1
|
Svorkdal N. Treatment of Inoperable Coronary Disease and Refractory Angina: Spinal Stimulators, Epidurals, Gene Therapy, Transmyocardial Laser, and Counterpulsation. Semin Cardiothorac Vasc Anesth 2016; 8:43-58. [PMID: 15372127 DOI: 10.1177/108925320400800109] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intractable angina from refractory coronary disease is a severe form of myocardial ischemia for which revascularization provides no prognostic benefit. Inoperable coronary disease is also accompanied by a “vicious cycle” of myocardial dystrophy from a chronic alteration of the cardiac sympathetic tone and sensitization of damaged cardiac tissues. Several adjunctive treatments have demonstrated efficacy when revascularization is either unsuccessful or contraindicated. Spinal cord stimulation modifies the neurologic input and output of the heart by delivering a very low dose of electrical current to the dorsal columns of the high thoracic spinal cord. Neural fibers then release CGRP and other endogenous peptides to the coronary circulation reducing myocardial oxygen demand and enhancing vasodilation of collaterals to improve the myocardial blood flow of the most diseased regions of the heart. Randomized study has shown the survival data at five years is comparable to bypass for high-risk patients. Transmyocardial laser revascularization creates small channels into ischemic myocardium in an effort to enhance flow though studies have shown no improvement in prognosis over medical therapy alone. Enhanced external counterpulsation uses noninvasive pneumatic compression of the legs to improve diastolic filling of the coronary vessels and promote development of collateral flow. The compressor regimen requires thirty-five hours of therapy over a seven-week treatment period. Therapeutic angiogenesis requires injection of cytokines to promote neovascularization and improve myocardial perfusion into the regions affected by chronic ischemia. Phase 3 trials are pending. High thoracic epidural blockade produces a rapid and potent sympatholysis, coronary vasodilation and reduced myocardial oxygen demand in refractory coronary disease. This technique can be used as an adjunct to bypass surgery or medical therapy in chronic or acute unstable angina. Epidurals are easy to perform and often available for outpatient or inpatient use. The rapid anti-ischemic effect may complement therapeutic angiogenesis or other interventions with delayed onset to clinical benefit. A new era for interventional and implant cardiology is beginning to emerge as more clinicians, including cardiologists, gradually learn new procedures to safely provide more therapeutic options for patients suffering refractory angina.
Collapse
Affiliation(s)
- Nelson Svorkdal
- Department of Anesthesia, Health Sciences Center, Winnipeg, Manitoba, Canada.
| |
Collapse
|
2
|
Abd El-Aziz TA, Hussein YM, Elsebaie MH, Mohammad HA, Mohamed RH. A New Metabolic Mechanism for Absence of Pain in Patients with Silent Myocardial Ischemia. Arch Med Res 2015; 46:127-32. [DOI: 10.1016/j.arcmed.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 01/08/2015] [Indexed: 11/16/2022]
|
3
|
Stress-induced hyperviscosity in the pathophysiology of takotsubo cardiomyopathy. Am J Cardiol 2013; 111:1523-9. [PMID: 23465096 DOI: 10.1016/j.amjcard.2013.01.304] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/21/2013] [Accepted: 01/21/2013] [Indexed: 01/14/2023]
Abstract
Takotsubo cardiomyopathy (TC) is characterized by transient hypokinesis of the left ventricular apex or midventricular segments with coronary arteries without significant stenosis. It is often associated with emotional or physical stress; however, its pathophysiology is still unclear. In the present study, we analyzed the alterations in blood viscosity and markers of endothelial damage induced by sympathetic stimulation in patients with previous TC. Seventeen women (mean age 71 years) with previous TC, included and investigated in the TC Tuscany Registry, were compared to a control group of 8 age- and risk factor-matched women with chest pain and coronary arteries free of stenosis. All subjects underwent the cold pressor test (CPT). Before and after the CPT, the hemorheologic parameters (whole blood viscosity at 0.512 s(-1) and 94.5 s(-1), plasma viscosity, erythrocyte deformability index, and erythrocyte aggregation), catecholamines, plasminogen activator inhibitor-1 (PAI-1), and von Willebrand factor levels were assessed. The patients with TC had significantly greater baseline PAI-1 levels (p <0.01) and lower erythrocyte deformability index values (p <0.01). After CPT, both the patients with TC and the controls had a significant increase in several hemorheologic parameters, catecholamines, and von Willebrand factor levels and a decrease in erythrocyte deformability index. However, the PAI-1 levels were significantly increased only in the patients with TC. Compared to the controls, the patients with TC had significantly greater values of whole blood viscosity at 94.5 s(-1) (p <0.05), PAI-1 (p <0.01), von Willebrand factor (p <0.05) and lower erythrocyte deformability index values (p <0.01) after CPT. In conclusion, the results of the present study suggest that in patients with TC, the alterations in erythrocyte membranes and endothelial integrity induced by catecholaminergic storm could determine microvascular hypoperfusion, possibly favoring the occurrence of left ventricular ballooning.
Collapse
|
4
|
Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain 2012; 25:143-50. [PMID: 22787543 PMCID: PMC3389317 DOI: 10.3344/kjp.2012.25.3.143] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/08/2012] [Indexed: 11/30/2022] Open
Abstract
Spinal cord stimulation has become a widely used and efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. This technique is likely to possess a savings in costs compared with alternative therapy strategies despite its high initial cost. Spinal cord stimulation continues to be a valuable tool in the treatment of chronic disabling pain.
Collapse
Affiliation(s)
- Young Hoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Korea
| |
Collapse
|
5
|
Barletta G, Del Pace S, Boddi M, Del Bene R, Salvadori C, Bellandi B, Coppo M, Saletti E, Gensini GF. Abnormal coronary reserve and left ventricular wall motion during cold pressor test in patients with previous left ventricular ballooning syndrome. Eur Heart J 2011; 30:3007-14. [PMID: 19700469 DOI: 10.1093/eurheartj/ehp325] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
AIMS To investigate whether and how cold pressor test (CPT) could affect myocardial perfusion and left ventricular (LV) function in patients with previous LV ballooning syndrome (LVBS). METHODS AND RESULTS Cold pressor test (3 min hand immersion in ice-water) was performed in 17 women with previous LVBS and in 7 age- and risk factor-matched women with chest pain and normal coronary arteries. At baseline and peak CPT, global and regional LV function, and myocardial perfusion were quantitatively assessed by real-time three-dimensional echocardiography (RT3DE) and myocardial contrast (SonoVue, Bracco) 2D echocardiography (MCE), respectively (Philips iE33 machine, X3-1 and S5-1 probes). Data were analysed off-line (QLab 6.0 software). Peripheral venous catecholamines were assayed by high performance liquid chromatography with electrochemical detection. Cold pressor test induced similar haemodynamic changes and catecholamine increase in controls and LVBS patients. Left ventricular ejection fraction decreased and transient new mid-ventricular and apical motion abnormalities developed in LVBS patients only (quantitative RT3D analysis), without corresponding perfusion defects (MCE). At peak CPT, coronary blood flow and velocity increased (quantitative MCE analysis) in control subjects only. CONCLUSION Cold pressor test induced LV wall motion abnormalities unmatched to regional coronary flow reduction in LVBS patients only. The reduced coronary reserve in response to CPT suggests microvascular dysfunction in LVBS patients.
Collapse
Affiliation(s)
- Giuseppe Barletta
- Non Invasive Cardiology, Department of Heart and Vessels, AOU Careggi, Florence 50134, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Insertion/insertion genotype of α2B-adrenergic receptor gene polymorphism is associated with silent myocardial ischemia in patients with type 2 diabetes mellitus. Clin Biochem 2010; 43:1201-4. [DOI: 10.1016/j.clinbiochem.2010.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 07/21/2010] [Accepted: 07/22/2010] [Indexed: 11/22/2022]
|
7
|
Foletti A, Durrer A, Buchser E. Neurostimulation technology for the treatment of chronic pain: a focus on spinal cord stimulation. Expert Rev Med Devices 2007; 4:201-14. [PMID: 17359225 DOI: 10.1586/17434440.4.2.201] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past 40 years we have seen how electrical stimulation for the relief of pain has progressed from an experimental treatment based upon a clinical theory to being on the threshold of becoming a standard of medical practice. While tens of thousands of devices are implanted every year, the mechanism of action still evades complete understanding. Nevertheless, technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable. Unlike most conventional treatments, neurostimulation cannot be restricted to one speciality as its clinical applications ignore the boundaries of medical specialities. Conditions such as neuropathic pain in the back and the leg, complex regional pain syndrome, ischemic pain due to peripheral vascular disease and coronary artery disease are likely to respond to spinal cord stimulation. Even though the evidence for efficacy remains unsatisfactory, the stimulation of the dorsal column has been remarkably successful in relieving pain and improving function in patients who have failed conventional management. The development, the technicalities and the most important clinical applications of spinal cord stimulation are reviewed here.
Collapse
Affiliation(s)
- Antonio Foletti
- University Hospital, Anesthesia and Pain Department, CHUV, 1000 Lausanne, Switzerland.
| | | | | |
Collapse
|
8
|
Buchser E, Durrer A, Albrecht E. Spinal cord stimulation for the management of refractory angina pectoris. J Pain Symptom Manage 2006; 31:S36-42. [PMID: 16647595 DOI: 10.1016/j.jpainsymman.2005.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2005] [Indexed: 12/21/2022]
Abstract
Despite sophisticated medical and surgical procedures, including percutaneous endovascular methods, a large number of patients suffer from chronic refractory angina pectoris. Improvement of pain relief in this category of patients requires the use of adjuvant therapies, of which spinal cord stimulation (SCS) seems to be the most promising. Controlled studies suggest that in patients with chronic refractory angina, SCS provides symptomatic relief that is equivalent to that provided by surgical or endovascular reperfusion procedures, but with a lower rate of complications and rehospitalization. Similarly, SCS proved cost effective compared to medical as well as surgical or endovascular approaches in a comparable group of patients. This technique is still met with reluctance by the medical community. Reasons for this disinclination may be related to incomplete understanding of the mechanism of action of SCS and the fact that SCS refers to the modulation of neuroendocrine parameters rather than to revascularization, which is currently the dominant treatment paradigm in coronary artery disease.
Collapse
Affiliation(s)
- Eric Buchser
- Anesthesia and Pain Management Services, Center for Neuromodulation EHC, Hospital of Morges, Morges, Switzerland.
| | | | | |
Collapse
|
9
|
Coppo M, Boddi M, Poggesi L, Bandinelli M, Abbate R, Gensini GF. Exaggerated local hand sympathetic but not renin-angiotensin system activation in patients with primary Raynaud's phenomenon. Microvasc Res 2006; 71:128-34. [PMID: 16476452 DOI: 10.1016/j.mvr.2005.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 12/12/2005] [Accepted: 12/19/2005] [Indexed: 10/25/2022]
Abstract
In Raynaud's disease (RD), an overactivity of sympathetic nervous system (SNS) was hypothesized but only indirect proofs were obtained. Complex interactions between the renin-angiotensin system (RAS) and SNS were reported without clear demonstrations of a RAS involvement. Recently, the use of ACE inhibitors and AT1 receptor antagonists in RD patients showed mixed results. The study of total and regional kinetics of tritiated noradrenaline (NA) and the measurements of local Angiotensin (Ang) I and II arterial-venous gradient were performed in 10 RD patients and 10 controls both in rest conditions and following a cold pressor test (CPT). Hand blood flow (HBF) was measured by strain-gauge plethysmography. Baseline HBF was slightly lower in patients than in controls, but during CPT, it significantly decreased only in RD patients (P < 0.01). Total (3H)-NA clearance and spillover were similar in the two groups throughout the study. On the contrary, baseline hand NA spillover was higher in RD patients than in controls and the difference further increased during CPT. Hand NA spillover was linearly related to HBF (P < 0.001). Arterial-venous Ang I and Ang II gradients were positive without difference between controls and patients throughout the study. In conclusion in RD patients, a pathological waste of NA from sympathetic nervous endings of the hand region, exaggerated by sympathetic stimulation, occurs but an enhanced local Ang II formation was not demonstrable.
Collapse
Affiliation(s)
- Mirella Coppo
- Cardiology 1, Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy.
| | | | | | | | | | | |
Collapse
|
10
|
Eisenhofer G. Sympathetic nerve function--assessment by radioisotope dilution analysis. Clin Auton Res 2005; 15:264-83. [PMID: 16032382 DOI: 10.1007/s10286-005-0292-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 04/28/2005] [Indexed: 12/26/2022]
Abstract
Radioisotope dilution measurements of norepinephrine spillover (rate of entry of the transmitter into plasma) provide more accurate assessments of sympathoneural transmitter release than allowed by measurements of plasma catecholamine concentrations alone. Measurements of total body norepinephrine spillover, as an index of global sympathetic outflow, allow effects on plasma clearance to be distinguished from effects on release of catecholamines into plasma, while spillovers from specific tissues enable examination of regionalized sympathetic responses. However, spillovers of norepinephrine represent only a fraction of the transmitter that escapes neuronal and extraneuronal uptake after release by nerves. Numerous factors may influence this fraction and measures spillovers independently of transmitter release by nerves. Modified radioisotope dilution methods for assessment of rate processes operating within and between intracellular and extracellular compartments have further improved our understanding of the relationships of norepinephrine release, uptake, spillover, turnover, and metabolism. This article reviews the breadth of information about sympathetic nerve function attainable using catecholamine radioisotope dilution analyses against a backdrop of the relative advantages and methodological limitations associated with the methodology.
Collapse
Affiliation(s)
- Graeme Eisenhofer
- Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA.
| |
Collapse
|
11
|
Svorkdal N. Pro: anesthesiologists' role in treating refractory angina: spinal cord stimulators, thoracic epidurals, therapeutic angiogenesis, and other emerging options. J Cardiothorac Vasc Anesth 2003; 17:536-45. [PMID: 12968247 DOI: 10.1016/s1053-0770(03)00182-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Nelson Svorkdal
- Department of Anesthesia, Health Sciences Center, Winnipeg, Manitoba, Canada
| |
Collapse
|
12
|
Wenzel RR, Bruck H, Noll G, Schäfers RF, Daul AE, Philipp T. Antihypertensive drugs and the sympathetic nervous system. J Cardiovasc Pharmacol 2001; 35:S43-52. [PMID: 11346218 DOI: 10.1097/00005344-200000004-00006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The sympathetic nervous system (SNS) plays an important role in the regulation of blood pressure homeostasis and cardiac function. Furthermore, the increased SNS activity is a predictor of mortality in patients with hypertension, coronary artery disease and congestive heart failure. Experimental data and a few clinical trials suggest that there are important interactions between the main pressor systems, i.e. the SNS, the renin-angiotensin system and the vascular endothelium with the strongest vasoconstrictor, endothelin. The main methods for the assessment of SNS activity are described. Cardiovascular drugs of different classes interfere differently with the SNS and the other pressor systems. Pure vasodilators including nitrates, alpha-blockers and dihydropyridine (DHP)-calcium channel blockers increase SNS activity. Finally, central sympatholytics and possibly phenylalkylamine-type calcium channel blockers reduce SNS activity. The effects of angiotensin-II receptor antagonists on SNS activity in humans is not clear; experimental data are discussed in this review. There are important interactions between the pressor systems under experimental conditions. Recent studies in humans suggest that an activation of the SNS with pure vasodilators in parallel increases plasma endothelin. It can be assumed that, in cardiovascular diseases with already enhanced SNS activity, drugs which do not increase SNS activity or even lower it are preferable. Whether this reflects in lower mortality needs to be investigated in intervention trials.
Collapse
Affiliation(s)
- R R Wenzel
- Department of Internal Medicine, University Hospital, Essen, Germany
| | | | | | | | | | | |
Collapse
|
13
|
Fernieini EM, Bennett JD, Silverman DG, Halaszynski TM. Hemodynamic assessment of local anesthetic administration by laser Doppler flowmetry. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2001; 91:526-30. [PMID: 11346729 DOI: 10.1067/moe.2001.114382] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The hemodynamic effects of local anesthetic administration with and without a vasoconstrictor were compared by using laser Doppler flowmetry. STUDY DESIGN Seventeen people participated in a single study session in which they were given 2 intraoral injections. The injections, which were administered in random order, consisted of 1.8 mL lidocaine (2%) with epinephrine (1:100,000) and mepivacaine (3%). Hemodynamic parameters consisting of blood pressure, heart rate, and laser Doppler flowmetry were reordered at regular intervals. RESULTS The laser Doppler flowmeter detected changes in the peripheral perfusion of the finger that were not detected by changes in blood pressure and heart rate. The greatest change was associated with anxiety and occurred just before the injection. The inclusion of epinephrine in the local anesthetic resulted in a persistence of these changes. CONCLUSION This investigation has confirmed the sensitivity of laser Doppler flowmetry as an investigational tool for assessing hemodynamic changes associated with anxiety and the administration of local anesthesia.
Collapse
Affiliation(s)
- E M Fernieini
- School of Dental Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06030, USA
| | | | | | | |
Collapse
|
14
|
Fedele F, Agati L, Pugliese M, Cervellini P, Benedetti G, Magni G, Vitarelli A. Role of the central endogenous opiate system in patients with syndrome X. Am Heart J 1998; 136:1003-9. [PMID: 9842013 DOI: 10.1016/s0002-8703(98)70156-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate the role of the endogenous opioid system (EOS) in abnormal pain perception in patients with syndrome X, we used a neuroendocrine approach, evaluating plasmatic luteinizing hormone (LH) changes after naloxone, a competitive antagonist of opioid receptors able to unblock tonic EOS inhibition on gonadotropin release. Thus LH response to naloxone test indicates the central EOS activity on hypothalamic luteinizing hormone-releasing hormone (LH-RH) inhibitory opioid receptors. METHODS Ten patients with syndrome X, 10 age-matched male patients with coronary artery disease (CAD), and 10 normal subjects were analyzed. Naloxone tests were performed between 8 and 9 am. Basal beta-endorphin and LH levels were determined on 4 blood samples at 20-minute intervals; after naloxone (0.1 mg/kg intravenously in 4 minutes), LH was measured on 8 samples at 15-minute intervals. In all patients the test was also performed after LH-RH administration. Anginal pain on exercise testing was subjectively scored on a 1 to 10 analogic scale and wall motion abnormalities were quantified by a wall motion score index. RESULTS Significant differences were found in LH release after naloxone (CAD 260.3 +/- 42.6 vs syndrome X 151.6 +/- 48.5 mIU/mL, P <.05), angina score (CAD 5.5 +/- 1.3 vs syndrome X 7.2 +/- 1.7, P <.05), and wall motion abnormalities (CAD 3.6 +/- 1. 2 vs syndrome X 2.8 +/- 1.9, P <.05). CONCLUSIONS The reduced LH release after naloxone in syndrome X, with a normal LH-RH response, suggests a lower central EOS activity, which may be related to the higher anginal pain perception.
Collapse
Affiliation(s)
- F Fedele
- I Cattedra di Cardiologia, Dipartimento di Scienze Cardiovascolari e Respiratorie, Università "La Sapienza di Roma" Rome, Italy
| | | | | | | | | | | | | |
Collapse
|
15
|
Langer A, Krucoff MW, Klootwijk P, Simoons ML, Granger CB, Barr A, Califf RM, Armstrong PW. Prognostic significance of ST segment shift early after resolution of ST elevation in patients with myocardial infarction treated with thrombolytic therapy: the GUSTO-I ST Segment Monitoring Substudy. J Am Coll Cardiol 1998; 31:783-9. [PMID: 9525547 DOI: 10.1016/s0735-1097(97)00544-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We sought to study the relation between recurrent ST segment shift within 6 to 24 h of initial resolution of ST elevation after thrombolytic therapy and 30-day and 1-year mortality. BACKGROUND Rapid and stable resolution of ST segment elevation in relation to thrombolytic therapy in patients with an acute myocardial infarction is an indicator of culprit artery patency. Whether recurrence of ST segment shift during continuous ST monitoring after initial resolution is related to poor prognosis has not been studied. METHODS ST segment monitoring was performed within 30 min after thrombolytic therapy for acute myocardial infarction. The predictive value of a new ST segment shift (assessed as > or = 0.1-mV deviation from the baseline) 6 to 24 h after thrombolytic therapy was studied with respect to 30-day and 1-year mortality. RESULTS Of 734 patients, 243 had a new ST segment shift (33%). The 30-day mortality rate in patients with an ST shift (7.8%) was significantly higher than that in patients without an ST shift (2.25%, p = 0.001), as was the 1-year mortality rate (10.3% vs. 5.7%, respectively, p = 0.025). Multivariable analysis revealed an independent predictive value of ST shift with respect to 30-day mortality (p = 0.008), even after consideration of multiple clinical risk factors in the overall Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries (GUSTO)-I mortality model (p = 0.0001). Moreover, the duration of the ST shift bore a direct relation with 1-year mortality (p = 0.008). CONCLUSIONS Detection of ST segment shift early after thrombolytic therapy for acute myocardial infarction is a simple, noninvasive means of identifying patients at high risk and is superior to other commonly assessed clinical risk factors. Thus, patients with a new ST shift after the first 6 h, but within 24 h, represent a high risk group that may benefit from more aggressive intervention, whereas patients without evidence of an ST shift represent a low risk subgroup.
Collapse
Affiliation(s)
- A Langer
- Division of Cardiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Kleinman B. Con: thoracic epidural anesthesia is not indicated in the treatment of unstable angina. J Cardiothorac Vasc Anesth 1997; 11:109-11. [PMID: 9058233 DOI: 10.1016/s1053-0770(97)90265-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- B Kleinman
- Department of Anesthesiology, Loyola University Siritch School of Medicine, Edward Hines Jr. Veterans Administration Hospital, Maywood, IL, USA
| |
Collapse
|
17
|
Richardt G, Münch G, Neumann FJ, Rauch B, Kurz T. Systemic and cardiac catecholamines during elective PTCA and during immediate PTCA for acute myocardial infarction. Basic Res Cardiol 1997; 92:52-60. [PMID: 9062652 DOI: 10.1007/bf00803757] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study investigated arterial and coronary venous catecholamine concentrations in patients undergoing either elective coronary angioplasty (PTCA) or direct PTCA for acute myocardial infarction. We included 17 patients with stenoses of the left anterior descending coronary artery (LAD) and 10 patients with acute anterior myocardial infarction (AMI) undergoing PTCA. During the initial balloon dilatation arterial and coronary venous plasma concentrations of norepinephrine and epinephrine were determined. In elective PTCA, coronary occlusion (2 min) resulted in a transient increase of arterial concentrations of norepinephrine (2.04 +/- 0.30 vs. 1.26 +/- 0.13 nmol/L before dilatation) and epinephrine (0.52 +/- 0.08 vs. 0.34 +/- 0.04 nmol/L) in the first minute of reperfusion, whereas coronary venous concentrations of catecholamines were not changed after dilatation. Among the 10 patients with AMI, immediate reperfusion of the LAD (TIMI grade 3) was achieved in 6 patients. In these patients, baseline arterial concentrations for norepinephrine (3.91 +/- 1.16 nmol/L) and epinephrine (4.68 +/- 2.07 nmol/L) were elevated and no transcardiac gradient for catecholamines was found. In the first minute after successful reopening of the LAD we detected a distinct rise of the transcardiac norepinephrine gradient from -0.10 +/- 0.53 to 85.02 +/- 24.64 nmol/L, which declined in the fifth minute of reperfusion of 4.36 +/- 2.30 nmol/L. Conversely, venous epinephrine and arterial concentrations for both catecholamines remained unchanged within the observation period. In the four patients with incomplete (TIMI 0-2) reopening of the LAD, we found no cardiac washout of norepinephrine. In summary, a transient rise of systemic catecholamines, but no cardiac release of norepinephrine was observed in patients after brief coronary occlusion. Conversely, a massive washout of norepinephrine from the infarcted myocardium occurred during AMI.
Collapse
Affiliation(s)
- G Richardt
- Medizinische Klinik II, Medizinische Universität zu Lübeck, Germany
| | | | | | | | | |
Collapse
|
18
|
The effects of antihypertensive drugs on the autonomic nervous system in elderly hypertensive patients with silent myocardial ischemia. Arch Gerontol Geriatr 1996; 22 Suppl 1:119-24. [DOI: 10.1016/0167-4943(96)86923-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
19
|
Opie LH. Calcium channel antagonists in the management of anginal syndromes: changing concepts in relation to the role of coronary vasospasm. Prog Cardiovasc Dis 1996; 38:291-314. [PMID: 8552788 DOI: 10.1016/s0033-0620(96)80015-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite the increasing evidence that alterations in coronary vascular tone can and do occur in patients with anginal syndromes, only in a minority of such patients with Prinzmetal's angina is there decisive evidence that the coronary vasodilation induced by calcium channel antagonists (CCAs) plays a specific therapeutic role. CCAs may also give therapeutic benefit in a number of conditions in which coronary vasoconstriction may contribute to ischemia, such as hyperventilation, cold-induced angina, or silent ischemia not caused by an increase in heart rate. Thus, the decision of whether or not to use CCAs in angina syndromes will often have to be made on grounds other than what appears to be a minor role of vasospasm in the overall spectrum of angina. There are preliminary indications that the long-term prognosis may be different among different categories of CCAs.
Collapse
Affiliation(s)
- L H Opie
- Heart Research Unit, University of Cape Town Medical School, South Africa
| |
Collapse
|
20
|
Piccirillo G, Fimognari FL, Santagada E, Munizzi MR, Viola E, Monteforte G, Bucca C, Durante M, Di Gioacchino C, Tarantini S, Lo Verde A, Cacciafesta M, Marigliano V. Power spectral analysis of heart rate in elderly hypertensive subjects with or without silent coronary disease. Angiology 1996; 47:15-22. [PMID: 8546341 DOI: 10.1177/000331979604700103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Much evidence indicates an involvement of the sympathetic nervous system in the genesis of silent myocardial ischemia. The authors assessed autonomic system activity by power spectrum analysis of heart rate variability in 21 elderly hypertensive men with and without angiographically confirmed coronary artery disease and compared the results with those from an age-matched control group. In the analysis an autoregressive algorithm was used to determine the power spectrum from an electrocardiographic recording of 512 consecutive RR intervals. The autonomic nervous system induces two distinct sinusoids: a low-frequency signal attributable to sympathetic activity and a high-frequency vagal response. In the hypertensive patients with coronary disease the authors also evaluated sympathetic activation after double-blind, placebo-controlled administration of metoprolol (100 mg/day), followed by amlodipine (10 mg/day), quinapril (20 mg/day), and amlodipine (5 mg/day) plus quinapril (10 mg/day).
Collapse
Affiliation(s)
- G Piccirillo
- Institute of Geriatrics, University of Rome La Sapienza, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Baroldi G. Morphological and functional significance of findings in unstable atherothrombotic plaque underlying acute coronary syndromes: a review. Int J Cardiol 1995; 49 Suppl:S3-9. [PMID: 7591315 DOI: 10.1016/0167-5273(95)02332-q] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- G Baroldi
- Institute of Biomedical Sciences, Medical School, University of Milan, Italy
| |
Collapse
|
22
|
Davies MK. Effects of ACE inhibitors on coronary haemodynamics and angina pectoris. BRITISH HEART JOURNAL 1994; 72:S52-6. [PMID: 7946804 PMCID: PMC1025593 DOI: 10.1136/hrt.72.3_suppl.s52] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M K Davies
- Department of Cardiology, Selly Oak Hospital, Birmingham
| |
Collapse
|
23
|
Silverman DG, Jotkowitz AB, Freemer M, Gutter V, O'Connor TZ, Braverman IM. Peripheral assessment of phenylephrine-induced vasoconstriction by laser Doppler flowmetry and its potential relevance to homeostatic mechanisms. Circulation 1994; 90:23-6. [PMID: 8026002 DOI: 10.1161/01.cir.90.1.23] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cutaneous laser Doppler flowmetry enables monitoring of changes in skin perfusion by quantifying the phase shift of laser light induced by moving red blood cells under a fiberoptic probe. It thus can identify the presence of and response to a vasoconstrictive stimulus. However, aspects of the technique must be defined before it can be used with maximum effectiveness. We evaluated the responses of two different laser Doppler outputs, the concentration of moving blood cells (CMBC) and red cell flux (CMBC times cell velocity), and the responses at two sites of probe application, the finger and forearm, during systemic infusions of phenylephrine. METHODS AND RESULTS Eight healthy volunteers were monitored with a brachial blood pressure cuff, ECG, and laser Doppler flowmeter probes applied to the palmar surface of the fourth finger and volar forearm of the arm opposite the pressure cuff. After baseline readings were obtained, the subjects received three 10-minute intravenous infusions of phenylephrine at rates of 0.4, 0.8, and 1.6 micrograms.kg-1.min-1. The two parameters, flux and CMBC, trended similarly. Flux and CMBC at the finger declined significantly in response to each infusion (P < .05 using repeated-measures ANOVA with Duncan's multiple range test). In contrast, flux and CMBC of the forearm had highly variable responses, with an overall increase during each infusion (P < .05 for % delta of forearm versus % delta of finger readings during the 0.4 microgram.kg-1.min-1 infusion). Heart rate declined significantly during each infusion, consistent with a baroreceptor-mediated response, even though systolic and diastolic blood pressures each increased by less than 2 mm Hg during the 0.4 microgram.kg-1.min-1 infusion. CONCLUSIONS As expected, laser Doppler readings at the finger decreased during infusion of an alpha 1-agonist. Although, like the digital vessels, forearm vessels have the potential to constrict, the increases in forearm readings suggest that these vessels are highly susceptible to homeostatic responses. The increase in CMBC (a parameter that is sensitive primarily to local changes in vascular caliber) suggested vasodilation of the underlying vessels. The forearm vasodilation and the concomitant decline in heart rate most likely represented vagally mediated baroreceptor activity, which was altered even though blood pressure changed minimally during the 0.4 microgram.kg-1.min-1 infusion. Thus, integrated assessment of skin perfusion at the finger and forearm may provide valuable information about the direct and indirect effects of a vasoactive stimulus. The present application of laser Doppler flowmetry suggests activation of vasodilatory reflexes despite minimal changes in blood pressure.
Collapse
Affiliation(s)
- D G Silverman
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Conn. 06520-8051
| | | | | | | | | | | |
Collapse
|
24
|
Bowker TJ. Covert coronary disease and non-invasive evidence of covert myocardial ischaemia: their prevalence and implications. Int J Cardiol 1994; 45:1-7. [PMID: 7995659 DOI: 10.1016/0167-5273(94)90049-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
25
|
Esler M. Clinical application of noradrenaline spillover methodology: delineation of regional human sympathetic nervous responses. PHARMACOLOGY & TOXICOLOGY 1993; 73:243-53. [PMID: 8115306 DOI: 10.1111/j.1600-0773.1993.tb00579.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The proportionality which in general exists between rates of sympathetic nerve firing and the overflow of noradrenaline into the venous drainage of an organ provides the experimental justification for the use of measurements of noradrenaline in plasma as a biochemical measure of sympathetic nervous function. Static measurements of noradrenaline plasma concentration have several limitations. One is the confounding influence of noradrenaline plasma clearance on plasma concentration. Other drawbacks include the distortion arising from antecubital venous sampling (this represents but one venous drainage, that of the forearm), and the inability to detect regional differentiation of sympathetic responses. Clinical regional noradrenaline spillover measurements, performed with infusions of radiolabelled noradrenaline and sampling from centrally placed catheters, and derived from regional isotope dilution, overcome these deficiencies. The strength of the methodology is that sympathetic nervous function may be studied in the internal organs not accessible to nerve recording with microneurography. Examples of the regionalization of human sympathetic responses disclosed include the preferential activation of the cardiac sympathetic outflow with mental stress, cigarette smoking, aerobic exercise, cardiac failure, coronary insufficiency, essential hypertension and in ventricular arrhythmias, and the preferential stimulation or inhibition of the renal sympathetic nerves with low salt diets and mental stress, and with exercise training, respectively. By application of the same principles, regional release of the sympathetic cotransmitters neuropeptide Y and adrenaline can be studied in humans. Cotransmitter release, however, is detected only with some difficulty. In restricted circumstances we find evidence of regional cotransmitter release to plasma, such as the release of neuropeptide Y from the heart at the very high rates of sympathetic nerve firing occurring with aerobic exercise, and cardiac adrenaline release also with exercise and after loading of the neuronal adrenaline pool by intravenous infusion of adrenaline.
Collapse
Affiliation(s)
- M Esler
- Human Autonomic Function Laboratory, Baker Medical Research Institute, Melbourne, Australia
| |
Collapse
|