[Health damage caused by smoking]

This paper describes the detrimental effects of smoking. More than 30% of the male and female Dutch population still smokes cigarettes. This figure compares unfavorably in international perspective. The smoking habit is responsible for approximately one third of all deaths from cardiovascular, pulmonary and malignant disease. Cigarette smokers face a 50% chance of dying as a result of a smoking related disease. The morbidity associated with smoking is also very substantial. Subjects who discontinue smoking before being struck by disease, and patients who quit the habit once early symptoms develop, have a more favorable outcome. For these reasons, and also because most patients esteem the opinion of their doctor, smoking behavior should be discussed during regular patient doctor contacts, and followed by the advice to quit smoking.

Anticoagulant properties, clinical efficacy and safety of efegatran, a direct thrombin inhibitor, in patients with unstable angina

AIMS

Thrombin plays a key role in the clinical syndrome of unstable angina. We investigated the safety and efficacy of five dose levels of efegatran sulphate, a direct thrombin inhibitor, compared to heparin in patients with unstable angina.

METHODS

Four hundred and thirty-two patients with unstable angina were enrolled. Five dose levels of efegatran were studied sequentially, ranging from 0.105 mg. kg(-1). h(-1)to 1.2 mg. kg(-1). h(-1)over 48 h. Safety was assessed clinically, with reference to bleeding and by measuring clinical laboratory parameters. Efficacy was assessed by the number of patients experiencing any episode of recurrent ischaemia as measured by computer-assisted continuous ECG ischaemia monitoring. Clinical end-points were: episodes of recurrent angina, myocardial infarction, coronary intervention (PTCA or CABG), and death.

RESULTS

Efegatran demonstrated dose dependent ex-vivo anticoagulant activity with the highest dose level of 1.2 mg. kg(-1). h(-1)resulting in steady state mean activated partial thromboplastin time values of approximately three times baseline. Thrombin time was also increased. Neither of the efegatran doses studied were able to suppress myocardial ischaemia during continuous ECG ischaemia monitoring to a greater extent than that seen with heparin. There were no statistically significant differences in clinical outcome or major bleeding between the efegatran and heparin groups. Minor bleeding and thrombophlebitis occurred more frequently in the efegatran treated patients.

CONCLUSION

Administration of efegatran sulphate at levels of at least 0.63 mg. kg(-1). h(-1)provided an anti-thrombotic effect which is at least comparable to an activated partial thromboplastin time adjusted heparin infusion. There was no excess of major bleeding. The level of thrombin inhibition by efegatran, as measured by activated partial thromboplastin time, appeared to be more stable than with heparin. Thus, like other thrombin inhibitors, efegatran sulphate is easier to administer than heparin. However, no clinical benefits of efegatran over heparin were apparent.

Sustained benefit at 10-14 years follow-up after thrombolytic therapy in myocardial infarction

AIMS

To investigate whether the benefit of thrombolytic therapy was sustained beyond the first decade. We report the 10-14 year outcome of 533 patients who were randomized to treatment with intracoronary streptokinase or to conventional therapy during the years 1980-1985.

METHODS AND RESULTS

Details of survival and cardiac events were obtained from the civil registry, from medical records or from the patient's physician. At follow-up, 158 patients (59%) of the 269 patients allocated to thrombolytic treatment and only 129 patients (49%) of the 264 conventionally treated patients were alive. The cumulative 1-, 5- and 10-year survival rates were 91%, 81% and 69% in patients treated with streptokinase and 84%, 71% and 59% in the control group, respectively (P=0.02). Reinfarction during 10-years of follow-up was more frequent after thrombolytic therapy, particularly during the first year. Coronary bypass surgery and coronary angioplasty were more frequently performed after thrombolytic therapy. At 10 years approximately 30% of the patients were free from subsequent cardiac events. Independent determinants of mortality were elderly age, indicators of impaired residual left ventricular function, multivessel disease and an inability to perform an exercise test at the time of hospital discharge.

CONCLUSION

Improved survival after thrombolytic therapy is maintained beyond the first decade. Age, left ventricular function, multivessel disease and an inability to perform an exercise test were independent predictors for long-term mortality, as they are predictors for early mortality.

Prior aspirin use predicts worse outcomes in patients with non-ST-elevation acute coronary syndromes. PURSUIT Investigators. Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy

Aspirin is beneficial in the prevention and treatment of cardiovascular events, but patients who have events while taking aspirin may have worse outcomes than those not on aspirin. We investigated the association between prior aspirin use and clinical outcomes in 9,461 patients with non-ST-elevation acute coronary syndromes enrolled in the Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, before and after adjustment for baseline factors. We also examined whether eptifibatide has a differential treatment effect in prior aspirin users. Prior aspirin users were less likely to have an enrollment myocardial infarction (MI) (vs unstable angina) (43.9% vs 48.8%, p = 0.001) but more likely to have death or MI at 30 days (16.1% vs 13.0%, p = 0.001) and at 6 months (19.9% vs 15.9%, p = 0.001). After adjustment, prior aspirin users remained less likely to have an enrollment MI (odds ratio 0.88, 95% confidence interval 0.79 to 0.97) and more likely to have death or MI at 30 days (odds ratio 1.16, 95% confidence interval 1.00 to 1.33) but not at 6 months (odds ratio 1.14, 95% confidence interval 0.98 to 1.33). In a multivariable model, eptifibatide did not have a different treatment effect in prior aspirin users compared with nonusers (p = 0.534). Prior aspirin users had fewer enrollment MIs but worse long-term outcomes than nonusers. We found no evidence for a different treatment effect of eptifibatide in prior aspirin users.

Prevalence of heart failure and left ventricular dysfunction in the general population; The Rotterdam Study

AIMS

To determine the prevalence of heart failure and symptomatic as well as asymptomatic left ventricular systolic dysfunction in the general population.

METHODS AND RESULTS

In 5540 participants of the Rotterdam Study (age 68.9+/-8.7 years, 2251 men) aged 55-95 years, the presence of heart failure was determined by assessment of symptoms and signs (shortness of breath. ankle oedema and pulmonary crepitations) and use of heart failure medication. In 2267 subjects (age 65.7+/-7.4 years, 1028 men) fractional shortening was measured. The overall prevalence of heart failure was 3.9% (95% CI 3.0+/-4.7) and did not differ between men and women. The prevalence increased with age, with the exception of the highest age group in men. Fractional shortening was higher in women and did not decrease appreciably with age. The prevalence of left ventricular systolic dysfunction (fractional shortening <=25%) was approximately 2.5 times higher in men (5.5%, 95% CI 4.1-7.0) than in women (2.2%, 95% CI 1.4-3.2). Sixty percent of persons with left ventricular systolic dysfunction had no symptoms or signs of heart failure at all.

CONCLUSIONS

The prevalence of heart failure is appreciable and does not differ between men and women. The majority of persons with left ventricular systolic dysfunction can be regarded as having asymptomatic left ventricular systolic dysfunction.

EUROPA substudies, confirmation of pathophysiological concepts. European trial on reduction of cardiac events with perindopril in stable coronary artery disease

In patients with coronary disease, ACE inhibitors may improve endothelial function in the coronary arteries as well as peripheral arteries, and may have anti-proliferative effects which might result in retardation of progression of coronary artery disease. In order to verify these pathophysiological concepts, a series of substudies will be conducted as part of the EUROPA programme. Angiographic and intravascular ultrasound examination of coronary arteries will be performed in approximately 400 patients before and after 3 years' treatment with either perindopril or placebo, in order to assess progression and possible regression of coronary lesions. B-mode ultrasonography of the brachial artery will be used as a model for changes in the coronary arteries, to assess endothelial function in response to ischaemia (reactive hyperaemia) and to vasoconstriction (cold pressor test). Three hundred patients will be investigated before and at different intervals after initiation of study treatment. In addition genetic characterization will be performed of patients participating in EUROPA in order to assess whether specific genotypes do respond more or less favourably to perindopril. In addition, the effect of perindopril will be investigated in patients with diabetes type II, since ACE inhibition in such patients may improve microvascular function and renal function. Integration of these substudies, as well as detailed analysis of other specific subgroups in EUROPA, will help us understand the effects of treatment with perindopril in patients with stable coronary artery disease.

Association between coronary angiograms and cardiac events--a prospective 3-year follow-up. INTACT-Investigators. International Nifedipine Trial on Antiatherosclerotic Therapy

The correlation between extent and severity of coronary artery disease as documented by quantitative coronary angiography and the incidence of cardiac events within 3 years was analyzed from a prospective study. In 73 out of 419 patients, 89 events occurred comprising 10 cardiac deaths, 15 non-fatal myocardial infarcts, 26 cases of unstable angina, and 38 coronary revascularization procedures (bypass graft operation or angioplasty). The incidence of any event correlated with the baseline number of all stenoses and high-grade stenoses (> or =20% and > or =50% diameter stenosis, respectively) (P<0.05). With respect to specific events, non-fatal myocardial infarcts and revascularization procedures were correlated with the number of all stenoses (P<0.05), but not with high-grade stenoses. Specification of coronary arteries revealed correlation of non-fatal myocardial infarcts and revascularization procedures with the number of high-grade stenoses in the left anterior descending artery. Finally, baseline left ventricular ejection fraction was found to be lower in patients who died of cardiac causes than in the remaining patients (49 +/- 10% vs. 67 +/- 13%; P<0.001). In conclusion, the total coronary stenosis burden seems to predict the incidence of subsequent cardiac events even better than the number of high-grade stenoses. Only in the left anterior descending artery high-grade stenoses seem to cause myocardial infarcts within a relatively short period of time justifying short-term revascularization in these patients.

The Cardiac Infarction Injury Score as a predictor for long-term mortality in survivors of a myocardial infarction

AIMS

The Cardiac Infarction Injury Score (CIIS) is an electrocardiographic classification system that was developed as a diagnostic tool to assess the extent of cardiac injury in acute myocardial infarction. We investigated the prognostic value of the CIIS in post-myocardial infarction patients.

METHODS AND RESULTS

The prognostic values of the CIIS for total and cardiac mortality was assessed in a large series (n = 3395) of patients who were enrolled in the ASPECT trial. Standard 12-lead electrocardiograms, recorded prior to hospital discharge were coded according to the CIIS and the Minnesota Code. Mean CIIS was 26 (range--8 to 59). After adjustment for other baseline characteristics, the CIIS was directly related to the risk of total mortality and cardiac mortality. At one-year follow-up the relative risks of CIIS > or = 40, CIIS 30-40 and CIIS 20-30 were significantly higher than in those with a CIIS < 20. The relative risks were, respectively, 2.3 (1.2-4.4), 2.2 (1.3-3.9) and 1.6 (0.9-2.9). At 3 year follow-up, the relative risks were, respectively, 2.1 (1.4-3.2), 1.7 (1.2-2.4) and 1.5 (1.0-2.1). The relative risks for total mortality were similar. When patients with major ECG abnormalities, as defined by the Minnesota code, were excluded, the associations were still significant in the CIIS classes 30-40 and > 40.

CONCLUSION

The CIIS ECG scoring system is an important predictor for long-term cardiac mortality in post myocardial infarction patients. It can easily be automated and is efficient for classifying cardiac injury in epidemiological studies.

Estrogen replacement decreases the level of antibodies against oxidized low-density lipoprotein in postmenopausal women with coronary heart disease

The effect of estrogen replacement therapy (ERT) on plasma lipid concentrations and oxidation parameters was studied in 25 hypercholesterolemic women with coronary heart disease (CHD). During ERT, the low-density lipoprotein cholesterol (LDLc) concentration decreased from 4.31 +/- 0.72 to 3.85 +/- 0.62 mmol/L (P < .01) and high-density lipoprotein cholesterol (HDLc) increased from 1.42 +/- 0.30 to 1.55 +/- 0.33 mmol/L (P < .01). The concentration of autoantibodies against oxidized LDL decreased from 25.9 +/- 22.0 to 22.7 +/- 19.9 mg/L (P < .05), indicating that ERT may have antioxidative effects in vivo. The lag time to oxidation and the LDL subclass pattern did not change. Analysis of the influence of smoking on the efficacy of ERT showed that ERT significantly affected LDLc and HDLc concentrations in 15 nonsmoking women. However, in 10 cigarette smokers, no significant changes in LDLc or HDLc levels were observed. Smoking did not affect the concentration of autoantibodies to oxidized LDL or the lag time. Medroxyprogesterone acetate ([MPA] 10 mg daily) added to ERT decreased HDLc by 9% (P < .01) but did not affect the LDLc level, LDL subclass pattern, or lag time. In conclusion, ERT may have antioxidative effects in vivo and favorably affects dyslipidemia in hypercholesterolemic women with CHD, especially when they refrain from smoking.

The additional effects of acipimox to simvastatin in the treatment of combined hyperlipidaemia

OBJECTIVES

Nicotinic acid, an effective drug for treatment of combined hyperlipidaemia, is often not tolerated because of side-effects. Acipimox is a nicotinic acid like lipid lowering drug with less side-effects. We studied whether the addition of acipimox to simvastatin improves the lipid profile in patients with a combined hyperlipidaemia.

DESIGN

Randomized double-blind placebo controlled crossover trial.

SETTING

Outpatient lipid clinic of a tertiary referral centre.

SUBJECTS

Eighteen patients with combined hyperlipidaemia treated with diet and 20-40 mg simvastatin for at least 3 months.

INTERVENTION

Acipimox in a daily dose of 3 X 250 mg for 12 weeks.

MAIN OUTCOME MEASURES

Effects on the concentration of LDLc, TG, HDLc, Lp(a) and Apolipoprotein B, as well as on LDL-size and LDL-resistance to oxidative modification.

RESULTS

Acipimox reduced Lp(a) levels by 8% (P < 0.05). A substantial but not statistically significant change in TG (-32%) and HDLc (+6%) levels was seen. All patients were found to have small dense LDL, with a size of 229 +/- 4 A. LDL size and the resistance to oxidation, reflected in the lag phase during in vitro oxidation, were not affected by the addition of acipimox. In a subgroup of 8 patients with the most severe hypertriglyceridaemia (baseline TG > 4 mmol L- [1]), acipimox induced a significant increase in HDLc (+ 15%, P < 0.01). The effects on TG (-41%), LDLc (-10%) and lag phase (+17%) were also more pronounced than in the group with a lower baseline TG, but none of these changes reached the level of significance.

CONCLUSIONS

Adding acipimox to simvastatin reduced Lp(a) and substantially but not significantly lowered TG. However, in patients with the highest TG levels. HDLc was also significantly improved.

[Antithrombotic treatment following acute ischemic heart disease: acetylsalicylic acid and (or) oral anticoagulants?; ASPECT-II, a new study]

In order to compare the efficacy and safety of three regimens of long-term antithrombotic treatment in patients with acute ischaemic syndromes, a prospective, randomized, open-label, multicentre study is being conducted in which 60-70 Dutch hospitals will participate. Eligible patients discharged following hospitalization for acute myocardial infarction or unstable angina pectoris are randomly assigned to receive either (a) adjusted full intensity oral anticoagulation (target range: 3.0-4.0 International Normalised Ratio (INR), (b) low dose aspirin or (c) combined therapy of low dose aspirin and adjusted low intensity oral anticoagulation (target range INR: 2.0-2.5). It is planned to enroll 8,700 patients within three years. During an estimated mean follow-up of 2.5 years the evolutions of total mortality, non-fatal myocardial infarction, non-fatal stroke and major bleeding complication will be assessed.

Diagnostic interpretation of electrocardiograms in population-based research: computer program research physicians, or cardiologists?

We assessed the performance of diagnostic electrocardiogram (ECG) interpretation by the computer program MEANS and by research physicians, compared to cardiologists, in a physician-based study. To establish a strategy for ECG interpretation in health surveys, we also studied the diagnostic capacity of three scenarios: use of the computer program alone (A), computer program and cardiologist (B), and computer program, research physician, and cardiologist (C). A stratified random sample of 381 ECGs was drawn from ECGs collected in the Rotterdam Study (n = 3057), which were interpreted both by a trained research physician using a form for structured clinical evaluation and by MEANS. All ECGs were interpreted independently by two cardiologists; if they disagreed (n = 175) the ECG was judged by a third cardiologist. Five ECG diagnoses were considered: anterior and inferior myocardial infarction (MI), left and right bundle branch block (LBBB and RBBB), and left ventricular hypertrophy (LVH). Overall, sensitivities and specificities of MEANS and the research physicians were high. The sensitivity of MEANS ranged from 73.8% to 92.9% and of the research physician ranged from 71.8% to 96.9%. The specificity of MEANS ranged from 97.5% to 99.8% and of the research physician from 96.3% to 99.6%. To diagnose LVH, LBBB, and RBBB, use of the computer program alone gives satisfactory results. Preferably, all positive findings of anterior and inferior MI by the program should be verified by a cardiologist. We conclude that diagnostic ECG interpretation by computer can be very helpful in population-based research, being at least as good as ECG interpretation by a trained research physician, but much more efficient and therefore less expensive.

Classification of heart failure in population based research: an assessment of six heart failure scores

Several scores based on symptoms and signs have been developed to assess the presence of heart failure. The goal of this study was to compare six heart failure scores in non-hospitalised subjects and to determine their usefulness in population based research. The scores were applied to 54 participants of a population based study. All underwent a complete medical examination, including chest X-ray, electrocardiography and Doppler echocardiography. Using all information available, a cardiologist, unaware of the results of the scores, clinically classified participants as having no, possible or definite heart failure. Sensitivity, specificity, predictive values and receiver operating characteristics were calculated, using the cardiologist's assessment as a gold standard. The cardiologist judged definite or possible heart failure to be present in 17 persons. All scores had a high sensitivity for the detection of definite heart failure, whereas the study of men born in 1913 and Walma's score had the highest sensitivity for the combination of possible and definite heart failure. Gheorgiade's and the Boston score had the highest positive predictive values. In conclusion, five of the six scores we studied are broadly similar in the detection of heart failure. The men born in 1913 score relies heavily on the assessment of dyspnea, resulting in a relatively large number of false positives. Although the scores are useful in detecting manifest heart failure, objective measurements of cardiac function appear necessary to reduce the false positive rate and accurately detect early stages of heart failure.

The additional effects of acipimox to simvastatin in the treatment of combined hyperlipidaemia

OBJECTIVES

Nicotinic acid, an effective drug for treatment of combined hyperlipidaemia, is often not tolerated because of side-effects. Acipimox is a nicotinic acid like lipid lowering drug with less side-effects. We studied whether the addition of acipimox to simvastatin improves the lipid profile in patients with a combined hyperlipidaemia.

DESIGN

Randomized double-blind placebo controlled crossover trial.

SETTING

Outpatient lipid clinic of a tertiary referral centre.

SUBJECTS

Eighteen patients with combined hyperlipidaemia treated with diet and 20-40 mg simvastatin for at least 3 months.

INTERVENTION

Acipimox in a daily dose of 3 x 250 mg for 12 weeks.

MAIN OUTCOME MEASURES

Effects on the concentration of LDLc, TG, HDLc, Lp(a) and Apolipoprotein B, as well as on LDL-size and LDL-resistance to oxidative modification.

RESULTS

Acipimox reduced Lp(a) levels by 8% (P < 0.05). A substantial but not statistically significant change in TG (-32%) and HDLc (+6%) levels was seen. All patients were found to have small dense LDL, with a size of 229 +/- 4 A. LDL size and the resistance to oxidation, reflected in the lag phase during in vitro oxidation, were not affected by the addition of acipimox. In a subgroup of 8 patients with the most severe hypertriglyceridaemia (baseline TG < 4 mmol L- [1]), acipimox induced a significant increase in HDLc (+15%, P < 0.01). The effects on TG (-41%), LDLc (-10%) and lag phase (+17%) were also more pronounced than in the group with a lower baseline TG, but non of these changes reached the level of significance.

CONCLUSIONS

Adding acipimox to simvastatin reduced Lp(a) and substantially but not significantly lowered TG. However, in patients with the highest TG levels, HDLc was also significantly improved.

Limitations of sensitivity, specificity, likelihood ratio, and bayes' theorem in assessing diagnostic probabilities: a clinical example

We evaluated the extent to which the sensitivity, specificity, and likelihood ratio of the exercise test to diagnose coronary artery disease vary across subgroups of a certain patient population. Among 295 patients suspected of coronary artery disease, as independently determined by coronary angiography, we assessed variation in sensitivity and specificity according to patient history, physical examination, exercise test results, and disease severity in 207 patients with and 88 patients without coronary artery disease, respectively. The sensitivity varied substantially according to sex (women 30% and men 64%), systolic blood pressure at baseline (53% to 65%), expected workload (50% to 64%), systolic blood pressure at peak exercise (50% to 67%), relative workload (33% to 68%), and number of diseased vessels (39% to 77%). The specificity varied across subgroups of sex (men 89% and women 97%) and relative workload (85% to 98%). The likelihood ratio varied (3.8 to 17.0) across the same patient subgroups, as did the sensitivity. As each population tends to be heterogeneous with respect to patient characteristics, no single level of these parameters can be given that is adequate for all subgroups. Use of these parameters as a basis for calculating diagnostic probabilities in individual patients using Bayes' theorem has serious limitations.

Modification of physical activity 5 months after myocardial infarction: relevance of biographic and personality characteristics

The relation between modification of physical activity, a risk factor for coronary heart disease, and personality characteristics was assessed in 166 survivors of a first myocardial infarction (MI). Physical activity was assessed before MI in retrospect and again 5 months after MI. Patients were divided into 3 categories according to their current daily-life physical activities: less active than before MI (n=24), equally active as before MI (n=82), or more active than before MI (n=60). A significant differentiation was found between patients who became less physically active than before MI and the other 2 categories. This less active category was characterized by feelings of disability, a low level of vigor, and feelings of anxiety. In addition, this patient group was on average older and more often female. The results were adjusted for participation in a cardiac rehabilitation program. Finally, the discussion recommends involving psychological intervention in the exercise program for the less active category of patients to diminish feelings of anxiety and disability and to improve vigor.

Usefulness of echocardiography in detecting left ventricular dysfunction in population-based studies (The Rotterdam Study)

In a population-based study, the routine 12-lead electrocardiogram was found to have a high negative predictive value for detecting left ventricular (LV) systolic dysfunction. Withholding echocardiography in persons without major electrocardiographic abnormalities, however, would result in a considerable underestimation of LV systolic dysfunction (sensitivity only 54%); thus, echocardiography remains an essential tool for detecting LV systolic dysfunction in population-based studies.

Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour

BACKGROUND

There is conclusive evidence from clinical trials that reduction of mortality by fibrinolytic therapy in acute myocardial infarction is related to the time elapsing between onset of symptoms and commencement of treatment. However, the exact pattern of this relation continues to be debated. This paper discusses whether or not appreciable additional gain can be achieved with very early treatment.

METHODS

The relation between treatment delay and short-term mortality (up to 35 days) was evaluated using tabulated data from all randomised trials of at least 100 patients (n = 22; 50,246 patients) that compared fibrinolytic therapy with placebo or control, reported between 1983 and 1993.

FINDINGS

Benefit of fibrinolytic therapy was 65 (SD 14), 37 (9), 26 (6) and 29 (5) lives saved per 1000 treated patients in the 0-1, 1-2, 2-3, and 3-6 h intervals, respectively. Proportional mortality reduction was significantly higher in patients treated within 2 h compared to those treated later (44% [95% CI 32, 53] vs 20% [15, 25]; p = 0.001). The relation between treatment delay and mortality reduction per 1000 treated patients was expressed significantly better by a non-linear (19.4-0.6x(+)29.3x-1) than a linear (34.7 - 1.6x) regression equation (p = 0.03).

INTERPRETATION

The beneficial effect of fibrinolytic therapy is substantially higher in patients presenting within 2 h after symptom onset compared to those presenting later.

Empirical psychological modeling of chest pain: a comparative study

In this study the psychological profiles of 67 patients with noncardiac chest pain (NCA) and 47 patients with coronary artery disease (CAD) were analyzed to construct an empirical-psychological model that would be able to discriminate these two groups. All patients were suffering from chest pain at the time of referral by their general practitioner. The noncardiac patients were significantly younger, more often female, single, and nonsmokers. The two groups differed significantly on anxiety, somatization, obsessive compulsive behavior, psychoneuroticism, and hyperventilation. Logistic regression analysis on the variables jointly, showed that age, gender, anxiety, and hyperventilation contributed significantly to the model for discriminating between the two groups. Crossvalidation showed that the constructed model was stable.

Long-term follow-up (10 to 17 years) after Mustard repair for transposition of the great arteries

BACKGROUND

The management strategies of patients who underwent Mustard repair for transposition (of the great arteries were changed in the 1970s: infants became eligible for direct surgical repair, so Blalock-Hanlon atrioseptostomy could be avoided, and cold cardioplegia was introduced for myocardial preservation. Data are lacking, however, regarding whether these changes have had positive effects on the long-term outcome. We therefore conducted a follow-up study on all 91 patients who underwent a Mustard repair for transposition of the great arteries in our institution between 1973 and 1980 to assess the incidence and clinical importance of sequelae as well as health-related quality of life for these patients.

METHODS

Patients who were alive and could be traced through local registrar's offices received an invitation to participate in the follow-up study, which consisted of an interview, physical examination, echocardiography, exercise testing, and standard 12-lead and 24-hour electrocardiography.

RESULTS

Patients operated on in the first 4 years had a significantly higher mortality rate and higher incidence of sinus node dysfunction than did patients operated on in the subsequent 4 years (25% vs 2% and 41% vs 3%, respectively). In contrast, the incidence of baffle obstruction necessitating reoperation was significantly higher in the second group. There were no significant differences in echocardiographic findings and exercise capacity between patients operated on in the first 4 years and in the subsequent 4 years. None of the patients had right ventricular failure; a mild degree of baffle leakage or obstruction was seen in 22% of the patients, and the mean exercise capacity was decreased to 84% +/- 16% of normal.

CONCLUSION

The changes introduced between 1973 and 1980 have resulted in a considerable reduction of mortality and incidence of sinus node dysfunction but have also resulted in a more frequent need for reoperation.

Optimal intensity of oral anticoagulant therapy after myocardial infarction

OBJECTIVES

This study attempted to determine the optimal intensity of anticoagulant therapy in patients after myocardial infarction.

BACKGROUND

Treatment with oral anticoagulant therapy entails a delicate balance between over- (risk of bleeding) and under-anticoagulation (risk of thromboemboli). The optimal intensity required to prevent the occurrence of either event (bleeding or thromboembolic) is not known.

METHODS

A method was used to determine the optimal intensity of anticoagulant therapy by calculating incidence rates for either event associated with a specific international normalized ratio. The numerator included events occurring at given international normalized ratios, and the denominator comprised the total observation time.

RESULTS

The study population included 3,404 myocardial infarction patients enrolled in the ASPECT (Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis) trial. Total treatment was 6,918 patient-years. Major bleeding occurred in 57 patients (0.8/100 patient-years), and thromboembolic complications in 397 (5.7/100 patient-years). The incidence of the combined outcome (bleeding or thromboembolic complications) with international normalized ratio <2 was 8.0/100 patient-years (283 events in 3,559 patient-years), with international normalized ratios between 2 and 3, 3.9/100 patient-years (33 events in 838 patient-years); 3.2/100 patient-years (57 events in 1,775 patient-years) for international normalized ratios between 3 and 4; 6.6/100 patient-years (37 events in 564 patient-years) for international normalized ratios between 4 and 5; and 7.7/100 patient-years (14 events in 182 patient-years) for international normalized ratios >5. After adjustment for achieved international normalized ratio levels, significant predictors were higher levels of systolic blood pressure and age.

CONCLUSIONS

If equal weight is given to hemorrhagic and thromboembolic complications, these results suggest that the optimal intensity of long-term anticoagulant therapy for myocardial infarction patients lies between 2.0 and 4.0 international normalized ratio, with a trend to suggest an optimal intensity of 3.0 to 4.0.

Modification of smoking habits five months after myocardial infarction: relationship with personality characteristics

The relationship between personality characteristics and spontaneous modification of smoking habits was assessed in 164 patients after their first myocardial infarction (MI). Smoking habits before the MI were investigated in retrospect and 5 months later. Smoking appeared to have decreased significantly. Persistent smokers could be differentiated from nonsmokers and exsmokers by a significantly high level of state-anxiety and depression. Young persistent smokers had a high level of depression; elderly persistent smokers were highly anxious and had a low level of somatization. The relationship between smoking behaviour modification and personality characteristics is discussed in association with intervention programmes.

Risk of stroke during long-term anticoagulant therapy in patients after myocardial infarction

Myocardial infarction survivors have an increased risk of stroke, which is reduced with long-term anticoagulant therapy. However, an estimated 10-times increase in risk of bleeding during such treatment has been reported. We evaluated the risk of stroke in patients after a myocardial infarction and examined the relationship of the risk of intracranial hemorrhage or cerebral infarction and the intensity of anticoagulant therapy. The study population consisted of 3,404 post-myocardial infarction patients who took part in a randomized, double-blind, placebo-controlled trial. Patients were randomized to treatment with anticoagulants (international normalized ratio range, 2.8-4.8) or matching placebo. Mean follow-up was more than 3 years. The incidence of stroke analyzed on "intention-to-treat" was 0.7 per 100 patient-years in the anticoagulant patients against 1.2 in placebo, a hazard ratio of 0.60, with 95% confidence interval of 0.40 to 0.90. In the anticoagulation group, 15 patients had cerebral infarction and 17 an intracranial bleeding, 3 of which occurred after withdrawal of treatment. In the placebo group, the numbers were 43 and 2. Of the 14 intracranial bleeds during anticoagulation, 6 occurred at an international normalized ratio between 3.0 and 4.0 and 8 at greater than 4.0. These results confirm that long-term anticoagulant therapy substantially reduces the risk of stroke in post-myocardial infarction patients. The increased risk of bleeding complications associated with anticoagulant therapy is offset by a marked reduction in ischemic events. The risk of intracranial bleeding is directly related to the intensity of anticoagulant treatment.

Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction

OBJECTIVE

To improve pre-hospital triage of patients with suspected acute cardiac disease.

DESIGN

Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.

METHODS

The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.

MAIN OUTCOME MEASUREMENTS

Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.

RESULTS

Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.

CONCLUSIONS

Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.

Estimated gain in life expectancy. A simple tool to select optimal reperfusion treatment in individual patients with evolving myocardial infarction

Currently several modes of reperfusion therapy for acute myocardial infarction are available. Streptokinase, accelerated alteplase and direct angioplasty are the most frequently used. These options are increasingly effective, but are also increasingly complex and costly. Since, unfortunately, physicians are often restricted by budget limitations, choices must be made in clinical practice to provide optimal therapy to individual patients. In order to guide such decision making, we developed a model to predict the expected benefit of therapy in terms of gain in life expectancy. Patients' life expectancy will decrease after infarction. Part of this loss can be prevented by early reperfusion therapy. The clinical benefit of therapy ranges from negligible gain in patients with small infarcts treated relatively late to an expected gain of more than 2 years in patients with extensive infarction treated within 3 h of onset of symptoms. The expected benefits are presented in a set of tables and depend on age, previous infarction, estimated infarct size, treatment delay and intracranial bleeding risk. With the help of these table, resources will be allocated in such a manner that patients who will benefit the most will receive the most effective therapy. Patients with similar expected treatment benefit will be offered the same mode of therapy. Future life years were discounted at 5% per year. The arbitrary thresholds currently applied for decision making at the Thoraxcenter are: no reperfusion therapy when the estimated gain in discounted life expectancy was < 1 month, streptokinase for 1-4 months and accelerated alteplase for a gain > or = 5 months. Direct angioplasty is recommended in patients with an estimated gain > or = 12 months, and in patients with an increased risk of intracranial bleeding. In this way, approximately 80% of our patients will be treated with thrombolytics (40% streptokinase and 40% accelerated alteplase), while in 10% direct angioplasty will be initiated. Patients with small infarcts presenting late will not receive reperfusion therapy. These threshold values have been chosen arbitrarily, and different thresholds may be selected in other centres. However, the developed model would guarantee that treatment decisions are made in a consistent manner, to provide optimal therapy for patients with evolving myocardial infarction, in spite of limited resources.

Pre-hospital thrombolytic therapy with either alteplase or streptokinase. Practical applications, complications and long-term results in 529 patients

OBJECTIVE

To assess the practical application, safety and long-term outcome of pre-hospital thrombolytic intervention with either alteplase or streptokinase in patients with extensive myocardial infarction.

DESIGN

Prospective study.

SUBJECTS

Patients with chest pain of more than 30 min duration, presenting within 6 h of symptom onset and with electrocardiographic evidence of extensive evolving myocardial infarction.

METHODS

Eligibility of patients was established by the general practitioner or the ambulance nurse using a standardized questionnaire with (contra-) indications for thrombolytic therapy. Computerized ECG was recorded by ambulance nurses. In the presence of extensive ST segment elevation (sum ST deviation of at least 1.0 mV), eligible patients received either 100 mg alteplase (n = 246) or 50 mg alteplase in the ambulance followed by 0.75 x 10(6) IE streptokinase in hospital (n = 90), or 1.5 x 10(6) IE streptokinase intravenously (n = 193).

MAIN OUTCOME MEASUREMENTS

Death and life-threatening complications (ventricular fibrillation, cardiac arrest) and side effects (hypotension, allergic reactions) during transportation to hospital and in the first 24 h following hospitalization, and survival up to 5 years follow-up.

RESULTS

From 1988-1993, 529 patients received thrombolytic treatment initiated pre-hospital. The time gained by pre-hospital administration of thrombolysis amounted to 50 min. The rate of complications during transportation and during the first 24 h after hospitalization was low. Hospital mortality was 2% and 1-year mortality 3%. Cumulative survival at 5 years was 92%. This was superior to the 84% 5-year survival observed in a matched group of 239 patients with similar baseline characteristics treated with alteplase in hospital.

CONCLUSIONS

Pre-hospital administration of either alteplase or streptokinase is feasible and safe and results in significant time gain. The long-term prognosis is excellent in spite of extensive evolving myocardial infarction upon admission.

Optimal pharmacological stress testing for the diagnosis of coronary artery disease: a probabilistic approach

Previous reports have suggested that dobutamine stress echocardiography compares favourably with other stress agent-imaging modality combinations for the detection of coronary artery disease. However, in daily clinical practice the value of a test is defined on a probability basis. To study the relative diagnostic contribution of clinical and dobutamine stress test variables, Bayesian analysis was performed in 223 patients with suspected coronary artery disease, who underwent coronary angiography and a high-dose dobutamine stress test in conjunction with electrocardiography, echocardiography and Technetium-99m sestamibi SPECT myocardial perfusion scintigraphy. According to the pre-test (clinical) probabilities, patients were divided into low-, intermediate- and high-risk groups; 155 patients were in the intermediate-risk group. After dobutamine stress echocardiography the number of patients in this intermediate-risk group was reduced to 102 (P < 0.0001). This reduction of patients in the intermediate-risk group by echocardiography was better than perfusion scintigraphy (102 vs 126 patients, P < 0.05) or classic markers of ischaemia such as angina and/or ST-segment changes (102 vs 150, P < 0.0001). Moreover, there was a good correlation between the echocardiographic post-test probabilities and the true distribution of coronary artery disease.

Cardiac status and health-related quality of life in the long term after surgical repair of tetralogy of Fallot in infancy and childhood

The long-term results of surgical repair of tetralogy of Fallot were assessed by means of extensive cardiologic examination of 77 nonselected patients 14.7 +/- 2.9 years after surgical repair of tetralogy of Fallot in infancy and childhood. Because of the frequent use of a transannular patch (56%) for the relief of right ventricular outflow tract obstruction, the prevalence of elevated right ventricular systolic pressure was low (8%), but the prevalence of substantial right ventricular dilation with severe pulmonary regurgitation was high (58%). The exercise capacity of patients with a substantially dilated right ventricle proved to be significantly decreased (83% +/- 19% of predicted) when compared with that of patients with a near normal sized right ventricle (96% +/- 13%). Eight out of 10 patients who had needed treatment for symptomatic arrhythmia had supraventricular arrhythmia, which makes supraventricular arrhythmia--in numbers--a more important sequela in the long-term survivors than ventricular arrhythmia. Older age at the time of the operation and longer duration of follow-up were not associated with an increase in prevalence or clinical significance of sequelae.

Measuring quality of life in patients with myocardial infarction or stroke: a feasibility study of four questionnaires in The Netherlands

OBJECTIVE

To test in patients with a history of myocardial infarction or stroke the feasibility of four quality of life measurements--the Nottingham health profile (NHP), the heart patients psychological questionnaire (HPPQ), the sickness impact profile (SIP), and the hospital anxiety and depression scale (HAD).

DESIGN

Subjects were tested and retested after an interval of 14 days: questionnaires were self assessed.

SUBJECTS

Participants were randomly selected from the Rotterdam stroke data bank (stroke patients; n = 16, mean (SD) age 66.0 (11.0) years and from the population based Rotterdam study (myocardial infarction; n = 20, mean (SD) age 72.7 (7.9) years, controls; n = 17, mean (SD) age 72.8 (7.3) years.

MEASUREMENTS AND MAIN RESULTS

Mean (SD) administration times for the NHP, HPPQ, SIP, and HAD were 7.9 (3.5), 10.5 (4.3), 21.0 (9.8), and 5.5 (2.8) minutes respectively. On average, the test-retest reliability was good, with Spearman correlations ranging from 0.31 to 0.95. In spite of the limited size of the study, all instruments were able to show differences between the study groups. For instance, median SIP total scores for myocardial infarction and stroke patients were 12.4 (interquartile range 7.0-19.1) and 11.4 (5.9-15.4) respectively, compared with 7.7 (3.7-11.3) in the control group (p values of 0.04 and 0.14 respectively).

CONCLUSIONS

This study suggests that use of the four instruments tested may be feasible and reliable for assessing aspects of quality of life in patients with a history of a myocardial infarction or stroke.

Efficacy of long-term anticoagulant treatment in subgroups of patients after myocardial infarction

OBJECTIVE

To investigate the efficacy of long term oral anticoagulant treatment in subgroups of patients after myocardial infarction.

DESIGN

Analysis of the effect of anticoagulant treatment in subgroups of hospital survivors of myocardial infarction based upon age, gender, history of hypertension, previous myocardial infarction, smoking habits, diabetes mellitus, Killip class, anterior location of infarction, thrombolytic therapy, and use of beta blockers.

SUBJECTS

Participants of a multicentre, randomised, double blind, placebo controlled trial that assessed the effect of oral anticoagulant treatment on mortality as well as cerebrovascular and cardiovascular morbidity in 3404 hospital survivors of acute myocardial infarction.

MAIN OUTCOME MEASURES

The effect of anticoagulant treatment on recurrent myocardial infarction, cerebrovascular events, and vascular events (the composite endpoint of reinfarction, cerebrovascular event, and vascular death).

RESULTS

Long term anticoagulant treatment was associated with a reduction in mortality of 10% (95% confidence interval -11% to 27%), recurrent myocardial infarction of 53% (41% to 62%), cerebrovascular events of 40% (10% to 60%) and vascular events of 35% (24% to 45%). Treatment effect with respect to recurrent myocardial infarction was comparable among all subgroups of patients. Although treatment effect appeared to be somewhat smaller in females than in males (-11% v -45%), and in patients with diabetes compared to those without (-14% v -42%) with respect to vascular events, none of these differences reached statistical significance. In multivariate analysis, more advanced age, previous myocardial infarction, diabetes mellitus, and heart failure during admission were independently associated with increased incidence of cardiovascular complications.

CONCLUSIONS

The relative benefit of long term anticoagulant therapy in survivors of myocardial infarction is not modified by known prognostic factors for cardiovascular disease.

Progression and regression of the atherosclerotic plaque

In animals in which atherosclerosis was induced experimentally (by a high cholesterol diet) regression of the atherosclerotic lesion was demonstrated after serum cholesterol was reduced by cholesterol- lowering drugs or a low-fat diet. Whether regression of advanced coronary arterly lesions also takes place in humans after a similar intervention remains conjectural. However, several randomized studies, primarily employing lipid-lowering intervention or comprehensive changes in lifestyle, have demonstrated, using serial angiograms, that it is possible to achieve less progression, arrest or even (small) regression of atherosclerotic lesions. The lipid-lowering trials (NHBLI, CLAS, POSCH, FATS, SCOR and STARS) studied 1240 symptomatic patients, mostly men, with moderately elevated cholesterol levels and moderately severe angiographic-proven coronary artery disease. A variety of lipid-lowering drugs, in addition to a diet, were used over an intervention period ranging from 2 to 3 years. In all but one study (NHBLI), the progression of coronary atherosclerosis was less in the treated group, but regression was induced in only a few patients. The overall relative risk of progression of coronary atherosclerosis was 0 x 62 and 2 x 13, respectively. The induced angiographic differences were small and did not produce any significant haemodynamic benefit. The most important result was tht the disease process could be stabilized in the majority of patients. Three comprehensive lifestyle change trials (the Lifestyle Heart study, STARS and the Heidelberg Study) studied 183 patients, who were subjected to stress management, and/or intensive exercise, in addition to a low fat diet, over a period ranging from 1 to 3 years. All three trials demonstrated less progression, and more regression with overall relative risks of 0 x 40 and 2 x 35 respectively, in the intervention groups. Angiographic trials demonstrated that retardation or arrest of coronary atherosclerosis was possible after an intervention, but the ultimate goal, regression of the lesion, was only achieved in a small number of patients. However, the ability to stabilize coronary atherosclerosis is a considerable achievement for those patients with coronary atherosclerosis.

Optimal use of coronary care units: a review

Patients at a low probability of acute cardiac pathology constitute a considerable proportion in many coronary care units (CCUs), such that physicians should consider more effective alternatives than CCU admission "to rule out myocardial infarction." In this article, strategies to increase the efficiency of managing patients with acute chest pain are reviewed. Algorithms aiming to improve the diagnostic accuracy of the general practitioner have been developed but require an electrocardiogram recorded at the home of the patient. Another method of triage encompasses the identification in the emergency room of the hospital of patients at a low probability of acute cardiac pathology by using predictive models that include laboratory assessments. A third strategy includes alternatives to CCUs for patients at a low risk of acute cardiac pathology, such as the creation of a simple observation unit. Finally, some investigators have sought to identify patients with good prognosis for early transfer from the CCU to lower levels of care. It is concluded that a combination of these approaches will be most efficient, and that the most appropriate choice will be determined by local circumstances.

Characteristics and prognosis of non-participants of a multi-centre trial of long-term anticoagulant treatment after myocardial infarction

Participants of a randomised trial may differ from eligible non-participants as a result of selection. We studied the distribution of prognostic factors and survival in eligible patients of a multi-centre trial of long-term oral anticoagulant treatment after myocardial infarction. All hospital survivors of myocardial infarction in one participating clinical centre of a multi-centre, randomised, double-blind, placebo-controlled trial of long-term anticoagulant treatment after myocardial infarction were screened for entry criteria. Subsequently, prognostic factors and survival of participants were compared with eligible but not randomised patients. The 350 participants were younger and were more often of male gender and more often smokers compared with 587 non-participants. Non-participants had more frequently suffered a previous myocardial infarction and were treated more often with diuretics and ACE-inhibitors, suggesting a higher proportion of patients with chronic heart failure in this group. Age, previous myocardial infarction and the use of diuretics at discharge were independent predictors of mortality, consent showed no association. Our findings indicate that participants of a clinical trial have a better prognosis during the first years following myocardial infarction compared to eligible non-participants as a result of a higher prevalence of cardiovascular risk factors associated with mortality in the non-participants.

Costs and effects of long-term oral anticoagulant treatment after myocardial infarction

OBJECTIVE

To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial infarction.

DESIGN

Cost-effectiveness analysis, based on a randomized, double-blind, placebo-controlled trial.

SETTING

Sixty Dutch hospitals.

PATIENTS

A total of 3404 hospital survivors of acute myocardial infarction randomized within a median period of 4 days after discharge to either oral anticoagulant treatment or placebo. The mean follow-up was 37 months.

INTERVENTION

Oral anticoagulant treatment aimed at a target international normalized ratio of 2.8 to 4.8.

MAIN OUTCOME MEASUREMENTS

Costs of hospital stay during readmissions, costs related to major cardiologic interventions, and costs of oral anticoagulant treatment.

RESULTS

The costs of oral anticoagulant treatment were estimated at 394 Dutch guilders (Dfl) per patient-year (Dfl 1 = US $0.58). Placebo patients stayed 18,830 days in the hospital compared with 15,083 days for anticoagulation patients. Average costs per patient of medical care during follow-up were estimated at Dfl 10,784 for placebo patients and Dfl 9878 for anticoagulation patients.

CONCLUSIONS

Costs of long-term anticoagulant treatment are outweighed by the costs of prevented clinical events.

Pre-hospital triage of patients with suspected myocardial infarction. Evaluation of previously developed algorithms and new proposals

OBJECTIVE

To evaluate previously developed algorithms for the improvement of pre-hospital triage of patients with suspected acute cardiac disease.

DESIGN

Prospective study.

SUBJECTS

Patients with symptoms of possible cardiac origin, who were seen by a general practitioner and subsequently referred to hospital in the municipality of Rotterdam.

METHODS

Prior to hospital admission, patients with suspected acute coronary disease recorded their symptoms by standardized questionnaire and a computerized ECG was made. All patients were hospitalized and a final diagnosis was established. Algorithms proposed by other investigators to distinguish patients with, from those without, acute cardiac disease were tested.

MAIN OUTCOME

Identification of patients whose likelihood for acute cardiac pathology was low (stable angina, atypical chest pain, other pathology) or high (myocardial infarction, unstable angina).

RESULTS

A total of 1005 patients were studied. Forty-two percent had myocardial infarction or unstable angina pectoris. Evaluation of previously developed algorithms showed that their diagnostic accuracy was poor in the pre-hospital setting. In a separate multivariate analysis, six characteristics from the clinical history and an electrocardiogram appeared to be independently and significantly associated with acute cardiac pathology. The presence of an abnormal ECG proved to be the most important predictor.

CONCLUSIONS

The hospital-based algorithms were unsuitable as a predictor for pre-hospital acute cardiac pathology. A new practical hospital admission model was developed, based on six clinical predictors, including analysis of an electrocardiogram. Following appropriate validation, this out-of-hospital protocol may lead to better triage decisions by the general practitioner.

Spontaneous coronary artery dissection during pregnancy and post partum

This report describes a 35-year-old 40 week pregnant woman who was hospitalized with a diagnosis of acute anteroseptal myocardial infarction. She sustained another, infero-posterior, infarction 4 days later. Coronary arteriography performed after successful Cesearean section displayed primary dissections of the right as well as both left coronary arteries. Her subsequent clinical course was uneventful with medical therapy. This patient is the first non-surgically treated survivor of peripartal spontaneous coronary artery dissection with a myocardial infarction prior to delivery.

Long-term follow-up after surgical closure of ventricular septal defect in infancy and childhood

OBJECTIVES

The purpose of this study was to assess the health-related quality of life of patients who underwent surgical closure of a ventricular septal defect at a young age between 1968 and 1980.

BACKGROUND

Since the beginning of open heart surgery for congenital cardiac malformations, the surgical techniques have continually improved. As a result, even infants have become eligible for surgical repair. Long-term follow-up data are not available on the health-related quality of life of nonselected patients after surgical repair at a young age. We therefore conducted a follow-up study of 176 infants and children consecutively operated on in one institution between 1968 and 1980.

METHODS

Patients who were alive and could be traced through the offices of local registrars received an invitation to participate in the follow-up study, consisting of an interview, physical examination, echocardiography, exercise testing and standard 12-lead and 24-h electrocardiography.

RESULTS

One hundred nine patients (78% of those eligible for follow-up) participated. The mean interval after operation (+/- SD) was 14.5 +/- 2.6 years. Eighty-four percent of the patients assessed their health as good or very good, and 89% had been free of any medical or surgical intervention since the operation. At physical examination all patients were in good health. Their mean exercise capacity was 100 +/- 17% (range 56% to 141%) of predicted values; 84% of the patients had a normal exercise capacity. Echocardiography demonstrated a small residual ventricular septal defect in seven patients (6%). There were no signs of pulmonary hypertension. No patient had symptomatic arrhythmias.

CONCLUSIONS

Long-term results of surgical closure of ventricular septal defect in infancy and childhood are good. Pulmonary hypertension is absent. Personal health assessment is comparable to that of the normal population, as is exercise capacity, even though many patients have anatomic, hemodynamic or electrophysiologic sequelae.

Acute and long-term outcome of directional coronary atherectomy for stable and unstable angina

The clinical efficacy and safety of directional coronary atherectomy for the treatment of stable and unstable angina were assessed in 82 patients with stable and 68 patients with unstable angina. Therefore, clinical and angiographic follow-up was obtained in a prospectively collected consecutive series of 150 atherectomy procedures. Restenosis was assessed clinically and by quantitative angiography. The overall clinical success rate of atherectomy for patients with unstable and stable angina was 88% and 91%, respectively. No significant differences were found for in-hospital event rates between the unstable and stable angina groups: death (1.5% vs 0%), myocardial infarction (10% vs 6%), and emergency bypass operation (3% vs 2%). These clinical events were related to the occurrence of abrupt occlusions (8.8% in patients with stable and 6.1% in those with unstable angina; p = NS). Clinical follow-up was achieved in 100% of the patients with stable and unstable angina at a mean interval of 923 and 903 days, respectively. Two-year survival rates were 96% and 97% in the populations with unstable and stable angina, respectively. There were no significant differences with respect to bypass surgery and angioplasty, but event-free survival at 2 years was significantly lower in the unstable (54%) than the stable (69%) angina group. Quantitative coronary angiography did not detect any difference in luminal renarrowing during the 6-month angiographic follow-up period. Although directional coronary atherectomy can be performed effectively in patients with unstable and stable angina, the long-term clinical outcome was less favorable in the unstable angina group.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of therapeutic quality control in a long-term anticoagulant trial in post-myocardial infarction patients

Various methods have been described to evaluate efficacy of anticoagulant therapy using the international normalized ratio (INR). We compared the following approaches: (1) total INR's or the most recent measurement; (2) percent time within therapeutic range, with INR changing directly or halfway between visits; and (3) total observation time assuming INR changing linearly. The study population comprised 1700 post myocardial infarction patients. Treatment comprised 3725 patient-years. There were 61,471 INR assessments with target therapeutic level of 2.8-4.8. Acenocoumarol as well as phenprocoumon were employed. Therapeutic achievement in the first months of treatment was low: less than 60% of INR's were in range. Treatment stabilized after 6 months. Patients on acenocoumarol were within range 70% of the time compared to 80% for phenprocoumon. Method 3 is preferred because it incorporates time and is capable of calculating incidence rates at different INR levels. Our findings call for an urgent improvement of standard of anticoagulant control in the first months following commencement of treatment.

[Complications shortly after transluminal angioplasty or following coronary surgery in 183 comparable patients with multi-vessel coronary disease]

OBJECTIVE

Description of the differences in complications within 30 days after percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery (CABG) in patients suffering from multiple vessel coronary disease.

DESIGN

Prospective, randomised.

SETTING

3 hospitals in the Netherlands.

METHOD

Between 1988 and 1992, 183 Dutch patients took part in the European Coronary angioplasty versus bypass revascularisation investigation (CABRI) and were randomly treated with PTCA or CABG. Apart from the clinical result, all complications and cardiac events from time of randomisation until 30 days after the intervention were registered.

RESULTS

The CABG group consisted of 88 patients with a total of 255 vascular obstructions, the PTCA group of 95 patients with 294 vascular lesions. In this short period of observation the clinical results of the two treatments were the same. The death rates were 1.1% and 2.1%, for CABG and PTCA respectively. The proportion of transmural, non-fatal myocardial infarctions was 2.3% in the CABG group versus 3.1% in the PTCA group. The proportion of reinterventions was higher in the PTCA group, 11.4% versus 1.1%.

CONCLUSION

The differences in death rate and myocardial infarctions are not significant, in contrast to the difference in the numbers of reinterventions. These results appear to be in accordance with those of other randomised studies. Although long-term evaluation is needed, treatment of multiple vessel coronary disease by means of PTCA seems a reasonable alternative to coronary surgery.

Evolution of coronary stenoses is related to baseline severity--a prospective quantitative angiographic analysis in patients with moderate coronary disease. INTACT Investigators. International Nifedipine Trial on Antiatherosclerotic Therapy

A correlation of the angiographic evolution of coronary stenoses (stenosis diameter > or = 20%) with morphological stenosis parameters at baseline could help to identify the risk of progressive stenoses. Therefore, the data of the prospective INTACT study (International Nifedipine Trial on Antiatherosclerotic Therapy) were reviewed. In 348 patients with moderate coronary artery disease, standardized coronary angiograms were taken 3 years apart and were quantitatively analysed. Changes in the minimal diameter of the 1063 preexisting coronary stenoses compared between both angiograms were set in relation to a number of conventional stenosis parameters at baseline. Regression analysis demonstrated a significant correlation of the changes in minimal diameter with baseline % diameter stenosis (r = 0.30; P < 0.001), minimal diameter (r = -0.28; P < 0.001) and reference diameter of stenoses (r = -0.14; P < 0.001). The changes were not correlated with stenosis length and plaque area. The baseline parameters of 22 preexisting stenoses progressing to occlusions differed from those remaining patent only with regard to the % diameter stenosis (43 +/- 9% vs 39 +/- 11%; P < 0.05). Additional progression of coronary disease became manifest through development of 228 stenoses and 19 occlusions at arterial sites free from definitive stenoses in the baseline angiograms. Thus, progression of atherosclerosis predominantly occurred in mild preexisting coronary stenoses and developed at previously angiographically normal sites. Since the conventional angiographic parameters analysed in this study failed to identify individual arterial sites with an increased risk for progression, definition of new angiographic parameters or application of new techniques seem mandatory to this end.

The causes of dilated cardiomyopathy: a clinicopathologic review of 673 consecutive patients

OBJECTIVES

The purpose of this study was to document the various causes of dilated cardiomyopathy in a large group of adult patients with congestive heart failure.

BACKGROUND

Previous reports of the causes of dilated cardiomyopathy have usually been case reports of a single specific etiology or review articles. The frequency of any single specific heart muscle disease is largely unknown.

METHODS

We evaluated 673 patients referred for congestive heart failure due to dilated cardiomyopathy. The evaluation included medical history, physical examination, routine blood chemistry and hematologic measurements, electrocardiography and echocardiography. Thyroid function tests, antinuclear antibody tests and urinary vanillylmandelic acid and metanephrine levels were also obtained. Endomyocardial biopsy with right heart catheterization was performed in every patient. Coronary arteriography was performed in patients who had at least two standard cardiovascular risk factors or a history suggestive of myocardial ischemia. The cases were retrospectively reviewed, and a final cause for dilated cardiomyopathy was listed for each patient.

RESULTS

The most common causes of dilated cardiomyopathy were idiopathic origin (47%), idiopathic myocarditis (12%) and coronary artery disease (11%). The other identifiable causes of dilated cardiomyopathy made up 31% of the total cases.

CONCLUSIONS

Idiopathic dilated cardiomyopathy is a common cause of congestive heart failure. Specific heart muscle diseases occur with much less frequency.