the risk of bleeding after cardiac catheterization .     

Complications of catheter ablation for atrial fibrillation: incidence and predictors

Introduction: Pulmonary vein (PV) isolation by catheter ablation is an increasingly used strategy to treat atrial fibrillation (AF). Complication rates from AF ablation reported in different case series vary widely. We conducted a retrospective analysis of 641 consecutive ablation procedures to assess complication rates, temporal trends, and clinical predictors of adverse outcomes.
Methods: All patients (n = 517) undergoing catheter ablation for AF at Johns Hopkins Hospital between February, 2001 and June, 2007 were prospectively enrolled in a database. Data from 641 consecutive procedures were analyzed and complications considered if they occurred within 30 days of ablation. Major complications were defined as those that required intervention, resulted in long-term disability, or prolonged hospitalization.
Results: Thirty-two major complications occurred in 641 procedures (5%). Among the patients with major complications, seven had cerebrovascular accident (CVA), eight had tamponade, one had PV occlusion with hemoptysis, and 11 had vascular injury requiring surgical repair and/or transfusion. No periprocedural deaths occurred, and no instances of esophageal injury were seen. Complication rates were higher during the first 100 cases (9.0%) than during the subsequent 541 (4.3%). Major adverse clinical events were associated with age > 70 years (P = 0.007; odds ratio 3.7, 95% confidence interval 1.4–9.6) and female gender (P = 0.014; odds ratio 3.0, 95% confidence interval 1.3–7.2). No other clinical or procedural predictors of complication were identified.
Conclusions: Complication rates from AF ablation remain significant, despite improved techniques and increased awareness of procedural risks. Both advanced age and female gender predict major adverse events, suggesting careful consideration of the risk/benefit profile in these patients prior to ablation.     

Seasonal changes in blood pressure and frequency of related complications in elderly Israeli patients with essential hypertension

BACKGROUND: Earlier studies on hypertension demonstrated seasonal variations in different age groups. However, slightly greater fluctuations were found in the hypertensive elderly. OBJECTIVE: We conducted a prospective 5-year study from January 1997 to December 2001 to evaluate the seasonal variation in blood pressure and the variables of age, gender, body mass index and related complications in elderly Israeli patients with essential hypertension. METHODS: Blood pressure was measured in four seasons in 182 patients (98 men and 84 women; age range 65-91 years) treated for hypertension in our outpatient clinic. RESULTS: Both systolic and diastolic mean blood pressures were higher during winter compared to summer (165 +/- 11.6 and 90 +/- 13.7 and 134 +/- 47.3 and 74 +/- 8.5 mm Hg, respectively; p < 0.001). There were no significant seasonal differences between spring and autumn or any correlation between the seasonal winter-summer difference in blood pressure and other studied parameters. Patients aged 65-75 years were unexpectedly more sensitive to winter-summer changes than older patients. There was a correlation between a large winter-summer difference in systolic blood pressure and a body mass index between 20 and 30, but there was none in lower or higher ranges. Supplementary antihypertension treatment was required during winter in 38% of these selected patients. Complications such as myocardial infarctions and strokes occurred twice as frequently in winter than in any other season (p < 0.0001). CONCLUSIONS: Both systolic and diastolic blood pressures were highest during winter. Hypertension complications were more frequent in winter. Our results refute those of earlier studies that failed to find significant seasonal variations in blood pressure among the elderly.     

Effect of gender on outcomes following renal artery stent placement for renovascular hypertension

To study the effect of gender on outcome following renal artery stent placement for renovascular hypertension, we prospectively followed 66 patients (30 males, 36 females) who underwent Palmaz stent placement in 88 renal arteries. There was no difference in the incidence of procedure-related complications between males and females. At 6-mo follow-up, the decrease in systolic (35 ± 30 mm Hg and 27 ± 25 mm Hg) and diastolic (15 ± 23 mm Hg and 14 ± 14 mm Hg) blood pressures was similar in female and male patients, respectively. Late follow-up at 19 ± 11 mo also showed no difference in blood pressure response. In 44 patients who underwent repeat angiography at a mean duration of 9.1 ± 5.6 mo after stent deployment, the incidence of restenosis was 26% in females and 24% in males (P = 0.85). We conclude that gender has no effect on the incidence of complications, blood pressure response, or angiographic restenosis in patients undergoing renal artery stent placement. Cathet. Cardiovasc. Diagn. 42:381–386, 1997. © 1997 Wiley-Liss, Inc.     

Outpatient endoscopic injection sclerosis of esophageal varices

We report our experience with outpatient endoscopic injection sclerosis (EIS). Fourteen patients receiving elective in patient EIS (30 patient sessions) were compared to 34 patients having elective outpatient EIS (133 patient sessions). The majority of the patients had Child's C alcoholic liver disease. There were two major complications in the 14 inpatients receiving elective EIS, one severe hemorrhage and one death, for a complication rate of 14%. There were no minor complications in this group. In the 34 patients undergoing outpatient EIS there was one major complication for a complication rate of 2.9% (bleeding) and no deaths. Minor complications in the outpatient group included chest pain in 9.0%, dysphagia without stricture in 6.0%, severe ulceration precluding EIS in 21.0%, and stricture of esophagus in 24.0%. The average cost for inpatient EIS was +1183.00 and for outpatient EIS, +339.00.     

Complications of percutaneous transhepatic catheterization of the portal venous system in patients with portal hypertension

We report here complications of percutaneous transhepatic catheterization of the portal venous system in 170 Japanese patients with portal hypertension. All patients underwent percutaneous transhepatic portography and percutaneous transhepatic obliteration of oesophagogastric varices was also performed in 29 patients. After retraction of the catheter, the puncture canal was plugged with gelatin sponge in 150 subjects and with one steel coil in 20 others. The overall complication rate was 16.5%. Intraperitoneal bleeding occurred in 10.6% of patients and 2.9% required blood transfusion. In these patients with intraperitoneal bleeding, the gelatin sponge was used for plugging after retraction of the catheter, while in the 20 patients with a steel coil plug, haemoperitoneum never occurred. Right pleural effusion was recognized in 3.5% of patients, intraperitoneal bile leakage in 1.8% and deterioration of liver function due to arteriovenous fistula in 0.6%. By univariate and multivariate analyses, female gender was the only risk factor for intraperitoneal bleeding among 150 patients investigated by percutaneous transhepatic catheterization of the portal venous system with gelatin sponge plugging. Intraperitoneal bleeding is the most important complication in patients with portal hypertension; it is difficult to predict intraperitoneal bleeding before retraction of the catheter in patients for whom gelatin sponge is used. Thus, for patients undergoing percutaneous transhepatic catheterization of the portal venous system, close follow up is recommended.     

In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry®-GWTG™

Bleeding, a common complication of acute myocardial infarction (AMI) treatment, is associated with worse outcomes. A contemporary model for major bleeding associated with AMI treatment can stratify patients at elevated risk for bleeding and is needed to risk-adjust AMI practice and outcomes. Using the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) database, an in-hospital major bleeding risk model was developed in a population of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. The model used only baseline variables and was developed (n = 72,313) and validated (n = 17,960) in patients with AMI (at 251 United States centers from January 2007 to December 2008). The 12 most statistically and clinically significant variables were incorporated into the final regression model. The calibration plots are shown, and the model discrimination is demonstrated in derivation and validation cohorts, as well as across key subgroups. The rate of major bleeding in the overall population was 10.8%. The 12 factors associated with major bleeding in the model were heart rate, baseline hemoglobin, female gender, baseline serum creatinine, age, electrocardiographic changes, heart failure or shock, diabetes, peripheral artery disease, body weight, systolic blood pressure, and home warfarin use. The risk model discriminated well in the derivation (C-statistic = 0.73) and validation (C-statistic = 0.71) cohorts. A risk score for major bleeding corresponded well with observed bleeding: very low risk (3.9%), low risk (7.3%), moderate risk (16.1%), high risk (29.0%), and very high risk (39.8%). In conclusion, the ACTION Registry-GWTG in-hospital major bleeding model stratifies risk for major bleeding using variables at presentation and enables risk-adjusted bleeding outcomes for quality improvement initiatives and clinical decision making.     

Biochemical evaluation of sympathetic nerve tone in essential hypertension.

The concentration of plasma catecholamines (CA), serum dopamine beta-hydoxylase (DBH) activity and plasma renin activity (PRA) were simultaneously measured in 55 patients with essential hypertension (EH). Further the enzyme activities of CA biosynthesis in human vas deferens excised at elective vasectomy were related with the blood pressure, plasma CA, serum DBH of 57 men at the time of vasectomy. Total plasma CA and norepinephrine (NE) were increased in 28 and 35% of patients with benign EH, respectively. Total plasma CA were also increased in 45% of men with elevated blood pressure prior to vasectomy. Total plasma CA were correlated with diastolic blood pressure in EH (p less than 0.01). Further, in men with normal and raised blood pressure prior to vasectomy, there was a significant correlation of total plasma CA with systolic and diastolic blood pressure (p less than 0.01). Total plasma CA were correlated with PRA in patients with EH (r=0.497, p less than 0.001). Capacity for NE biosynthesis, vas deferens tyrosine hydroxylase (TYH) activity and dopa decarboxylase (DDC) activity were increased in men with raised blood pressure. There was a direct correlation of total plasma CA with the activities of TYH and DDC (r=0.46, and 0.54, p less than 0.005). Increased sympathetic nerve tonicity associated with increased neurotransmitter biosynthesis may be an important factor responsible for blood pressure elevation in men prior to vasectomy and in others with EH. The some patients with EH may have a renin-catecholamine relationship and both pressor systems may be linked to be a pathogenic factor for the elevation of blood pressure.     

Hemodynamic effects of different ventilatory patterns. A prospective clinical trial

We compared the hemodynamic effects of three different ventilatory patterns including two variations of the I:E ratio (2:1 and 3:1) and a PEEP-pattern with the MAWP being equal in all three patterns. The study was performed on 15 patients without lung or cardiovascular disease who were ventilated after elective abdominal surgery. Each of the patients was subjected to the three different pressure wave curves. The IPPV served as control. Hemodynamic measurements included TEE registration of the LV cross-sectional areas, diameters and wall thickness as well as arterial blood pressure and heart rate. As a result, we found no significant differences in the hemodynamic effects of all three patterns. Compared with IPPV, they showed a reduction of systolic and diastolic blood pressure, LV dimensions and systolic wall stress. Assessed with the end systolic quotient, LV contractility remained constant.     

Metabolic syndrome in type 2 diabetes mellitus in isfahan, iran: prevalence and risk factors

Background: Our goal was to estimate the prevalence and risk factors of metabolic syndrome (MetSyn) in people with type 2 diabetes mellitus (T2DM) using routinely collected data from a clinical information system at Isfahan Endocrinology and Metabolism Research Centre, Iran. Methods: Consecutive diabetic patients (9889 total, 4164 male and 5725 female) from Isfahan Endocrinology and Metabolism Research Centre outpatient clinics, Iran, have been examined. The mean (SD) age of participants was 52.0 (10.9) years with a mean (standard deviation) duration of diabetes of 6.4 (6.4) years at initial registration. A modified National Cholesterol Education Program-Adult Treatment Panel III definition with body mass index instead of waist circumference was used for the MetSyn. Results: The prevalence of MetSyn was 65.0% [95% confidence interval (CI) 64.0, 65.9], with higher rate in females than males (71.7 [95% CI: 70.5, 72.8] female and 55.8 [95% CI: 54.3, 57.3] male) and it was greater with older age. The age-adjusted prevalence rate of MetSyn was associated with female gender, duration of diabetes, fasting blood glucose, systolic and diastolic blood pressure, body mass index (BMI), smoking, proteinuria, insulin-treatment, triglyceride, cholesterol, HDL cholesterol, hypertension, and dyslipidemia. Using a stepwise binary logistic regression model, age, gender, fasting blood glucose, systolic and diastolic blood pressure, BMI, triglyceride, and cholesterol were significant predictors of MetSyn for T2DM patients. Conclusions: These data suggest MetSyn in this population of Iranian type 2 diabetic patients is common, and with an estimated prevalence of 65%, MetSyn clearly poses a formidable health threat to Iranian diabetic patients. Lifestyle interventions in T2DM subjects are needed in Iran to halt the burden of macro- and micro-vascular complications in T2DM.     

Arterial hypertension difficult to control in the elderly patient. The significance of the "white coat effect"]

OBJECTIVE: Previous studies have revealed a high prevalence of white coat effect among treated hypertensive patients. The difference between clinic and ambulatory blood pressure seems to be more pronounced in older patients. This abnormal rise in blood pressure BP in treated hypertensive patients can lead to a misdiagnosis of refractory hypertension. Clinicians may increase the dosage of antihypertensive drugs or add further medication, increasing costs and producing harmful secondary effects. Our aim was to evaluate the discrepancy between clinic and ambulatory blood pressure in hypertensive patients on adequate antihypertensive treatment and to analyse the magnitude of the white coat effect and its relationship with age, gender, clinic blood pressure and cardiovascular or cerebrovascular events. POPULATION AND METHODS: We included 50 consecutive moderate/severe hypertensive patients, 58% female, mean age 68 +/- 10 years (48-88), clinic blood pressure (3 visits) > 160/90 mm Hg, on antihypertensive adequate treatment > 2 months with good compliance and without pseudohypertension. The patients were submitted to clinical evaluation (risk score), clinic blood pressure and heart rate, electrocardiogram and ambulatory blood pressure monitoring (Spacelabs 90,207). Systolic and diastolic 24 hour, daytime, night-time blood pressure and heart rate were recorded. We considered elderly patients above 60 years of age (80%). We defined white coat effect as the difference between systolic clinic blood pressure and daytime systolic blood pressure BP > 20 mm Hg or the difference between diastolic clinic blood pressure and daytime diastolic blood pressure > 10 mm Hg and severe white coat effect as systolic clinic blood pressure--daytime systolic blood pressure > 40 mm Hg or diastolic clinic blood pressure--daytime diastolic blood pressure > 20 mm Hg. The patients were asked to take blood pressure measurements out of hospital (at home or by a nurse). The majority of them performed an echocardiogram examination. RESULTS: Clinic blood pressure was significantly different from daytime ambulatory blood pressure (189 +/- 19/96 +/- 13 vs 139 +/- 18/78 +/- 10 mm Hg, p < 0.005). The magnitude of white coat effect was 50 +/- 17 (8-84) mm Hg for systolic blood pressure and 18 +/- 11 (-9 +/- 41) mm Hg for diastolic blood pressure. A marked white coat effect (> 40 mm Hg) was observed in 78% of our hypertensive patients. In elderly people (> 60 years), this difference was greater (50 +/- 15 vs 45 +/- 21 mm Hg) though not significantly. We did not find significant differences between sexes (males 54 +/- 16 mm Hg vs 48 +/- 17 mm Hg). In 66% of these patients, ambulatory blood pressure monitoring showed daytime blood pressure values < 140/90 mm Hg, therefore refractory hypertension was excluded. In 8 patients (18%) there was a previous history of ischemic cardiovascular or cerebrovascular disease and all of them had a marked difference between systolic clinic and daytime blood pressure (> 40 mm Hg). Blood pressure measurements performed out of hospital did not help clinicians to identify this phenomena as only 16% were similar (+/- 5 mm Hg) to ambulatory daytime values. CONCLUSIONS: Some hypertensive patients, on adequate antihypertensive treatment, have a significant difference between clinic blood pressure and ambulatory blood pressure measurements. This difference (White Coat Effect) is greater in elderly patients and in men (NS). Although clinic blood pressure values were significantly increased, the majority of these patients have controlled blood pressure on ambulatory monitoring. In this population, ambulatory blood pressure monitoring was of great value to identify a misdiagnosis of refractory hypertension, which could lead to improper decisions in the therapeutic management of elderly patients (increasing treatment) and compromise cerebrovascular or coronary circulation.     

Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy

BACKGROUND/AIMS: In acute variceal bleeding (AVB) hepatic venous pressure gradient (HVPG) is associated with prognosis. However, this has not been studied in patients receiving the currently recommended therapy. We evaluate here the performance of early HVPG measurement as a predictor of treatment failure in patients with acute variceal bleeding managed with the current standard treatment and whether clinical variables might be of similar predictive accuracy. METHODS: We included 117 patients with AVB in whom HVPG was measured within 48 h of admission. The main endpoint was 5-day failure, a composite of uncontrolled bleeding, early rebleeding or death within 5 days. RESULTS: Eighteen patients (15%) had 5-day failure. Multivariate analysis identified three variables independently associated with 5-day failure: HVPG 20, systolic blood pressure at admission <100 mmHg and non-alcoholic cause of cirrhosis. The discriminative capacity of this model was good (c statistic: 0.79). When only clinical variables were included in the analysis, Child-Pugh class, systolic blood pressure at admission and etiology were the independent predictors. This model had also a good discriminative ability (c statistic: 0.80). CONCLUSIONS: HVPG independently predicts short-term prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy, but similar predictive accuracy can be achieved using only simple clinical variables that have universal applicability.     

Does Chemoradiation Therapy Increase the Incidence of Complications with Self-Expanding Coated Stents in the Management of Malignant Esophageal Strictures?

Background: Expandable stents offer excellent palliation of malignant dysphagia and digestive-respiratory fistula. There are insufficient data regarding factors that may affect the complication rate of expandable stents, but an association between previous treatment with chemotherapy and/or radiation therapy and stent-related life-threatening complications has been suggested. Methods : We retrospectively analyzed our data on 60 patients; in all of them, a coated Wallstent had been successfully placed for malignant dyspbagia and/or digestive-respiratory fistula. Our objective in this study was to determine the overall complication rate as well as whether previous or ongoing chemoradiation therapy increased the rate of life-threatening complications. Results : Among 21 patients with no previous chemotherapy or radiation therapy, two (9.5%) had life-threatening complications (both had bleeding tumors; blood transfusions were required in two and endoscopic hemostasis in one). Among 39 patients who had had either radiation therapy, chemotherapy, or both, life-threatening complications occurred in three (8%). Two of the three had gastrointestinal bleeding (two received blood transfusions, and one had external radiation therapy), and in the third, an esophageal tear was treated with the stent. There was no procedure- or stent-related mortality in either group. Conclusions : Palliation of malignant dysphagia or digestive-respiratory fistulas with the coated Wallstent in patients with previous chemotherapy and/or radiation therapy is not associated with an increased risk of life-threatening complications.     

Long-term follow-up of coarctation of the aorta repaired by patch angioplasty

The long-term complications of patch plasty repair for coarctation of the aorta were assessed retrospectively in 119 patients who were operated upon from 4 days to 13 years of age. There were 7 late deaths and 17 patients were lost to follow-up. Thus 95 patients were followed up for a minimum period of 3 years (mean 6.3 years). In addition, graded exercise tests were performed on 15 patients and 11 normal controls, measuring systolic blood pressure response and arm-leg blood pressure gradients. In this series, 16 patients (17%) were hypertensive, while 25 (26%) had a resting systolic arm-leg gradient greater than 20 mm Hg. Re-coarctation occurred more frequently when surgery had been undertaken under 1 month of age. Review of chest X-rays revealed calcification in the patch in 4 patients, one of whom subsequently went on to aneurysm formation. In a second child aneurysm formation was detected at repeat operation. Exercise tests showed a significantly higher systolic arm pressure in patients (mean: 165.3 mm Hg) when compared to controls (mean: 139.2 mm Hg) (P = 0.017) and a significant increase in arm-leg systolic gradient viz. 36 and 5.9 mm Hg, respectively (P = 0.0016). A good correlation was found between the systolic arm pressure and the systolic arm-leg gradient after exercise (r = 0.822; P = 0.0001). We conclude that the most important long-term complication following an aortic patch plasty, is re-stenosis. The development of an aneurysm was observed only twice. We believe that this apparently rare occurrence, as assessed on chest radiographs; is related to the young age (53% under 1 year) at which the repairs were carried out. Another possible reason may be that the follow-up period is not yet long enough.     

Early ambulation after diagnostic heart catheterization

The general recommended strategy after arterial invasive procedures is a 4- to 6-hour bed rest that is associated with patient discomfort and increased medical costs. We hypothesized that mobilization of selected patients at the second hour would not increase vascular complications. Coronary angiography was performed through the femoral route via 6-Fr catheters. Homeostasis was achieved by manual compression and maintained with a compressive bandage. A total of 1,446 patients were ambulated at the second hour and 1,226 of them were discharged without complication. A total of 220 patients required further follow-up due to blood oozing; 154 patients were conventionally ambulated due to difficult arterial access, longer (>15 minutes) compression time, hematoma formation within 2 hours, or hypertensive state (blood pressure >180/100 mm Hg). Twenty-five (16%) of those patients developed minor bleeding after ambulation. No major bleeding or large hematoma was observed during in-hospital observation. Ecchymosis (10% [2-hour group] vs 21% [4-5 hour group]) and small hematomas (22% vs 9%) were the most frequent complications after discharge. Early mobilization of selected patients undergoing diagnostic heart catheterization through the femoral artery via 6-Fr catheters is safe and associated with acceptable bleeding complication rates.     

The fate of systemic blood pressure in patients after effectively stented coarctation.

AIMS: The current study was designed to assess midterm results of stent implantation into the aorta for native and recurrent coarctation (CoA) in children and young adults. METHODS AND RESULTS: Forty-three patients (native CoA, 8; female, 12) were treated with stent implantation at a median age of 16.8 years (range 7.9-44.8 years). Only stents dilatable to an adult size aorta were implanted. All but two patients with functionally univentricular hearts had arterial hypertension. Exercise tests, 24-h blood pressure, clinical examination, echocardiography, and elective catheterization were used to assess follow-up. The narrowed segment was widened significantly from a median of 8 to 12.4 mm (P < 0.0005). The peak-to-peak gradient between the ascending and the descending aorta was lowered significantly from a median of 22 mmHg to 1 mmHg (P < 0.0005). No major complications occurred. The systolic blood pressure at the right arm was lowered significantly (P < 0.0005) from 144 mmHg before stent implantation to 128 mmHg at the last visit. At a median follow-up of 30 months (3-72 months), 68% of all patients were classified to be normotensive. CONCLUSION: Stent implantation for selected patients with recurrent and native CoA is safe and may effectively reduce the blood pressure gradient across the CoA site. We suggest using only stents dilatable to an adult size aorta. However, arterial hypertension persists in a significant number of the patients. Impaired elastic properties of the aorta may be the cause for this finding.     

Plasma concentration of urotensin II is raised in hypertension

OBJECTIVES: Urotensin II is the most potent vasoconstrictor known. Its role in hypertension has not been investigated. Here, we studied the plasma levels in hypertensive and normotensive human subjects. DESIGN: A cross-sectional case-control study. SETTING: Hypertension clinic and research clinic of a university teaching hospital. PARTICIPANTS: Sixty-two hypertensive outpatient subjects (52% male, aged 57 +/- 13 years) and 62 normotensive controls (45% male, aged 54 +/- 13 years) recruited from the general population. MAIN OUTCOME MEASURES: Plasma urotensin II levels measured by radioimmunoassay, systolic and diastolic blood pressure. RESULTS: Plasma urotensin II was 8.8 +/- 0.9 pmol/l in normotensive controls and 13.6 +/- 1.4 pmol/l in hypertensive subjects (P = 0.005). In multiple regression analysis, systolic blood pressure was related to plasma urotensin II (beta = 0.31, P < 0.001) and age (beta = 0.28, P = 0.001), accounting for 10 and 8%, respectively, of the variance in systolic blood pressure. There was no significant correlation with gender, renal function or diabetes. CONCLUSIONS: Plasma urotensin II was raised in hypertensive patients compared to normotensive controls, and was directly related to systolic blood pressure. Our findings raise the possibility that urotensin II may have an aetiological role in hypertension and its complications.