Abstract Purpose To determine associations between multiple vascular risk factors (VRF) at ∼73 years and progression of white matter hyperintensities (WMH) from ∼73 to ∼76 years. Methods We ...calculated correlations and generalised estimating equation (GEE) models of a comprehensive range of VRF at 73 years and change in WMH volume from 73 to 76 years. Results Higher systolic (rho=0.126, P =0.009) and diastolic (rho=0.120, P =0.013) blood pressure at 73 years were significant predictors for greater WMH volume at 76 years in a simple correlation model. However, neither measured blood pressure nor self-reported hypertension at 73 years were significant predictors of WMH volume change in a fully adjusted model which accounted for initial WMH volume at 73 years. Lower HDL cholesterol (Beta=-0.15 %ICV, -1.80 ml; P <0.05) and current smoking (Beta=0.43 %ICV, 5.49 ml; P <0.05) were the only significant VRF predictors of WMH volume change from 73 to 76 years. Conclusions A focus on smoking cessation and lipid lowering, not just anti-hypertensives, may lead to a reduction in WMH growth in the eighth decade of life.
Background: Cardiac allograft vasculopathy (CAV), a form of accelerated atherosclerosis, is the major cause of late death in heart transplant recipients. Routine annual coronary angiography has been ...used as the standard surveillance technique for CAV in most transplant centers.
Hypothesis: The aim of this study was to investigate the clinical utility of routine angiographic surveillance in the detection and management of CAV in transplant recipients.
Methods: We reviewed the case notes and angiograms of 230 patients who underwent cardiac transplantation in our unit between January 1986 and January 1996 and survived beyond the first year post transplantation.
Results: Significant complications secondary to angiography arose in 19 patients (8.2%). Cardiac allograft vasculopathy was present on none of angiograms performed 3 weeks post transplantation, but was identified in 9 patients (4%) at the first annual angiogram and an additional 25 patients by the fifth annual angiogram. A target lesion suitable for angioplasty was only identified in two patients, and only limited procedural success was achieved in both cases. Twenty‐five patients (11%) died during the study period, and the most common cause of late death was graft failure which occurred in 10 patients. All patients who died from graft failure had significant CAV at autopsy, but the most recent coronary angiogram had been normal in eight of these patients.
Conclusions: These data clearly illustrate the limited clinical utility of routine angiographic surveillance for CAV in heart transplant recipients and prompted us to abandon this method of surveillance in our unit.
Previous studies have found some significant, but weak, gender differences in panic and agoraphobia with females generally being more symptomatic. The present study sought to expand this line of ...research by examining alcohol use and self-medication in relation to gender differences and measures of psychopathology. Seventy-four male and 162 female patients with panic disorder with agoraphobia were compared. There were some significant, but relatively small, gender differences with females reporting higher levels of phobic avoidance. Males reported significantly more weekly alcohol intake and also perceived alcohol to be a more effective strategy in coping with anxiety. Alcohol-related factors were significantly correlated with several measures of psychopathology for males but this was less evident in females. The correlations were not large but the results do suggest that a subset of males consume moderate to large amounts of alcohol, believe self-medication to be an effective anti-anxiety strategy, and yet report higher levels of psychopathology such as social fears.
Background: Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow‐up. Although repeat angiography ...usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information.
Hypothesis: The study was undertaken to evaluate the relationship between endothelial dysfunction and subangiographic atheroma in patients with CPNA undergoing repeat angiography because of unstable symptoms.
Methods: We investigated nine patients with CPNA (8 women, mean age 57 ± 9 years) undergoing repeat angiography because of unstable anginal symptoms. After normal angiography, simultaneous coronary epicardial and microvascular vasomotor responses to intracoronary vasodilators acetylcholine (10−6 M), adenosine (18 μg) and nitroglycerin (300 μg) were investigated in the left anterior descending artery using quantitative angiography and Doppler flow measurements. The presence of subangiographic atheroma was assessed by intravascular ultrasound.
Results: Three patients demonstrated proximal and distal epicardial vasoconstriction and a reduction in coronary flow in response to acetylcholine, indicating concordant epicardial and microvascular endothelial dysfunction. These changes were associated with chest pain and ischemic electrocardio‐graphic changes in two patients. None of the remaining patients suffered chest pain in response to intracoronary acetylcholine. Six patients had significant subangiographic disease (intimal thickness >0.3 mm) on intravascular ultrasound imaging, and multivariate analysis indicated a significant relationship (R2 = 0.89, overall p = 0.001) between the extent of subangiographic disease and both plasma cholesterol concentration and hypertensive history. No significant relationship was demonstrated between endothelial dysfunction and the extent of subangiographic disease.
Conclusion: Concordant epicardial and microvascular endothelial dysfunction may be pathophysiologically and clinically significant in unstable patients with CPNA but does not appear to be directly related to the extent of subangiographic atheroma.
The possible algogenic effects of elevated serum endothelin levels in cardiac syndrome X were investigated in a case-control study that examined somatic pain perception in the forearm during ...submaximal effort tourniquet and cold immersion tests. Pain threshold to both ischemic and cold stimulation of the forearm was demonstrated to be significantly lower in patients with syndrome X than in matched healthy controls, and a negative correlation between ischemic pain threshold and endothelin levels was demonstrated.
This study examined the phenomenology of the initial panic attack in 85 panic disorder patients with or without agoraphobia. Patients were divided into minimal and extensive avoiders and three ...domains were assessed: precipitating factors, location of initial panic, and reaction to the panic. No apparent precipitating factor could be identified in approx 40% of the patients. The most common precipitants were injury/illness and interpersonal conflict. Extensive avoiders were more likely to have experienced the initial panic in classic agoraphobic situations. Public transportation was the most common location for the total sample. In reaction to the panic, minimal avoiders were more likely to have gone to a hospital emergency room (ER) whereas extensive avoiders were more likely to have done nothing in terms of help-seeking. Many patients with either minimal or extensive avoidance avoided the locations where the initial panic occurred, suggesting that circumscribed avoidance does not always generalize.
Background Raised plasma endothelin concentrations have previously been reported in patients with cardiac syndrome X, but it is not known whether these levels vary between clinically distinct ...subgroups in this heterogeneous condition.
Methods and Results We compared plasma immunoreactive endothelin levels in 54 patients with angina pectoris and normal coronary angiograms and 21 healthy control subjects. The patient group was divided into 4 clinically distinct subgroups: 7 with left bundle branch block (group A); 7 with previous myocardial infarction (group B); 24 with positive exercise electrocardiography (group C); and 16 with negative exercise electrocardiography (group D). The plasma endothelin concentration was significantly higher in patients compared with control subjects (3.7 2.9 to 4.3 vs 2.96 2.4 to 3.4 pg/mL, respectively, median interquartile range;
P = 0.002). Endothelin concentrations were most significantly elevated in group A and group B (4.5 3.6 to 5.2 pg/mL;
P = 0.005 and 4.1 3.9 to 4.5 pg/mL;
P = 0.001, respectively). Plasma endothelin concentrations were also significantly elevated in group C (3.7 2.8 to 4.1 pg/mL;
P = 0.02) but not in group D (3.0 2.5 to 3.8 pg/mL;
P = 0.3).
Conclusions Plasma endothelin concentration is elevated in patients with angina pectoris and angiographically normal coronary arteries, particularly those with left bundle branch block or previous myocardial infarction. (Am Heart J 1998;136:412-7.)
To determine whether 64-slice multidetector computed tomographic coronary angiography (MDCTA) can accurately assess the coronary artery lumen in symptomatic patients with previous coronary artery ...stents and potential in-stent restenosis (ISR). The primary aim was to determine the accuracy of binary ISR exclusion using MDCTA compared with invasive catheter angiography (ICA). Secondary aims were comparisons of stent dimensions measured using MDCTA and variables that affect accuracy. Forty patients with previous stent placement underwent both ICA and 64-slice MDCTA after elective presentation with chest pain, and ICA quantitative coronary angiographic data were used as the reference standard. Thirty-six men and 4 women (age 64 ± 10 years; range 44 to 83) with 103 stents (2.8 ± 1.6 stents/patient) were comparatively evaluated (stent exclusion rate 9.6%). There were 45 bare-metal and 58 drug-eluting stents (20 ± 18 months after implantation) with an average diameter of 3.23 ± 0.7 mm. Overall accuracy for the detection of significant ISR showed sensitivity, specificity, and positive and negative predictive values of 85%, 86%, 61%, and 96% for proximal stents ≥3 mm, which improved to 100%, 94%, 81%, and 100%; if the visible luminal diameter on MDCTA was <1.5 mm, accuracy decreased to 40%, 84%, 29%, and 90%, respectively. In conclusion, 64-slice MDCTA assessment of symptomatic patients with suspected clinically significant ISR is a realistic alternative to ICA if reference stent diameter is ≥2.5 mm and visible lumen cross-sectional diameter is ≥1.5 mm, for which a negative MDCTA result virtually excludes the presence of significant ISR.
Abstract Objectives This study sought to assess the safety and effectiveness of the drug-filled stent (DFS) (Medtronic, Santa Rosa, California) in the treatment of patients with coronary artery ...disease. Background Polymer-free drug-eluting stents have the potential to improve clinical outcomes and facilitate shorter durations of dual antiplatelet therapy. The polymer-free DFS is made from a trilayered continuous wire with an outer cobalt chromium layer, a middle tantalum layer, and an inner lumen coated with sirolimus. Small laser-drilled holes on the abluminal stent surface control drug elution. Methods The RevElution trial enrolled 100 patients with de novo coronary lesions 2.25 to 3.50 mm in diameter and length ≤27 mm in 2 cohorts of 50 patients for angiographic, intravascular ultrasound, and clinical assessment at 9 or 24 months, with optical coherence tomography performed in a subset of 30 patients at each time period. The primary endpoint was angiographic in-stent late lumen loss at 9 months compared with Resolute zotarolimus-eluting stent (Medtronic) historical control data. Results Fifty patients with 56 lesions were treated with DFS in the 9-month cohort. In-stent late lumen loss was 0.26 ± 0.28 mm for DFS and 0.36 ± 0.52 mm for Resolute (pnoninferiority <0.001). The binary angiographic restenosis rate was 0%. Median stent strut coverage by optical coherence tomography was 91.4%, 95.6%, and 99.1% at 1, 3, and 9 months, respectively. One non–Q-wave myocardial infarction occurred, with a 9-month target lesion failure rate of 2.1%. No stent thrombosis occurred. Conclusions At 9 months, the polymer-free DFS was safe and effective with high rates of early strut coverage and noninferior late lumen loss compared to Resolute. (Medtronic RevElution Trial RevElution; NCT02480348 )
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