Rechtsprechung aktuell

Ohne Zusammenfassung     

Should every patient undergo cardiac catheterization after myocardial infarction?

During the past few decades, management of patients with myocardial infarction has dramatically evolved. High-risk patients are now identified by a variety of noninvasive tests, and aggressive use of reperfusion strategies has improved clinical outcomes. Despite the benefits of reperfusion, only a few patients are eligible to receive thrombolytic therapy. Mortality rates among patients excluded from thrombolytic trials (15% to 20%) have been far greater than those eligible for treatment (3% to 10%). Because most deaths occur within the first few days of infarction, interventions designed to reduce mortality should be performed acutely. Immediate catheterization allows identification of high-risk anatomy that may benefit from surgery and allows coronary angioplasty to be performed as a reperfusion strategy (when appropriate). Furthermore, catheterization allows documentation of ejection fraction, vessel patency, number of diseased vessels, and residual stenosis, all of which have been predictive of prognosis. Conversely, frequently repeated noninvasive diagnostic tests are associated with increased cost, are generally performed in low-risk patients, and 60% to 80% of patients with myocardial infarction ultimately require catheterization anyway. It is possible that early catheterization and percutaneous transluminal coronary angioplasty when indicated may effectively risk stratify patients (eliminating the need for noninvasive testing), may reduce morbidity and mortality, and shorten the length of hospital stay.     

Inhibition of interleukin-2-stimulated enhancement of human natural killer (NK) cell activity by carbaryl, an anticholinesterase insecticide.

The potency of the anticholinesterase (antiCHE) insecticides as serine hydrolase inhibitors, and evidence for serine hydrolase activity in interleukin-2 (IL2) signalling suggest that the natural killer (NK) cell may be a target for dysregulation by antiCHE insecticides. NK cells are large granular lymphocytes (LGL) that respond to IL2 by proliferating and increasing their cytolytic efficiency. In the present study, we assessed the effects of carbaryl (CA, an antiCHE insecticide) and alpha-naphthol (NA, the major metabolite of CA) on both target cell killing per se and IL2 enhancement of target cell killing by human NK cells. Human LGL, collected from the peripheral blood of normal donors, were cultured for 4 days with human recombinant IL2 (HRIL2), then assayed by a 51Chromium (51Cr) release assay for lytic activity against human K562 cells. When added at the beginning of the culture period, CA inhibited enhancement of cytolytic efficiency in a concentration-dependent manner; at concentrations (0.5 and 5.0 microM) compatible with no cholinergic toxicity. Reduction of the effector/target cell (E/T) ratio in the 51Cr release assay markedly enhanced the observed inhibition by CA. In one experiment, inhibition increased from 6% to 20%, 17% to 35%, and 53% to 73% at 0.5, 5.0, and 50 microM CA, respectively, when E/T was reduced from 10:1 to 2.5:1. This result is consistent with reduced cytolytic efficiency of individual NK cells exposed to CA. NA had no effect at 0.5 or 5.0 microM but caused some inhibition at 50 microM. Neither CA nor NA produced LGL death. When CA or NA was added directly to the 51Cr release assay, inhibition was not observed. The mechanism of inhibition of IL2-stimulated enhancement of target cell killing is not yet known, however, the results are consistent with impairment of IL2 signalling, by CA.     

Role of nuclear cardiology for determining management of patients with stable coronary artery disease

Both radionuclide angiography and myocardial perfusion imaging provide important insights that determine the management of patients with stable coronary artery disease. Both nuclear cardiology procedures have clearly demonstrated use in the noninvasvie identification of severe (left main or three-vessel) coronary artery disease and the noninvasive assessment of prognosis and thereby determine which patients should be sent to coronary angiography. Both radionuclide angiography and myocardial perfusion imaging provide prognostic information that is independent of resting left ventricular function and coronary anatomy and thereby influence the decision regarding which patients should be sent to coronary revascularization. This review considers the evidence supporting the uses of these nuclear cardiology procedures and provides suggestions regarding their cost-effective application.