Acute & Interventional Cardiology 2003; Volume 10: pages AIC 1- AIC 88

The objective of this study was to describe the context, procedural outcome and long-term results of contemporary small vessel (SV) coronary artery stenting. It was set in a tertiary cardiology centre. The study was designed as a retrospective analysis of the procedural and long-term results in a consecutive series of patients undergoing implantation of an SV stent (defined as < 2.5 mm) in 1999–2000. Of the 1,130 percutaneous coronary interventions (PCIs) in the study period, 138 (12%) involved placement of SV stents. Of these interventions 58% consisted of SV stents as sole treatment. Some 69% of patients were male and their mean age was 58 years; 46% were hypertensive, 13% diabetic, 84% hypercholesterolaemic and 18% were smokers. Of these patients 54% were in anginal classes III and IV. Of the SV stents fitted, 94% were 2.5 mm and 6% were 2.0 mm. 75% of SV stents were implanted in main epicardial vessels. The mean follow-up for these patients was 17 months. Long-term symptomatic benefit was achieved in 76%. The major adverse cardiac events (MACE) rate was 15%, comprising 1% acute myocardial infarction (AMI) and 14% re-PCI. There were no deaths. In conclusion, SV stenting in the modern era, in an unselected series of patients, is performed in 12% of PCI procedures. It comprises the sole treatment in 58% of these interventions. The majority of SV stents are 2.5 mm and are placed in main coronary arteries. Procedural and long-term results are excellent. These data may inform the choice of treatment for patients with SV disease and may be useful in planning studies in stenting SVs....

A significant left main coronary artery (LMCA) stenosis is an important predictor of survival in patients with coronary artery disease. In the past, percutaneous coronary intervention (PCI) was generally restricted to patients with protected left main disease; and >50% stenosis of the LMCA was a contraindication to balloon angioplasty. In the pre-stent era, results of left main balloon angioplasty were poor. For example, in one series, in-hospital mortality was 9.1% in the elective group and 50% in the acute group. The development of coronary stenting and effective antiplatelet therapy in the 1990s stimulated renewed interest in PCI for LMCA disease. A number of studies reported good outcomes for protected LMCA lesions, though results in haemodynamically unstable patients remained poor. The figures for a number of studies of elective PCI for unprotected left main stenosis are also described. The best documented outcomes so far are one-year actuarial survival of 89% in high-risk patients and 98% in low-risk patients. If severe calcification is obvious on angiography or ultrasound then debulking seems sensible. The data suggest that directional coronary atherectomy alone or with stenting may be associated with reduced restenosis rates. The use of glycoprotein IIb/IIIa inhibitors and drug-eluting stents may further improve the outlook for patients with LMCA stenosis....

Glucose-insulin-potassium (GIK) therapy addresses the metabolic changes of ischaemia secondary to acute myocardial infarction. These changes include elevated plasma free fatty acid concentration and glucose intolerance. A meta-analysis of trials from the pre-thrombolysis era showed a significant reduction in the number of deaths in the GIK group in comparison to placebo (16.1% vs. 21% respectively, p=0.004). High-dose GIK therapy was found to be of particular benefit. Three randomised trials in the post-thrombolysis era have been published, with variable results. The DIGAMI study (in diabetics) and the ECLA pilot trial had positive results: in the latter there was a 60% reduction in in-hospital mortality in patients who received GIK therapy plus reperfusion. By contrast, the Pol-GIK trial was negative. Outstanding questions include the usefulness of GIK therapy and beta blockade in the presence of thrombolysis or primary angioplasty. GIK therapy and beta blockade might act in complementary fashion to antagonise the metabolic changes of ischaemia while thrombolysis or angioplasty improve early reperfusion and limit infarct size. Patients with acute coronary syndrome might benefit more from GIK therapy since they have some coronary flow....

The first public report on how the NHS manages acute myocardial infarction (MI) in English hospitals was published on 19th November 2002. The report, based on almost 40,000 records collected by the Myocardial Infarction National Audit Project (MINAP) team based at the Royal College of Physicians (RCP), gave rise to much media commentary, the BBC news leading with the headline Heart units too slow with vital drugs. ...

With the publication recently of the results of learned deliberations of two working parties of the Royal College of Physicians (RCP),1,2 attention continues to focus on the organisational and training aspects of the care of the seriously ill. These documents are the latest in a series of publications that have made proposals for improvement. The intensive care medicine (ICM) community has for many years been drawing attention to the plight of the critically ill, with frustratingly little response from the UK Department of Health. The Audit Commission report Critical to Success3 provided independent evidence that variation in facilities and patterns of operation had important impacts on patient care and cost-effectiveness. Published subsequently were a report of the National Expert Group Comprehensive Critical Care4 and an operational document from the Department of Health....

The donor crisis in heart transplantation John Pepper n the area of heart failure, public debate and research funding have been focused on new trends such as xenotransplantation and tissue engineering. Neither approach is expected to have an important role during this decade. We should not neglect organ transplantation, though it is dependent on a scarce resource. Legislation can be effective in the long term, but improving rates of organ donation has more to do with changing attitudes and behaviour. ...

Infective endocarditis can be difficult to diagnose, especially in the absence of typical clinical features or Duke criteria. Seeding of emboli to the cerebral cortex can give rise to neurological symptoms. In the case presented here amnesia was, unusually, the most prominent feature....

Early angiography and revascularisation are beneficial for patients with non-ST segment elevation myocardial infarction (NSTEMI). However, the Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK) demonstrated low levels of revascularisation in the UK in patients at high cardiovascular risk. In the study described here, the authors attempted to streamline their referral process for acute revascularisation and conducted an audit to quantify the delay and to monitor outcomes. There were 1,640 percutaneous coronary interventions (PCIs) in West Yorkshire during the year 2000; of these 45% were acute interventions. The catheter laboratory database identified 212 acute PCI patients with a Leeds city postcode. Average times from admission to angiogram, angiogram to intervention, and intervention to discharge are described, as are patient characteristics. Acute and six-month outcome data are given for the whole cohort and for a high-risk subgroup. The six-month composite rate of death and myocardial infarction was lower than that observed in PRAIS-UK. The data show that the time delay between admission and intervention can be kept to a reasonable level....

Cardiopulmonary bypass and the median sternotomy incision have revolutionised cardiac surgery, helping coronary artery bypass to become a routine procedure. Cardiopulmonary bypass was originally developed to allow open-heart surgery, but was adopted for coronary surgery because it provided a still operating field. However, the cost of good surgical access has been a large scar, with slow recovery and occasional serious wound complications. Adaptation of robotic technology from production engineering provides a new way of performing coronary artery bypass grafting (CABG) without large incisions, and often without cardiopulmonary bypass. Although the first endoscopic robotic cases were reported several years ago, widespread adoption of the new technique is still some way off. We review the progress of robotic CABG to date, and discuss current research fields....

There is a lack of standards pertaining to stopping antiplatelet agents in patients with acute coronary syndromes prior to coronary surgery. We conducted a national survey of all centres performing cardiac surgery in the UK and Ireland into practices and standards in relation to clopidogrel and aspirin before coronary artery surgery (n=36). The response rate was 89%. The majority of centres used combination antiplatelet therapy in either some or all pre-operative acute coronary syndrome patients (79%). Aspirin alone is given in 19% of this surgical subpopulation. Aspirin is stopped 4.9 + 0.5 days (mean + SEM) and clopidogrel 6.5 + 0.5 days prior to surgery. There are no clear departmental policies in most cases (21 of 32 units) regarding cessation of clopidogrel. A subjective increase in bleeding was reported in 69% of centres; in 15 centres (47%) patients had returned to theatre for bleeding. Many units in the UK still do not have a policy regarding antiplatelet therapy in those patients with acute coronary syndromes who are awaiting coronary bypass surgery. A randomised controlled trial is probably the correct way of evaluating the best strategy on use and omission of aspirin and clopidogrel in this setting....

The objective of this survey was to estimate the proportion of episodes of acute coronary syndromes (ACS) without ST segment elevation in relation to the total number of acute chest pain presentations. We attempted to estimate costs associated with glycoprotein (GP) IIb/IIIa inhibitor treatment in patients with high-risk features. This was a prospective survey set in a typical British district general hospital, serving a population of about 300,000. It took place over a 14-week period. The participants were all patients presenting with chest pain of possible cardiac origin, identified by intensive surveillance of all emergency medical admissions (EMAs) in patients over 16 years of age and all adult and elderly medicine in-patients. At the time of the study, the upper limit of normal for troponin T (TnT) used in this hospital was 0.05 µg/L. The main outcome measures were: the proportion of EMAs due to chest pain of likely cardiac origin; the number of episodes of ACS without ST elevation as a proportion of all EMAs; and the projected prescribing costs of GPIIb/IIIa inhibitor treatment for high-risk cases. We found that 22% (CI 20.07–23.5%) of all EMAs were due to chest pain likely to be of cardiac origin. One event of ACS without ST elevation was generated for every 25.6 (CI 23.8–28.6) EMAs. Using a TnT value of > 0.1 µg/L to define high risk and suitability for GPIIb/IIIa inhibitor treatment, a minimum of 66% of patients with ACS without ST elevation would be eligible for treatment. In the study hospital, this translates to an annual cost of £131,000 (equivalent to £43,600 per 100,000 catchment population) or £11.45 per all-cause hospital EMA. In conclusion, about two thirds of patients with ACS without ST elevation have high-risk features and would potentially benefit from treatment with GPIIb/IIIa inhibitors. The costs of drug treatment are appreciable, but financial planning can be assisted by the data presented here....

The Coronary Artery Revascularisation in Diabetes (CARDia) trial is an investigator-initiated study and is the first prospective study designed specifically to address the hypothesis that optimal percutaneous coronary intervention (PCI) with stenting and abciximab is not inferior to up-to-date coronary artery bypass grafting (CABG) as a revascularisation strategy for diabetics with multivessel or complex single vessel coronary disease....

Background: With an incidence rate of 30–50%, atrial fibrillation (AF) after bypass surgery continues to be one of the most common complications. The possibilities of haemodynamic instability and thromboembolism necessitate the initiation of antiarrhythmic and anticoagulant therapy. Despite early initiation of therapy, AF can increase post-bypass morbidity and mortality. It can also prolong intensive care unit and hospital stay and further increase resource utilisation. In this article we review the pathophysiology, risk factors, effect on resource utilisation, current prophylactic and therapeutic strategies, and risk-benefit assessment of anticoagulant therapy in post-bypass AF. Methods: This is a review of the medical literature on post-bypass AF from January 1980 to March 2003. Relevant older references were also reviewed. Clinical and research studies on the mechanisms, pathophysiology, risk factors, complications, resource utilisation, prophylaxis and management were collected from the Medline, Embase, Cinhal and Sigle databases and reviewed. Conclusion: AF significantly increases complications and resource utilisation after bypass surgery. Prophylactic therapy could significantly reduce the incidence of AF. In AF lasting more than 48 hours, anticoagulant or antiplatelet therapy based on individual risk assessment is recommended....

End-stage heart failure represents a major public health challenge and carries a poor prognosis. After a 30-year gestation period, mechanical assist devices are now poised to make a significant impact in the treatment of heart failure patients. This review gives a general overview of the subject and describes some of the devices currently available in greater detail....

Recent developments in the management of non-ST elevation acute coronary syndromes (ACS) have included the introduction of glycoprotein (GP) IIb/IIIa inhibitors. The National Institute for Clinical Excellence (NICE) has published guidelines on their use, which state that these agents should be given to all high-risk patients. Here, we present the results of a national survey of 1,000 consultant cardiologists and general physicians. A total of 361 replies were analysed: 98% of respondents treated patients with ACS and 92% of respondents had access to troponin assays. Overall, 241 (67%) of respondents prescribed GP IIb/IIIa inhibitors for ACS. There was a significant difference between cardiologists and generalists, with 194 (77%) cardiologists and 46 (42%) general physicians prescribing GP IIb/IIIa inhibitors in ACS (p=0.0013). Despite the presence of government guidelines regarding the administration of GP IIb/IIIa antagonists in ACS, we calculate that only 32% of respondents are prescribing IIb/IIIa inhibitors as recommended by NICE...

Thrombolytic therapy remains the predominant reperfusion strategy for ST segment elevation myocardial infarction (STEMI) in the UK, with government policy directed towards optimising thrombolytic delivery. However, the publication of the first Myocardial Infarction National Audit Project (MINAP) report last year informed us that only 28% of hospitals supplying data treated the target 75% of eligible patients inside 30 minutes....

The ability to deliver increased cardiac services in line with the National Service Framework (NSF) is dependent on a skilled workforce being developed at an unprecedented rate. The numbers of trained staff are at present inadequate, and they will remain so using traditional models of training....