Impact of the introduction of drug eluting stents on clinical outcomes in patients undergoing percutaneous and surgical coronary artery revascularisation procedures in Western Australia.

Background: Increasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002. We assessed the impact of these changes on one-year outcomes for the total population of patients undergoing coronary artery revascularisation procedures (CARP) in Western Australia between 2000-2004.

Methods: Clinical and linked administrative data (inpatient admissions and death) were merged for all patients who had their first CARP with stent or CABG in Western Australia between 2000-2004.

Randomized trial comparing 600- with 300-mg loading dose of clopidogrel in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention: results of the Platelet Responsiveness to Aspirin and Clopidogrel and Troponin Increment after Coronary intervention in Acute coronary Lesions (PRACTICAL) Trial.

Background: There is uncertainty about the benefit of a higher loading dose (LD) of clopidogrel in patients with non-ST elevation acute coronary syndrome (NSTEACS) undergoing early percutaneous coronary intervention (PCI).

Methods: We compared the effects of a 600- versus a 300-mg LD of clopidogrel on inhibition of platelet aggregation, myonecrosis, and clinical outcomes in patients with NSTEACS undergoing an early invasive management strategy. Patients with NSTEACS (n = 256, mean age 63 years, 81.

Complex coronary sinus fistula in a 58-year-old female.

Coronary artery aneurysms and arterio-venous fistulae are uncommon malformations. We report the case of a 58-year-old woman with a large aneurysmal fistula arising from the left coronary tree and involving the entire coronary sinus venous system, resulting in significant left-to-right shunt. We discuss the management of aneurysmal fistulae of the coronary arteries, and the merits of prophylaxis for thrombotic complications of large aneurysms.

Obstruction of the right coronary artery ostium by an aortic valve papillary fibroelastoma.

Aortic valve papillary fibroelastomas are rare benign tumours which may present with the sequele of embolisation, coronary occlusion or sudden death. We report a case of a 68 year old lady presenting with unstable angina who appeared at coronary angiography to have thrombus in the right coronary ostium. Increasing right territory ischaemia prompted echocardiography, which diagnosed a mass in the right coronary ostium.

Intravenous flecainide versus amiodarone for recent-onset atrial fibrillation.

In a randomized, double-blind, controlled study of 98 patients with atrial fibrillation (AF) (present for > or = 30 minutes, < or = 72 hours, and a ventricular response of > or = 100 beats/min), intravenous flecainide (2 mg/kg, maximum 150 mg) was compared with intravenous amiodarone (7 mg/kg) and placebo. Exclusion criteria included significant left ventricular dysfunction, inotrope dependence, recent antiarrhythmic therapy, hypokalemia, and pacemaker dependence. Reversion to stable sinus rhythm within 2 hours of starting medication was considered likely to be due to drug effect.

Placebo-controlled trial of enteric coated aspirin in coronary bypass graft patients. Effect on graft patency.

Objective: To determine whether slow-release enteric coated aspirin (100 mg daily), commenced before operation, improves the patency of saphenous vein (SV) coronary artery bypass grafts at six months.

Design And Setting: Double-blind, randomised, placebo-controlled study at a teaching hospital.

Results: One hundred and forty patients were randomly allocated to receive enteric coated aspirin or matching placebo.

Usefulness of atrial electrograms recorded via central venous catheters in the diagnosis of complex cardiac arrhythmias.

Objective: To assess the role of intravascular atrial electrograms in improving the diagnosis of complex cardiac arrhythmias in critically ill patients.

Design: Prospective, clinical study comparing the accuracy of cardiac rhythm diagnosis using standard surface electrocardiogram (EKG) and intravascular atrial electrograms.

Setting: Intensive care unit of a university teaching hospital.

Aspirin and thrombolytic therapy in the management of acute myocardial infarction.

The use of aspirin and thrombolytic agents in the management of acute myocardial infarction is now accepted as standard clinical practice, but not all patients with heart attack are suitable for such therapy. This article provides practical guidelines for patient management and the background information on which these recommendations are based.

Effect of alpha 1-adrenoceptor blockade on ventricular ectopic beats inacute myocardial infarction.

Experimental studies have shown that alpha1-adrenoceptor blockade can reduce ventricular arrhythmia associated with myocardial ischaemia. To examine the efficacy of prazosin in clinical acute infarction 38 patients were randomized, on presentation, to prazosin or placebo. Oral therapy was commenced at 0.

Safety and convenience of a mechanical injector pump for coronary angiography.

Coronary angiography and left ventriculography was performed in 5,887 consecutive patients over a 5-year period using a mechanical injector pump activated by a foot switch. Five coronary dissections occurred, four of the right coronary artery and one of the left internal mammary artery, which had been grafted to the left anterior descending artery. One patient had angina following an air embolus; there were no significant intramyocardial injections of contrast agent.

Verapamil withdrawal as a possible cause of myocardial infarction in a hypertensive woman with a normal coronary angiogram.

Verapamil is an effective and relatively-safe antihypertensive drug. Serious adverse effects are uncommon and mainly have been related to the depression of cardiac contractility and conduction, especially when the drug is combined with beta-blocking agents. We report a case in which myocardial infarction coincided with the introduction of captopril and the withdrawal of verapamil in a previously asymptomatic woman with severe hypertension.

Effectiveness of amiodarone on ventricular arrhythmias during and after acute myocardial infarction.

A randomized, placebo-controlled study examined the effect of amiodarone on the incidence of ventricular arrhythmias after acute myocardial infarction (AMI). Two hundred patients with AMI were randomized to receive amiodarone, 200 mg every 8 hours for 1 month, followed by 200 mg/day, or placebo, starting 48 hours after the onset of chest pain. Twenty-four-hour Holter monitoring was performed on day 1, repeated after 8 days and subsequently at 3-month intervals.

Comparison of pulsed Doppler and thermodilution methods for measuring cardiac output in critically ill patients.

We obtained 145 consecutive cardiac output measurements in 38 critically ill patients, using the invasive thermodilution and the noninvasive pulsed Doppler methods. The mean thermodilution cardiac output (TDCO) was 5.7 +/- 1.

Comparison of transthoracic electrical impedance and thermodilution methods for measuring cardiac output.

Cardiac output was measured 120 times in 27 critically ill patients using the thermodilution and transthoracic electrical impedance methods. Both the minimum and mean values for the distance between the inner electrodes, and a variety of values for the resistivity of blood (rho) were substituted in the Kubicek's empiric formula for calculating cardiac output by transthoracic electrical impedance. Using the mean distance between the inner electrodes and a rho-value of 150 ohm X cm gave the best agreement between the methods (mean difference 0.

Cigarette smoking and ventricular arrhythmia in coronary heart disease.

With use of 24-hour ambulatory electrocardiographic monitoring, the effect of 1 hour of cigarette smoking on cardiac rhythm in 73 patients with coronary heart disease was studied. Fifteen subjects had no arrhythmia; 37 subjects had fewer than 2 atrial or ventricular premature complexes (APCs or VPCs)/hour, with APCs possibly related to smoking in 2 and VPCs related to smoking in 1. Nineteen subjects had more than 2 VPCs/hour (range 4 to 368) and had 16 +/- 29 VPCs/hour (+/- standard deviation) less during than before smoking (p less than 0.

Effect of beta adrenergic blockade on thallium-201 myocardial perfusion imaging.

Nine patients with stable angina (group 1) underwent maximal treadmill stress testing and thallium-201 (201T1) myocardial scintigraphy after intravenous propranolol hydrochloride, and after placebo. Though seven of the nine patients exercised longer after propranolol than after placebo, this difference did not reach statistical significance. Propranolol, however, significantly reduced the mean maximum rate pressure product.

Randomized controlled trial of vasodilator therapy after myocardial infarction.

Hemodynamic changes and mortality and morbidity were compared in a randomized controlled trial of sodium nitroprusside after acute myocardial infarction. Fifty patients with a mean pulmonary capillary wedge pressure of more than 20 mm Hg within 24 hours of acute infarction were randomly assigned to one of two groups: 25 patients treated with nitroprusside and 25 treated with furosemide. Nitroprusside rapidly produced a sustained decrease in systemic vascular resistance and increase in cardiac index (thermodilution).

Prazosin in the treatment of severe chronic congestive cardiac failure.

The acute haemodynamic effects of prazosin 5 mg were investigated in 11 patients with severe chronic congestive cardiac failure. Six patients had their antifailure therapy discontinued while five continued on their usual medication. Two patients were exercised before and after prozosin.

Comparison of vasodilator drug prazosin with digoxin in aortic regurgitation.

Intravenous administration of the vasodilator sodium nitroprusside has beneficial haemodynamic effects in subjects with severe aortic regurgitation while acute digitalisation can produce unwanted effects associated with an increase in systemic vascular resistance. This study compares the haemodynamic effects of the vasodilator prazosin and digoxin in eight patients with isolated severe aortic regurgitation. Prazosin 5 mg orally resulted in a 12 +/- 3 (SE) per cent increase in cardiac index (thermodilution), maintained over four to six hours, while digoxin 0.