Prognostic value of myocardial perfusion imaging in patients with known or suspected stable angina pectoris: evaluation in a setting in which myocardial perfusion imaging did not influence the choice of treatment

OBJECTIVE: Previous investigations on the prognostic value of myocardial perfusion imaging (MPI) were performed under circumstances in which the test result was known to the patient's physician. We wanted to examine the prognostic value of MPI in patients with known or suspected stable angina in a setting in which MPI could not influence the diagnostic and therapeutic strategy. DESIGN: A prospective series of 507 patients referred to coronary angiography for this condition were examined by MPI before angiography. Management was based on symptoms and angiographic findings, as the results of MPI were not communicated. Patients were followed for a mean of 45.3 +/- 7.7 months. RESULTS: During follow-up, 20 patients (3.9%) suffered from myocardial infarction, 19 (3.8%) died and eight (1.6%) were revascularized >1 year after MPI resulting in a combined annual event rate of 2.5%. Patients with normal MPI had a low annual event rate of 1.6% (or 1.1% with regard to myocardial infarction or death only). In contrast, event rates in patients with reversible or mixed ischaemia were 4.0% per year. MPI added independent prognostic value to standard clinical data in a multivariate Cox model. CONCLUSION: We could confirm that in patients with known or suspected stable angina, MPI is a valuable risk stratifying tool.     

Symptoms of unstable angina in patients with and without diabetes

Patients with diabetes experience cardiac autonomic neuropathy that may affect the way they perceive the symptoms of unstable angina (UA). The purpose of this study was to examine symptom differences in patients with and without diabetes during an episode of UA. A convenience sample of 50 women and 50 men were recruited. Patients with diabetes were more likely to have a history of hypercholesterolemia (83% vs. 60%), prior history of heart disease (85% vs. 65%), and prior angiogram (85% vs. 67%). Patients with diabetes reported having less nausea (20% vs. 40%), less squeezing (25% vs. 48%) and less aching (25% vs. 45%) type pain, and more hyperventilation (27.5% vs. 11.7%). Other cardiac symptoms were similar between the groups. Further study of symptom presentation in patients with diabetes is warranted given their high levels of morbidity and mortality from cardiac disease.     

Prognostic value of quantitative stress myocardial perfusion imaging in unstable angina patients with negative cardiac enzymes and no new ischemic ECG changes

Background. Limited data are available on the value of quantitative stress myocardial perfusion imaging (MPI) in patients with unstable angina. In this report we sought to study the long-term prognostic value of quantitative stress MPI in patients hospitalized with unstable angina with no new ischemic electrocardiographic changes and negative cardiac enzymes. Methods and Results. The study population consisted of 136 patients who were hospitalized at the Methodist Hospital, Houston, Tex, with unstable angina and subsequently underwent MPI before discharge. Cox proportional hazards (regression) analysis was performed to identify clinical and MPI predictors of hard cardiac events (death or nonfatal myocardial infarction). During a mean follow-up of 31 ± 17 months, 20 patients (15%) sustained either cardiac death (n = 12) or nonfatal myocardial infarction (n = 8). The significant multivariate predictors of cardiac events were the total perfusion defect size (P = .002), the presence of reversible perfusion defects (P = .01), and the presence of multiple perfusion defects (P = .03). The perfusion defect size was significantly larger in patients with events than in those without events (21% ±20% vs 12% ± 14%, P = .002). Kaplan-Meier analysis showed that cardiac events were much more likely to develop in patients with defects involving 15% or more of the left ventricle than in those with defects involving less than 15% of the left ventricle (P = .003). Conclusions. In patients hospitalized with unstable angina with no new ischemic electrocardiographic changes and negative cardiac enzymes, quantitative stress MPI provides powerful prognostic information that can be used in the risk stratification of these patients. (J Nucl Cardiol 2005;12:32-6.)     

辨证论治冠心病心绞痛100例

冠心病心绞痛是临床上常见病、多发病,近年来发病有逐渐上升的趋势,给人们的健康造成了极大危害。2000年1月~2007年9月,笔者采用中医辨证论治治疗冠心病心绞痛100例,临床效果满意,现报道如下。1临床资料100例均为门诊病人,其中男56例,女44例;年龄最小41岁,最大75岁,平均58岁;病     

Deleted in Oral Cancer-1 Expression Upregulates Proapoptosis Elements in Microsatellite-Unstable Human Colorectal Cancer

Background: We previously reported differential expression of the growth suppressor, deleted in oral cancer-1 (DOC-1), in microsatellite-unstable (MSI+) versus microsatellite-stable colorectal cancer (CRC) cell lines. MSI+ CRC cell lines demonstrated decreased DOC-1 expression and decreased apoptosis. Transfection of wild-type DOC-1 into an MSI+ cell line (SW48) resulted in increased apoptosis. We undertook our current experiment to identify specific elements modulated by DOC-1 expression that result in increased apoptosis.Methods: SW48 is an MSI+ CRC cell line that does not constitutively express DOC-1. SW48 was suspended in culture medium and incubated to 60% confluence. Half the plates were transfected with cytomegalovirus (CMV)-DOC-1. At 30 hours, RNA and protein were isolated with Trizol. Complementary DNA microarray was performed to compare SW48^CMV-DOC-1 with SW48, which lacks DOC-1. Signal intensity was analyzed by GenePix Pro 3.0 software. Expression ratios .67 and 1.5 were considered significant. Poor-quality spots were flagged and excluded from analysis. Real-time polymerase chain reaction was performed to determine DOC-1 levels in both cell lines.Results: Successful transfection of DOC-1 was confirmed by real-time polymerase chain reaction and by Western blot. Microarray revealed significant differential expression of DOC-1, as expected. Increased DOC-1 expression in SW48^CMV-DOC-1 was associated with significantly increased expression of proapoptosis components of the caspase cascade (CASP7, CASP9) and bcl2/bax pathway (BNIP3, BNIP3L, BID).Conclusions: DOC-1 expression promotes apoptosis by upregulation of specific elements of the caspase cascade and bcl2/bax pathways. DOC-1 therefore deserves further study as a candidate for the therapeutic modulation of apoptosis in MSI+ CRC.     

Highlighting the need for better patient care in stable angina: results of the international Angina Treatment Patterns (ATP) Survey in 7074 patients

BACKGROUND: Stable angina is a growing problem worldwide. Diagnostic methods and treatment regimens are established but data on actual practice are sparse and pre-date current guidance. OBJECTIVES: To compare diagnosis and treatment information with guideline recommendations, and to assess impact on quality of life. METHODS: This international epidemiological survey recruited patients through primary and secondary care clinicians from China, Czech Republic, Greece, Hungary, Portugal, Russia and Slovak Republic. Participants experienced at least one episode of stable angina within the previous four weeks. Outcomes included use of diagnostic techniques, pharmacological treatments, surgical intervention, secondary prevention and quality of life. RESULTS: The study included 7074 patients, average age 63.3 (sd 10.3). Diagnosis of angina was most frequently as a result of chest pains (87.4%) with confirmation by resting ECG in only 54.9%. Advice regarding risk factors was frequently given although secondary prevention was often ineffective with 41% of treated hypertensives lacking effective control. 97% of patients were taking at least one of the primary therapies for stable angina recommended by the guidelines with rates of individual therapies varying greatly across countries. Quality of life was lowest in countries with low rates of surgical intervention and poor observance of guidelines on pharmaceutical therapy. CONCLUSION: Results show that the management of patients with stable angina does not meet recommended standards, although the appropriateness of these guidelines in poorer countries needs further investigation. Overall, the survey indicates that improved medical care and risk factor management would enhance prognosis and improve quality of life.     

Autonomic antecedents to variant angina exacerbation after beta-blockade withdrawal

We describe a patient with nonsignificant coronary artery disease who experienced variant angina after beta -blockade withdrawal. Standard therapy with nifedipine and nitrates aimed at suppressing symptoms and typical transient ST-segment elevations was superseded by the reinstitution of metoprolol. The autonomic alternations before and after readministration of metoprolol were analyzed by time and spectral indices of heart rate variability (HRV). Metoprolol reduced the HRV and reversed the low-frequency/high-frequency power ratio toward a more physiological autonomic balance. We conclude that the reinstitution of beta -blocker acted protectively by preventing surges of sympathetic activity on an underlying basis of parasympathetic predominance.     

Urgent and emergency coronary artery bypass grafting for acute coronary syndromes

BACKGROUND: Urgent and emergency coronary artery bypass grafting may be associated with significant mortality and morbidity. We report our recent experience with this group of patients. METHODS: A retrospective analysis of 441 patients undergoing urgent and emergency surgery over a 3-year period was carried out. Multivariate analysis was used to identify subgroups of patients who were most at risk of death. RESULTS: The 30-day mortality was 3.3 and 16.3% in the urgent and emergency groups, respectively. Urgent surgery was associated with significantly shorter duration of ventilation (16 h vs 69 h) and stay at the intensive care unit (31 h vs 102 h). The incidence of pneumonia, pulmonary embolism, renal failure and neurological events were also less in the urgent group. The preoperative use of the intra-aortic balloon pump was low (0.8% in the urgent group and 4.8% in the emergency group). Multivariate analysis showed that patients over 70 years of age (odds ratio 3.2, 95% confidence interval 1.1-9.5) with left main stenosis (odds ratio 4.4, 95% confidence interval 1.5-12.4) complicated by cardiogenic shock (odds ratio 17.8, 95% confidence interval 5.2-61.1) were at highest risk of death. Patients transferred directly to theatre from cardiac catheter laboratory following failed percutaneous interventions were found to be most at risk. Mortality in this group was 29%, with 50% patients being in shock and 36% having left main stenosis. CONCLUSION: Satisfactory results have been obtained in urgent coronary artery bypass grafting, but acute coronary syndromes complicated by cardiogenic shock remain a high-risk group. Further studies are needed to define the optimal operative management in this group of patients.     

Intensity of antianginal therapy in patients referred for coronary angiography: a comparison of fee-for-service and health maintenance organization therapeutic strategies

BACKGROUND: No formal criteria have been developed to guide medical therapy for angina prior to revascularization, and no comparisons have been made between health maintenance organization (HMO) and fee-for-service (FFS) hospitals with respect to angina treatment. HYPOTHESIS: Using a literature-based measure of medical intensity, we tested the hypothesis that there is no difference in anginal medical therapeutic intensity between HMO and FFS systems. METHODS: For each antianginal drug, we developed a model from which an intensity score between 0 and 100 could be calculated. Average and maximal daily doses of drug were fit to a sigmoid curve such that they represented scores of 50 and 99, respectively. Overall intensity scores were obtained by weighted and unweighted averaging of three scores from nitrates, calcium-channel blockers, and beta blockers. This model was applied to 199 patients undergoing angiography at an FFS and an HMO hospital. RESULTS: HMO patients were taking more classes of antianginal drug (1.9 vs. 1.0, p < 0.001). Overall unweighted (17.7 vs. 11.7, p = 0.02) and weighted (27.3 vs. 16.9, p = 0.003) intensity scores for both HMO and FFS patients were low. HMO intensity scores for the use of beta blockers were greater than FFS scores (19.2 vs. 9.6, p = 0.002). The intensity scores for the use of nitrates and calcium blockers were similar. CONCLUSIONS: Models for the measurement of anginal medical therapy intensity can provide important information regarding medical therapy prior to revascularization. The overall intensity of medical therapy was low in both health care systems. These findings have important implications for patient management, guideline development, and national healthcare policy.