Endothelial function in patients with and without diabetes mellitus with different degrees of coronary artery stenosis

PURPOSE: To evaluate endothelial function using flow-mediated dilatation (FMD) of the brachial artery in patients with and without diabetes mellitus (DM) with different degrees of coronary artery stenosis. METHOD: We investigated 293 patients, 69 (23.6%) of whom had DM. FMD and coronary arteriography were performed. RESULTS: Patients with DM had a significantly lower FMD (mean +/- SD, 3.7 +/- 3.8%) compared with patients without DM (mean +/- SD, 5.2 +/- 5.3%) (p < 0.05). When the results were broken down by the severity of coronary artery disease (CAD) (no significant coronary artery stenosis, 1-vessel disease, 2-vessel disease, and 3-vessel disease) the only statistically significant difference between diabetics and nondiabetics was found in patients without significant coronary stenosis (mean FMD +/- SD: 5.2 +/- 4.4% in diabetics, 7.6 +/- 5.4% in nondiabetics [p < 0.05]). CONCLUSION: In CAD patients, the presence of DM was associated with endothelial dysfunction. The difference in the FMD was clearly expressed between patients with and without DM in the subgroup without significant coronary stenosis, and was no longer present with advanced coronary atherosclerosis.     

Aortoiliac Angiography During Coronary Artery Angiography Detects Significant Occult Aortoiliac and Renal Artery Atherosclerosis in Patients with Coronary Atherosclerosis

PURPOSE: Peripheral atherosclerosis (renal and aortoiliac localizations) are frequently detected in aged patients with concomitant coronary artery disease (CAD): the risk of finding peripheral disease is increased in patients with CAD. Angiography of the aortoiliac vessels performed at the time of coronary angiography may detect any occult renal artery stenosis and atherosclerotic involvement of the aortoiliac segment. We sought to determine utility of performing angiography of aortoiliac and renal arteries during coronary arteriography in patients with known or suspect coronary atherosclerosis. METHODS: Medical records of all patients undergoing combined coronary and aortoiliac angiography between May 1998 and December 2002 was retrospectively reviewed. Moderate to severe arterial stenosis (>50% stenosis), vessel occlusion, aneurismal vessels were noted as significant angiographic findings. Contrast-induced nephropathy was defined as a rise in serum creatinine of > or =25% form baseline. RESULTS: In the study period 112 patients (81 males, mean age 68.4+/-7.8 years) with known or suspected CAD underwent combined cardiac catheterization and aortoiliac angiography. Pretreatment with 0.45% saline at a rate of 1 ml/kg/h for 12 h was administered to all patients. Significant findings were reported in 37 (33%) patients including 14 renal artery stenoses, 8 aortic aneurismal disease, and 15 aortoiliac lesions. Most patients with significant findings had 2 and 3-vessel CAD. A strong correlation was found between the number of risk factors and the frequency of angiographic findings (r = 0.92). Complications include six contrast-induced nephropathy: no case required renal replacement therapy. CONCLUSIONS: Aortoiliac and renal atherosclerosis is frequently associated to multivessel CAD. In selected patients undergoing cardiac catheterization aortoiliac angiography may be practical in detecting occult renal or aortoiliac artery lesions. Further clinical outcome studies are strongly required to support this strategy.     

Evaluation of overall fibrinolytic activity in patients with coronary artery ectasia: Global fibrinolytic capacity

OBJECTIVE: Since the role of fibrinolytic activity is unclear in coronary artery ectasia, we investigated the entire fibrinolytic activity by a new test, global fibrinolytic capacity (GFC) in the ectasia patients. METHODS AND RESULTS: Thirty-four ectasia patients (18 male, mean age: 58 +/- 8 years) presenting with acute coronary syndrome and 25 controls (14 male, mean age: 56 +/- 9 years) with normal coronary artery were evaluated. GFC, D-dimer and other hemostatic factors were assessed. Clinical characteristics were comparable in both groups. Serum GFC (4.6 +/- 2.1 vs. 3.1 +/- 2.1 microg/ml, p = 0.03) and D-dimer levels (0.69 +/- 0.42 vs. 0.41 +/- 0.38 ng/ml, p = 0.02, respectively) were significantly higher in ectasia patients than in controls. They were also higher in subgroup of patients with myocardial infarction (four patients) compared with other ectasia patients and controls (p = 0.04, 0.01, respectively). Other hemostatic factors were not different in both groups. GFC was correlated with D-dimer (r = 0.76, p = 0.01). CONCLUSION: Our results suggest that fibrinolytic system activation may develop in ectasia patients with acute coronary syndrome. It can be induced by thrombus formation in ectatic segment of coronary artery.     

Increased heat generation from atherosclerotic plaques in patients with type 2 diabetes: an increased local inflammatory activation

OBJECTIVE: Patients with coronary artery disease (CAD) and diabetes show increased inflammatory activation. Thermography detects local inflammatory involvement as heat generation. The aim of this study was to investigate whether patients with CAD and diabetes have increased local heat generation compared with nondiabetic patients. RESEARCH DESIGN AND METHODS: We enrolled patients undergoing percutaneous coronary interventions: 45 diabetic patients and 63 nondiabetic patients, serving as the control group, matched for age, type of clinical syndrome, statin and aspirin intake, and angiographic stenosis (%). Coronary thermography was performed, and temperature difference (DeltaT) between the atherosclerotic plaque and the proximal vessel wall was measured. RESULTS: Patients with diabetes had increased temperature difference compared with nondiabetic patients (DeltaT: 0.17 +/- 0.18 degrees C vs. 0.09 +/- 0.02 degrees C, P = 0.01). Twenty-one diabetic and 22 nondiabetic patients suffered from acute coronary syndromes (ACSs) (P = 0.22). Patients with diabetes and ACSs had increased temperature difference compared with nondiabetic patients with ACSs (DeltaT: 0.29 +/- 0.31 degrees C vs. 0.15 +/- 0.21 degrees C, P = 0.02), which is the same as patients with diabetes and chronic stable angina (DeltaT: 0.09 +/- 0.08 degrees C vs. 0.05 +/- 0.04 degrees C, P = 0.006). Twenty-three diabetic and 30 nondiabetic patients were under therapy with statins (P = 0.72). Patients with diabetes under statins had lower temperature difference compared with untreated patients (DeltaT: 0.11 +/- 0.12 degrees C vs. 0.22 +/- 0.21 degrees C, P = 0.02), which is the same as nondiabetic patients under statins (DeltaT: 0.05 +/- 0.04 degrees C vs. 0.13 +/- 0.18 degrees C, P = 0.01). CONCLUSIONS: Patients with diabetes have increased temperature difference compared with nondiabetic patients. Patients with diabetes under statins showed decreased temperature difference compared with untreated patients, suggesting that statins have a favorable effect in patients with diabetes and CAD.     

心肌灌注显像剂~(99m)Tc-Tetrofosmin临床应用的研究

目的：通过与冠状动脉造影比较,评价９９ｍＴｃ－ Ｔｅｔｒｏｆｏｓｍｉｎ心肌灌注显像在冠心病诊断中的价值。方法：对 ２４例受检者（ＣＨＤ１４例,非 ＣＨＤ１０例）进行静息和运动负荷状态下的９９ｍＴｃ－ Ｔｅｔｒｏｆｏｓｍｉｎ心肌 ＳＰＥＣＴ显像,同期也行冠状动脉造影。结果：以冠状动脉造影为金标准,９９ｍＴｃ－Ｔｅｔｒｏｆｏｓｍｉｎ心肌 ＳＰＥＣＴ显像诊断冠心病的灵敏度、特异性和准确率分别为９２．３％,６０％和７８．３％。结论：９９ｍＴｃ－Ｔｅｔｒｏｆｏｓｍｉｎ心肌灌注显像在冠心病诊断中具有较高的临床价值。     

Increased coronary sinus blood temperature: correlation with systemic inflammation

BACKGROUND: Recent studies have shown that patients with single vessel coronary artery disease (CAD) suffering from acute coronary syndromes (ACS) have increased coronary sinus (CS) blood temperature compared with the right atrium (RA). The aim of this study was to investigate whether there is a correlation between systemic inflammatory indexes and CS temperature and whether there is a difference in CS temperature between patients with single vs. multivessel disease. MATERIALS AND METHODS We included consecutive patients scheduled for coronary angiography for recent-onset chest pain evaluation. We measured C-reactive protein (CRP) levels in the study population. Coronary sinus and RA blood temperature measurements were performed by a 7F thermography catheter. DeltaTau was calculated by subtracting the RA from the CS blood temperature. RESULTS: The study population comprised 53 patients with ACS, 25 patients with stable angina (SA) and 22 subjects without CAD (control group). DeltaTau was greater in patients with ACS and with SA compared with the control group (0.22 +/- 0.10 degrees C, 0.18 +/- 0.04 degrees C vs. 0.14 +/- 0.07 degrees C, P < 0.01 for both comparisons). The ACS group had greater DeltaTau compared with the SA group, although the difference did not reach statistical significance (P = 0.09). Eighteen (39.1%) out of 46 patients with multivessel disease had three-vessel disease and 28 (60.8%) had two-vessel disease. DeltaTau between patients with multivessel and single vessel disease was similar (0.22 +/- 0.01 degrees C, 0.19 +/- 0.01 degrees C, P = 0.17). The levels of CRP were well correlated with DeltaTau (R = 0.35b, P < 0.01). CONCLUSIONS: Systemic inflammation is well correlated with CS temperature; thus, an inflammatory process could be the underlying mechanism for increased heat production from the myocardium.     

Beyond coronary sinus angiography: the value of coronary arteriography and identification of the pericardiophrenic vein during left ventricular lead placement

OBJECTIVE: The purpose of this study was to define the role coronary arteriography (venous phase) for improving the success of left ventricular (LV) lead implantation and to define the value of identifying the pericardiophrenic vein for optimal LV lead placement in biventricular (bi-v) device implantation. METHODS: Seventy-seven patients underwent bi-v device implantation between July 2002 and October 2003. If the coronary sinus (CS) could not be accessed, then left coronary arteriography was performed during the same procedure. CS access was guided by venous phase images of the coronary arteriogram. The pericardiophrenic vein was identified by selective cannulation or direct visualization. Patients with Cr > 1.5 had gadolinium used as the contrast agent. RESULTS: Seventy-five successful implants were performed (97%). In seven patients (9%) repeated attempts at retrograde cannulation of the CS failed (attempt time 130 +/- 20 minute, mean +/- SD). In these patients, coronary arteriography helped define the location of the CS, which was subsequently successfully cannulated. In six patients the pericardiophrenic vein was identified either during occlusion venography of the CS (postthoracotomy, veno-venous collaterals, n = 2) or during selective cannulation of the pericardiophrenic vein (using a DAIG Csl catheter, n = 4). The vein was directly visualized in three patients who underwent surgical LV lead implantation. LV leads in all these cases were implanted in areas not overlying the preidentified pericardiophrenic vein. During follow-up, none of these patients had evidence of phrenic nerve stimulation. CONCLUSIONS: Intraoperative left coronary arteriography increases the success of CS cannulation. Identification of the pericardiophrenic vein is a useful method to avoid phrenic nerve stimulation.     

Percutaneous assessment of coronary blood flow and cardiac biomarkers

The aim of this study was to compare blood flow determined by coloured microspheres vs. Doppler intravascular ultrasound (US) combined with angiography. A second endpoint was to assess cardiac troponin I (cTnI) as a marker of myocardial injury. Doppler and microspheres were compared in 11 closed chest pigs. Blood flow was measured by catheter-based percutaneous technique in the left circumflex artery (LCx) and compared with coloured microspheres injected in the left ventricle. cTnI was measured in all pigs (73). The mean blood flow (mL/min-1) was 23.3 +/- 8.7 vs. 21.9 +/- 12.1 by Doppler vs. microspheres (p = 0.156), correlation coefficient r = 0.90, p = 0.006. The mean coronary flow with Doppler technique and microspheres in the middle LCx was 22.9 +/- 7.6 vs. 21.2 +/- 6.2 (p = 0.077), and distal 23.9 +/- 10.9 vs. 23.1 +/- 12.1 (p = 0.698). Coronary blood flow measured by Doppler and angiography was comparable to myocardial blood flow measured by coloured microspheres injected in the left atrium or the left ventricle. cTnI was more sensitive to ischaemia than CK-MB mass.     

Diabetes exacerbates angiographic coronary lesion progression in subjects with metabolic syndrome independent of CRP levels

BACKGROUND: Metabolic syndrome is gaining more attention as a special cluster of cardiovascular risks. However, its role, with or without diabetes, in predicting atherosclerosis progression, remains largely undetermined. We investigated the predictors for angiographic coronary atherosclerosis progression in patients with metabolic syndrome and angina pectoris. METHODS: Patients with metabolic syndrome and angina pectoris who underwent repeat coronary angiograms and had serum samples at the time of first catheterization were enrolled for analysis (N=113). A modified Gensini scoring system was used to define CAD progression between the index and follow-up angiograms. Those who had significant angiographic progression of coronary disease were classified as the progression group (N=42) and those who did not as the non-progression group (N=71). RESULTS: There were more cases of diabetes mellitus (52% vs. 31%, p=0.040) in the CAD progression group. The progression group also had higher baseline fasting blood glucose (150+/-73 vs. 117+/-46 mg/dl, p=0.010) but similar LDL cholesterol (114+/-38 vs. 109+/-33 mg/dl, p=0.421) than the non-progression group. In terms of inflammatory markers, there was no difference in hs-CRP (p=0.208), MCP-1 (p=0.514), or sCD40L (p=0.549) between the groups. In binary logistic regression, diabetes mellitus remained a significant predictor of CAD progression (OR 2.43, p=0.030) for patients with metabolic syndrome and angina pectoris, but hs-CRP and LDL-C were not. CONCLUSION: Diabetes mellitus, but not inflammatory marker hs-CRP or LDL-C, is a significant predictor of angiographic CAD progression in patients with metabolic syndrome and angina pectoris.     

Early assessment of coronary flow reserve by transthoracic Doppler echocardiography predicts late remodeling in reperfused anterior myocardial infarction.

BACKGROUND: Microvascular integrity is an essential determinant of favorable late outcome in reperfused myocardial infarction. Coronary flow reserve (CFR) can be assessed by transthoracic Doppler echocardiography and provides a functional estimate of microvascular integrity downstream from the patent infarct-related vessel. OBJECTIVE: We sought to assess the effects of CFR in predicting late left ventricular (LV) remodeling in patients with reperfused acute anterior myocardial infarction treated with primary angioplasty. METHODS: In all, 31 patients admitted with acute anterior myocardial infarction underwent primary angioplasty of the infarct-related vessel. After angioplasty, angiographic thrombosis in myocardial infarction (TIMI) grade and myocardial blush were scored. On the first day, all underwent stress echocardiography and CFR evaluation of left anterior descending coronary artery by transthoracic Doppler. All patients had resting 2-dimensional echocardiography at 1, 3, and 6 months for assessment of LV function. RESULTS: CFR could be successfully assessed in 31 patients. After 6 months 5 patients showed LV dilatation (group I), whereas 26 patients did not show significant variation (group II). On day 1, CFR was higher (group I = 1.43 +/- 0.11 vs group II = 1.67 +/- 0.26, P =.005) and the deceleration time of diastolic left anterior descending coronary artery flow velocity was longer (group I = 212 +/- 41.4 milliseconds vs group II = 286 +/- 106.7 milliseconds, P <.02) in patients without, compared with those with LV remodeling, whereas there was no difference in angiographic parameters. CONCLUSION: Early assessment of CFR and the pattern of baseline diastolic coronary flow velocity by transthoracic Doppler echocardiography is feasible, safe, and more useful than angiographic indices in identifying patients at high risk of remodeling in spite of successful primary angioplasty.     

A new approach for rapid assessment of the cardiac rest period for coronary MRA.

BACKGROUND: Effective suppression of cardiac motion is crucial for MR coronary angiography (MRCA). Thus, we evaluated a new technique for rapid and automatic detection of the cardiac rest period in comparison to the conventional visual assessment of the coronary artery rest periods. METHODS: One hundred and thirty-five consecutive cardiac patients were examined (Philips Intera CV 1.5 T, Best, The Netherlands). Visual assessment of the left and right coronary rest periods was done using a cine-SSFP scan with a transversal slice orientation (retrospective gating, 40 phases/cardiac cycle); the coronary rest period was defined as the duration of the coronary artery being completely within a region of interest placed on the outer edge of the cross-section of the vessel. Common coronary rest period as determined from visual assessment was defined as the intersection of both coronary artery rest periods. For comparison, an automatic technique was applied: using the position of the shim volume to define a correlation kernel, the cross-correlations of consecutive cine images were registered and displayed in a graph. Based on these cross-correlation values, the cardiac rest period was detected. The correlation between the visual and automated analysis was assessed. RESULTS: A high correlation between the automatically and visually determined starting points for the coronary artery rest periods and the cardiac rest period was found. The automatically assessed cardiac rest period was significantly shorter in comparison to the visually assessed left and right coronary artery rest period (103 +/- 46 ms vs. 158 +/- 72 ms and 117 +/- 52 ms, respectively; p < 0.001). However, the common coronary rest period demonstrated excellent agreement with the cardiac rest period (r = 0.93, p < 0.001) without a significant difference in duration (109 +/- 52 ms vs. 103 +/- 46 ms). CONCLUSIONS: Automated analysis of the cardiac rest period yielded similar results compared to the visual analysis. This rapid assessment of a cardiac acquisition window may be most helpful for MRCA, especially when aiming at 3-dimensional coverage of the whole coronary arterial tree during a single scan.     

Comparison of radial and Cartesian imaging techniques for MR coronary angiography.

BACKGROUND: Magnetic resonance coronary angiography (MRCA) has traditionally been performed using a Cartesian k-space data acquisition scheme. Radial k-space sampling is known to be less sensitive to motion artifacts. Thus, potential improvements may be achieved with radial k-space data acquisition using steady state free precession (SSFP) techniques. We directly compared SSFP three-dimensional (3D)-MRCA using radial and Cartesian data acquisition. METHODS: Forty-four consecutive patients with suspected coronary artery disease underwent free-breathing, navigator-corrected MRCA of the left or right coronary artery using SSFP (TR/TE/flip angle: 4.5 ms/2.3 ms/90 degrees) with radial and again with Cartesian k-space filling. Quantitative MRCA was performed with a dedicated multiplanar reformatting software to determine: visual score for image quality (low=1, high=4), vessel sharpness, visible vessel length, number of visible side branches, and average vessel diameter. Diagnostic accuracy for detection of > or = 50% coronary artery stenosis was calculated in comparison to invasive X-ray angiography. RESULTS: Radial data acquisition resulted in a significant (p<0.01) increase in vessel sharpness (55.6+/-7.2% vs. 45.9+/-7.0%) but a decrease in average vessel diameter (2.6+/-0.5 mm vs. 3.0+/-0.4 mm), number of visible side branches (2.1+/-1.1 vs. 3.0+/-1.7) and number of assessable coronary artery segments (66% vs. 73%) compared to Cartesian approach. There was no significant difference regarding the diagnostic accuracy (80.8% vs. 83.9%), the visual score (2.6+/-0.9 vs. 3.0+/-0.9) and the visible vessel length (92.1+/-36.0 mm vs. 99.9+/-32.4 mm). CONCLUSIONS: MRCA with radial k-space sampling appears to be on a par with Cartesian approach with respect to the diagnostic performance in an unselected patient population. Nevertheless, with current implementations, radial sampling is inferior to Cartesian sampling regarding the visualization of side branches despite better vessel sharpness.     

Prognostic value of carotid intima-media thickness in detection of coronary atherosclerosis in patients with calcified aortic valve stenosis.

OBJECTIVE: Aortic stenosis (AS) coexists with coronary artery disease (CAD) in at least 30% of patients. Patients with concomitant CAD may benefit from simultaneous coronary bypass grafting. This study aimed to evaluate the prognostic value of carotid intima-media thickness (IMT) in patients with AS in assessing concomitant CAD. METHODS: Group I consisted of 33 patients (mean age +/- SD, 61.0 +/- 8.2 years; 18 men and 15 women) with AS but without CAD on angiograms. Group II consisted of 34 patients (64.4 +/- 8.0 years; 25 men and 9 women) with AS and CAD confirmed angiographically. A control group included 36 patients (61.2 +/- 4.9 years; 18 men and 18 women) with normal coronary arteries and no AS. Maximal IMT was assessed in all patients at the common carotid artery, bulb, and internal carotid artery and expressed as a mean value. RESULTS: There were no differences among the respective groups with regard to age, sex, frequency of hypertension, diabetes, and smoking habit, although patients with CAD were more often hyperlipemic (P = .038). The IMT of the common carotid artery, bulb, and internal carotid artery was significantly higher in patients with AS and CAD compared with both the control group and patients with AS only. The multivariable regression model revealed that CAD (P < .001), AS (P = .006), male sex (P = .034), age (P < .001), and diabetes mellitus (P = .047) were independent risk factors for IMT thickening. A mean IMT value of greater than 1.2 mm was predictive (sensitivity, 73.5%; specificity, 72.7%) of concomitant CAD in patients with AS. CONCLUSIONS: Intima-media thickness increases in patients with AS. The greatest IMT values are observed in patients with both AS and CAD. Patients with AS might be suspected of having CAD when the IMT value exceeds 1.2 mm.     

-374T/A polymorphism of the RAGE gene promoter in relation to severity of coronary atherosclerosis

BACKGROUND: We have recently reported that homozygosity for the minor A-allele of RAGE (receptor for advanced glycation end products) -374T/A polymorphism may exert a protective effect toward the development of angiographic coronary artery disease (CAD). Here we focused on the putative involvement of this functional RAGE polymorphism on the severity of coronary atherosclerosis as assessed by angiography. METHODS: In a total of 234 consecutive Caucasian patients with angiographically proven CAD, the severity of coronary atherosclerosis was assessed by the number of diseased vessels (greater than 50% stenosis). Genotyping for the -374T/A variant was performed by means of PCR-RFLPs. RESULTS: The mean number of diseased vessels was significantly lower in patients with the AA genotype (1.47+/-0.68) than in those with the AT or TT genotype (1.88+/-0.82, p=0.029). After confounding variables were controlled for, the number of diseased vessels remained significantly different in the AA genotype carriers from that in the AT or TT carriers (p=0.041, ANCOVA). CONCLUSIONS: Our data suggest that the RAGE -374T/A polymorphism is one of the likely candidate determinants for the genetic variance of disease phenotype in coronary atherosclerosis.     

Determinants of myocardial hypoperfusion analyzed for the interventricular septum using power Doppler harmonic imaging with contrast echocardiography in humans: a methodologic approach for clinical practice.

BACKGROUND: To evaluate determinants of myocardial hypoperfusion using power Doppler harmonic imaging (PDHI) with myocardial contrast echocardiography (MCE) in clinical practice, a retrospective clinical study was performed comparing echocardiographic and angiographic data. Angiographic data of patients with a normal coronary angiogram (non-CAD) and symptomatic patients with low flow conditions caused by a stenosis of the left anterior descending coronary artery (LAD) or occlusion, or TIMI-II-flow in the LAD were compared with the PDHI data. METHODS AND RESULTS: In 32 patients, MCE was performed with a System Five Performance ultrasound system (GE Vingmed Ultrasound, Horten, Norway). Myocardial perfusion was semiquantitatively analyzed with the EchoPac 6.2b.134 software, bolus injection with Optison (0.35 mL with 5 mL saline flush), and continuous infusion with Levovist (400 mg/mL(-1); 3.5-5 mL/min(-1)) were performed (8 non-CAD patients, 8 CAD patients, respectively). After bolus injection, Doppler intensity (DI) kinetics showed a significant decrease of maximum DI wash-in rate (eg, apical septum [AS]: 4.9 +/- 3.3 vs 2.4 +/- 1.9 dB/s(-1)), of peak maximum DI (eg, AS: 25.3 +/- 6.3 vs 16.4 +/- 5.7 dB), and of DI determined 10 and 20 seconds after peak maximum DI (eg, AS: 22.1 +/- 4.9 vs 10.8 +/- 4.6 dB; AS: 20.4 +/- 5.3 vs 8.0 +/- 3.8 dB, respectively) using a trigger interval once every 3 cardiac cycles when normal perfused areas were compared with hypoperfused areas. During infusion coronary transit time (3.3 +/- 0.9 vs 7.0 +/- 3.6 seconds), maximum DI wash-in rate (eg, AS: 3.2 +/- 1.3 vs 1.3 +/- 0.8 dB/s(-1)) and DI-maximum plateau (eg, AS: 28.6 +/- 4.7 vs 18.3 +/- 6.4 dB) significantly decreased, respectively. CONCLUSION: Regional myocardial hypoperfusion at rest can be detected by using PDHI with MCE in clinical practice, according to a standardized methodologic protocol.     

Coronary intervention: where are we now?

Coronary interventional techniques are used widely in the treatment of patients with coronary artery disease. With modern dilatation equipment the angiographic success rate of coronary balloon angioplasty may exceed 90%, but complications due to acute coronary occlusion may require emergency coronary artery bypass surgery (2-4%), or result in acute myocardial infarction (2-5%) or in-hospital death (0-2%). In most patient groups the long-term outcome of successful coronary angioplasty is good, but restenosis of a successfully dilated stenosis occurs in about 30% of cases, necessitating re-intervention in a significant proportion of patients. Other interventional methods of treating coronary artery stenosis, including directional and rotational coronary atherectomy, endoluminal stenting, and laser angioplasty, have been used in preliminary clinical studies. The acute results of these techniques are encouraging but the restenosis rate remains high and the long-term results are uncertain. The results of randomised clinical trials comparing coronary interventional techniques with alternative treatment methods are awaited.     

Prognostic value of epicardial coronary artery constriction to the cold pressor test in type 2 diabetic patients with angiographically normal coronary arteries and no other major coronary risk factors

OBJECTIVE: Endothelium-dependent coronary dilation is impaired in diabetic patients and has been found to independently predict cardiovascular events (CVEs) in patients with multiple coronary risk factors. The aim of this study was to evaluate the outcome of type 2 diabetic patients on the basis of epicardial coronary dysfunction. RESEARCH DESIGN AND METHODS: We examined 56 control subjects (aged 51.7 +/- 6.4 years) using coronary artery response to the cold pressor test (quantitative coronary angiography) and compared them with 72 type 2 diabetic patients (aged 50.3 +/- 8.5 years) without other major coronary risk factors. RESULTS: Average diameter change was 17.2 +/- 10.4% in the control subjects, dilation occurred in 91.1% of subjects, no change occurred in 8.9%, and there was no constriction. Average diameter change was -14.4 +/- 12.1% in diabetic patients (P < 0.001 vs. control subjects), constriction occurred in 73.6%, no change occurred in 26.4%, and there was no dilation. CVEs were recorded with a mean follow-up of 45 +/- 19 months. There was 1 CVE in the control group and 26 CVEs in 18 of 72 diabetic patients (P < 0.001 vs. control subjects), with 23 events in 16 of 53 diabetic patients with coronary artery constriction (P < 0.001 vs. control subjects), and 3 events in 2 of 19 diabetic patients with no diameter change (NS vs. control subjects). CONCLUSIONS: In type 2 diabetic patients without other major coronary risk factors, constriction of angiographically normal coronary arteries to the cold pressor test is predictive of long-term CVEs.     

Evaluation of acute stress-induced regional myocardial ischemia: Comparison of regional contractile and metabolic indices to easily accessible global left ventricular indices

In clinical studies stress-induced myocardial ischemia in patients with coronary artery disease is used to evaluate the severity of this disease. The discussion on the importance of some parameters measured during this intervention is controversial, other parameters are difficult to obtain. On the basis of an experimental model of stress-induced myocardial ischemia, we tried to find an index that reflects best this cardiac state. We therefore compared in eight anesthetized open-chest dogs control conditions with three other hemodynamic states with increasing imbalance between myocardial oxygen demand and oxygen supply: severe stenosis on circumflex coronary artery, 60 s cardiac sympathetic nerve stimulation (CSNS) with a severe stenosis on circumflex coronary artery, and 60 s complete occlusion of circumflex coronary artery. Using a one-way analysis of variance, we found two significantly changed parameters during the stress-induced ischemia: Regional lactate extraction was turned to production (32 +/- 4 vs. -4 +/- 1%) and the ratio of dP/dtmin to dP/dtmax was decreased (1.13 +/- 0.05 vs. 0.67 +/- 0.05; control vs. CSNS with a severe stenosis on circumflex coronary artery). We conclude that the ratio of dP/dtmin to dP/dtmax is an easily accessible, sensitive, and dynamic index for characterization of an stress-induced myocardial ischemia.     

Alanine aminotransferase and gamma-glutamyl transferase are associated with the metabolic syndrome but not with angiographically determined coronary atherosclerosis

BACKGROUND: Recently, elevated liver enzymes have attracted great interest as potential novel markers of cardiovascular risk. Their association with angiographically determined coronary artery disease (CAD) is unknown. METHODS: We enrolled 1000 consecutive patients undergoing coronary angiography for the evaluation of suspected or established stable CAD. The metabolic syndrome (MetS) was defined according to ATP-III criteria; significant CAD was diagnosed in the presence of coronary stenoses with lumen narrowing >/=50%. RESULTS: Serum alanine aminotransferase (ALT), the ALT/aspartate aminotransferase (AST) ratio, and serum gamma-glutamyl transferase (GGT) were significantly higher in patients with the MetS than in subjects without the MetS (34+/-21 vs. 29+/-20 U/l; p<0.001, 1.16+/-0.39 vs. 1.00+/-0.36 U/l, p<0.001; and 53+/-88 vs. 43+/-57 U/l, p=0.001, respectively) but were similar in patients with significant CAD as in those who did not have significant CAD at angiography (p=0.592; p=0.731, and p=0.716, respectively). Analysis of covariance after multivariate adjustment including alcohol consumption confirmed that ALT, ALT/AST ratio, and GGT were significantly and independently associated with the MetS but not with significant CAD. CONCLUSIONS: ALT, the ALT/AST ratio, and GGT are associated with the MetS but not with angiographically determined coronary atherosclerosis.