LA CONSULTA SEMANAL

1: CMAJ 2002 Jan 8;166(1):51-9 [Texto completo]

New advances in the management of acute coronary syndromes: 3. The role of catheter-based procedures.

Buller CE, Carere RG.

Vancouver General Hospital, British Columbia. cehbuller@shaw.ca

Publication Types: Review Review, Tutorial

2: J Am Coll Cardiol 2001 Jun 15;37(8):2170-214 [Texto completo]

American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.

Bashore TM, Bates ER, Berger PB, Clark DA, Cusma JT, Dehmer GJ, Kern MJ, Laskey WK, O'Laughlin MP, Oesterle S, Popma JJ, O'Rourke RA, Abrams J, Bates ER, Brodie BR, Douglas PS, Gregoratos G, Hlatky MA, Hochman JS, Kaul S, Tracy CM, Waters DD, Winters WL Jr; American College of Cardiology. Task Force on Clinical Expert Consensus Documents.

Publication Types: Consensus Development Conference Review

3: West J Med 2001 Apr;174(4):257-61 [Texto completo]

Coronary artery disease: Part 1. Epidemiology and diagnosis.

Link N, Tanner M.

Department of Medicine, New York University School of Medicine, New York, NY 10016, USA. nlink@bhc.org

Coronary artery disease (CAD) is the leading cause of death in Americans, accounting for about 500,000 deaths every year. The annual incidence of myocardial infarction (MI) is about 1.5 million. As many as 2 million middle-aged men may have silent myocardial ischemia. (1)

Publication Types: Review

4: West J Med 2001 May;174(5):330-5 [Texto completo]

Coronary artery disease: part 2. Treatment.

Link N, Slater W.

Department of Medicine, New York University School of Medicine, New York, NY 10016, USA. nlink@bhc.org

5: Chest 2001 Feb;119(2):493-501 [Texto completo]

Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review.

Yip HK, Wu CJ, Yeh KH, Hang CL, Fang CY, Hsieh KY, Fu M.

Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan, Republic of China.

BACKGROUND: While coronary dissection, which is one of the most frequently occurring complications during interventional procedures, has various forms, extensive coronary dissection retrograde to the coronary sinus of Valsalva (CSV) is very rarely observed. METHODS AND RESULTS: Within the last 5 years, we retrospectively reviewed our experience with 4,700 consecutive patients who underwent angioplasty procedures, 7 of whom (0.15%) developed extensive coronary dissection retrograde to the CSV. Six of the seven patients developed retrograde dissection of the right CSV during angioplasty to the right coronary artery. One of the seven patents developed retrograde dissection of the left CSV during angioplasty to the left anterior descending artery. Retrograde dissection, which extended to the ascending aorta in two patients, was observed by transthoracic echocardiography and surgical findings, respectively. Five patients were successfully treated by coronary stenting. However, this complication caused four patients to have acute myocardial infarctions, resulting in emergency surgery for one patient and in-hospital death for another. CONCLUSIONS: Our experience increased our understanding of this very rare complication. However, this complication may be life threatening, and patients in this clinical setting may have a potential risk for acute myocardial infarction, emergency surgery, or even sudden cardiac death. Therefore, it is important to learn how to promptly diagnose and manage this complication.

6: Circulation 2000 Mar 21;101(11):1344-51 [Texto completo]

Coronary physiology revisited : practical insights from the cardiac catheterization laboratory.

Kern MJ.

Department of Internal Medicine, Division of Cardiology, Saint Louis University Health Sciences Center, St. Louis, MO 63110, USA. kernm@slu.edu

Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making.

Publication Types: Review

7: J Am Coll Cardiol 2000 Feb;35(2):380-1

Comment on: J Am Coll Cardiol. 2000 Feb;35(2):371-9.

Management of myocardial infarction: looking beyond efficacy.

Natarajan MK, Mehta S, Yusuf S.

Publication Types: Comment Editorial Review

8: Am Heart J 1999 Aug;138(2 Pt 2):S158-63

Do new devices add to the results of PTCA in acute myocardial infarction?

Moses J, Moussa I.

Interventional Cardiology, Lenox Hill Hospital, 130 E 77th Street, New York, NY 10021, USA.

Several randomized trials have established that timely mechanical reperfusion with the use of balloon angioplasty is superior to thrombolytic therapy in patients with acute myocardial infarction. Furthermore, recent data from prospective randomized trials suggest that primary stent implantation may further improve the results of balloon angioplasty by reducing the need for repeat interventions at follow-up. The role of IIb-IIIa platelet receptor antagonists as adjunctive therapy to catheter-based coronary interventions in acute myocardial infarction is promising, but the incremental benefit that these agents add to stent implantation awaits the results of dedicated randomized trials. Mechanical thrombolysis or thrombectomy devices may have a role in a minority of patients with large thrombus burden.

Publication Types: Review

9: Am Heart J 1999 Aug;138(2 Pt 2):S142-52

Cost-effectiveness of reperfusion strategies.

Parmley WW.

University of California, 505 Parnassus Avenue, San Francisco, CA 94143-0124, USA.

Reperfusion of acute myocardial infarction has become the standard of management during the first few hours. Cost per year of life saved is one measure of the effectiveness of reperfusion strategies. Estimates of the cost per year of life saved have been approximately $17,000 for streptokinase and percutaneous transluminal coronary angioplasty and approximately $33,000 for tissue plasminogen activator. Assuming that percutaneous transluminal coronary angioplasty is more effective than thrombolysis, we calculated the cost-effectiveness of this strategy in different hospital settings. The estimated costs in hospitals with existing cardiac catheterization laboratories were $11,000 per year of life saved for primary angioplasty and $14,000 for thrombolysis compared with no intervention. In hospitals without catheterization facilities, it would be cost-ineffective to build such laboratories only to treat acute infarction with angioplasty. Preliminary results suggest that stenting may also be cost-effective in association with angioplasty.

Publication Types: Review

10: Can J Cardiol 1998 Oct;14(10):1259-66

Technology and application of ultraminiature catheter pressure transducers.

Zimmer HG, Millar HD.

Carl-Ludwig-Institute of Physiology, University of Leipzig, Germany. zimmer@medizin.uni-leipzig.de

After a brief historical account of the methods for pressure measurements in the cardiovascular system, the basic structural elements of a new generation of miniaturized catheter pressure transducers are described. These catheters have an outside diameter at the tip of 0.9 mm (3 French) and have been routinely applied in left and right heart catheterization in intact, anesthetized rats. Together with cardiac output measured by the thermodilution technique, a complete set of basal functional parameters can be obtained in vivo. The method of cardiac catheterization in rats is accurate, reliable and easy to perform. As to left heart function, changes occurring in several models of cardiac hypertrophy and heart failure have been recorded and correlated with morphological and metabolic alterations. In addition, the functional effects of catecholamines and thyroid hormones have been evaluated. In addition to the routine catheterization procedure, a double catheter method has been introduced recently, which allows measurement of left ventricular isovolumetric pressure in intact rats. Catheterization of the right ventricle requires a more refined catheter with a characteristic bend at the tip so that it can be comfortably slid from the right atrium into the right ventricle. With this method it was found that right ventricular systolic pressure was elevated markedly in rats with chronic myocardial infarction induced by ligation of the left anterior descending coronary artery, by pulmonary artery banding, by intermittent chronic hypoxia and by noradrenaline administration. The ultraminiature catheter pressure transducer has also been successfully applied in an isolated working rat heart preparation. Recent modifications of this kind of catheters also enabled the catheterization of the left ventricle in mice. Future applications of ultraminiature catheter pressure transducers may be directed to catheterization of the pulmonary artery in rats and to the in vivo and in vitro assessment of heart function of transgenic mice.

Publication Types: Review

11: Clin Cardiol 1998 Mar;21(3):207-10

Unstable angina: specialty-related disparities in implementation of practice guidelines.

Reis SE, Holubkov R, Zell KA, Edmundowicz D, Shapiro AH, Feldman AM.

Department of Medicine, University of Pittsburgh, Pennsylvania, USA.

BACKGROUND: The agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care patients with unstable angina. Prior to publication, studies demonstrated that when compared with cardiologists, internists were less likely to use effective pharmacologic therapies or revascularization in patients with unstable angina. HYPOTHESIS: The study was undertaken to determine whether the AHCPR guideline publication abolished specialty-related disparities in care. METHODS: We performed a chart review of consecutive patients hospitalized at a university-affiliated institution with an admission diagnosis of chest pain in the absence of myocardial infarction and a noncardiac etiology. Treatment and diagnostic cardiac testing were compared between risk-stratified patients cared for by a generalist (n = 125) and those whose care was guided by a cardiologist (n = 211). RESULTS: In those with low-risk unstable angina, generalists were less likely to prescribe recommended aspirin (71 vs. 88%, p < 0.01) and beta blockers (9 vs. 37%, p < 0.001), and heparin (20 vs. 49%, p < 0.001), and to perform a recommended diagnostic stress test or cardiac catheterization (28 vs. 60%, p < 0.001). In those with at least intermediate risk, generalists were less likely to prescribe beta blockers (19 vs. 52%, p < 0.001), heparin (19 vs. 66%, p < 0.001), and nitrates (77 vs. 96%, p < 0.001), and to refer for diagnostic testing (19 vs. 65%, p < 0.001). Generalists' care was associated with significantly lower hospital charges. CONCLUSIONS: AHCPR guidelines for the evaluation and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studies are necessary to evaluate the barriers to implementation of the AHCPR guidelines.