Left Main Coronary Angioplasty: Assessment of a "Risk Score" to Predict Acute and Long-Term Outcome

Due to the recent emergence of adjunctive techniques such as cardiopulmonary bypass support, left main angioplasty may become more routinely applied in the near future. In order to choose the best possible therapy, a precise risk assessment will be desirable. Twenty-two left main angioplasties were thus reviewed and patients were divided in two groups according to a risk score adapted from a previously published jeopardy score. Group I included patients with a risk score ≤ 6 and group II patients with a risk score > 6. A cutoff criterion of six points was chosen because it represents the maximal amount of myocardium put at jeopardy from a single coronary stenosis. The success rate of the procedure was 77% and was similar in both groups. Of the 12 patients in group I, two patients underwent in-hospital bypass surgery and one of them died. Among the ten patients of group II, one sustained a myocardial infarction, three underwent acute surgery, and one patient died postoperatively. After a mean follow-up of 41 months, the total mortality rate was 17% in group I and 30% in group II. The long-term event-free survival rate was 75% in group I and 10% in group II (P = 0.004). The risk score was found to be a potentially important predictor of sustained success (long-term success: 4.4 ± 2.9 vs no long-term success: 8.3 ± 3.4; P = 0.01), although sophisticated statistical analysis was limited by the small number of patients. Thus, in patients with a low risk score, angioplasty seems to be an appropriate treatment while it appears that surgery should remain the standard therapy for patients with a calculated high risk score. However, the clinical significance of this new risk score remains to be determined with more elaborate statistical analysis applied to a larger number of patients.     

Primary Health Care and the Addictions: where to start and where to go*

The development of community services for problem drinkers is briefly traced over the last 40 years. The numbers of drinkers in need of advice and treatment far exceeds the available resources. Family practice would be an ideal place in which to further primary care and prevention but lack of time, knowledge and motivation for probing into patients' drinking habits detract from the potential. A pilot study of opportunistic screening in general practice is described whereby a yellow label affixed to a patient's medical record card registers the average weekly alcohol intake. In a sample of 400 patients, 16% were high or intermediate risk drinkers. Each high risk drinker presented with a medical condition which could, in either aetiology or management, be related to high consumption. By discussing this, patients were often motivated to drink less or abstain. Various suggestions are made how better medical training and education could improve the diagnosis and treatment of drinking problems.