Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.     

Follow up study of angina in patients aged 30 to 59 in general practice.

In 1979, 51 general practitioners in the Northern region identified 336 patients aged 30 to 59 who had angina pectoris. Information was obtained on their treatment and how angina affected their daily lives. This study reviews the same patients after an interval of four years. Of the 307 who were not lost to follow up, 38 (12%) had died and 44 (14%) were free from angina in the last year. Drugs seemed to be used to their best advantage, with a fourfold increase in the use of the newer calcium antagonists and long acting trinitrate preparations. Many patients still suffered from angina, which was severely affecting their daily lives, but only 41 patients had had exercise electrocardiograms recorded or more detailed investigations; this includes 16 (6%) patients who had had coronary artery bypass surgery.     

Capacities of multidetector spiral computed tomography in the planning and postoperative examination of patients undergoing coronary artery bypass surgery

Multiple investigations show that multidetector spiral computed tomography (MSCT) bypass grafting becomes an alternative to invasive coronary angiography in detecting coronary graft stenoses and occlusions. The investigation retrospectively estimated the patency of aortocoronary and mammary coronary artery anastomoses by MSCT bypass grafting. Examinations were made in 85 (326 anastomoses) patients who had undergone aortocoronary and mammary coronary artery bypass surgery and had MSCT bypass grafting within 3 years after the surgery. In the first year following the surgery, 18 patients with graft stenotic changes, as evidenced by MSCT, underwent intervention coronary angiography, the sensitivity and specificity of which was 100%. The results of clinical and instrumental examinations were also compared with graft incompetence, as shown on MSCT that revealed that MSCT bypass grafting was the only noninvasive technique to evaluate early coronary graft closure both in the absence of clear signs of myocardial ischemia according to the data of exercise tests and in the presence of recurrent angina pectoris.     

Venous Graft Surgery in Treatment of Coronary Heart Disease

Sixty-seven patients have had aortocoronary venous graft bypass surgery by one surgeon for the relief of symptoms of severe coronary heart disease, including eight emergency operations. The overall operative, hospital, and late mortality was low in patients with favourable myocardial function and no previous myocardial infarction. There was a 7% mortality in patients with a normal preoperative chest radiogram, 8% mortality when the left ventricular end-diastolic pressure was normal preoperatively, and a 5% mortality in patients who had normal left ventricular angiograms. The overall mortality in all elective operations for cardiac pain resistant to medical treatment was 15·8%. 89% of survivors improved; 67% are pain-free. Exercise tolerance in survivors is increased by 135%, atrial pacing results are improved by 10%. Left ventricular end-diastolic pressure is unchanged. Left ventricular function on angiography is improved. The improvement in left ventricular function assessed objectively correlates positively with vein-graft patency, as does freedom from angina pectoris.     

Prognosis of new and worsening angina pectoris.

The natural history of new and worsening angina pectoris was studied in 251 men aged under 70 years. Most were ambulant and all were referred by selected general practitioners to a special hospital clinic over two and a half years. Heart attacks developed in 39 patients, nine of whom died. Seventy-two per cent of the attacks occurred within six weeks of the onset or worsening of angina. Of the 212 patients who did not suffer myocardial infarction and who were clinically reviewed six months after their first attendance 66 had been pain free for the previous three months and 14 had experienced only infrequent attacks of angina. Of the 128 men aged under 65 years who were previously in employment 81% had returned to full-time work six months after their first attendance. A discriminant function analysis using many variables was made to develop a predictive index that would allow patients with new or worsening angina who were likely to develop serious cardiac complications to be identified. This did not prove possible, and the only predictive factor of significance was an increased cardiothoracic ratio. The syndrome of new and worsening angina has a low risk of early death, and many patients are symptom free six months later. In general, emergency coronary arteriography and surgery is not indicated.     

Current management of unstable angina

The patient with unstable angina (angina of recent onset, of changing pattern or occurring at rest) is at high risk of myocardial infarction and sudden death. Patients with simple angina of recent onset can generally be managed out of hospital. Those with progressive angina or angina at rest should be admitted to a coronary care unit, kept at bed-rest, and given propranolol and long-acting nitrates when such therapy is indicated. With these approaches the rate of infarction within 1 to 3 months after the onset of unstable angina is about 12% (as compared with 40% before 1970); the mortality in the same period is less than 2% (as compared with 17% before 1970), though during the first year it is about 17%, much higher than in patients with stable angina and in survivors of acute myocardial infarction.Urgent aortocoronary bypass grafting has proven to be unnecessary and probably undesirable for most patients with unstable angina, and is now generally reserved for patients who continue to have angina in hospital while receiving full medical therapy. The ongoing management of patients whose angina is controlled during the acute phase remains controversial. The main options are to operate on every possible patient, to operate only on those with certain distributions of coronary artery lesions, and to operate only on those who have recurrent symptoms. Further studies are required to delineate the etiology and the Optimal management of unstable angina.     

Acute coronary syndromes following abrupt cessation of oral propranolol therapy.

Abrupt cessation of oral propranolol therapy was followed by 15 acute coronary events in 14 patients with severe angina who had been receiving propranolol in daily doses of 80 to 400 mg for periods of 7 days to 6 years. Propranolol had been stopped 1 to 14 days before each acute event because of angiographic study (seven patients), increasing symptoms (three), acute coronary insufficiency (one), asymptomatic bradycardia (one), elective surgery (one) and unknown reasons (two). Before abrupt cessation of propranolol treatment anginal symptoms had been stable in six instances but had increased in the other nine. Cessation was followed by rapid progression of symptoms prior to 11 of the 15 acute events. There were six acute transmural myocardial infarctions with three deaths, three intramural myocardial infarctions, one with ventricular fibrillation, and six episodes of acute coronary insufficiency, Unstable angina followed nine of the events and responded to propranolol therapy (160 to 320 mg/d) in eight instances. Three other patients underwent aortocoronary bypass surgery; perioperative acute myocardial infarction occurred in two. These data suggest that in a minority of patients abrupt cessation of propranolol may be hazardous, particularly in severe or unstable disease. Cessation or propranolol therapy in such patients should be gradual and closely observed. Recurrent symptoms respond to reinstitution of propranolol therapy.     

Long-term clinical efficiency of endovascular treatment using Cypher rapamycin-eluting stents in patients with coronary heart disease

The study was undertaken to analyze the long-term results in patients with coronary heart disease (CHD) one year or more after Cypher stent implantation. It covered 1221 patients. One-, two-, and three- vessel lesions were observed in 693 (56.8%), 344 (28.2%), and 184 (15%) patients, respectively. A total of 1967 Cypher stents were implanted. The results of treatment were analyzed 1 and 2 years after intervention. The efficiency of a procedure was evaluated by the following parameters: the presence or absence of anginal symptoms, the presence and absence of complications (fatal outcome, myocardial infarction). The following morphological parameters: the rate of restenosis and that of late stent thrombosis were also assessed. The results of one- and two-year follow-ups were used to make a multivariate analysis of the clinical and morphological predictors of coronary complications (fatal outcome, myocardial infarction, recurrent angina pectoris) in the late period, as well as the predictors of restenosis and late stent thrombosis. Restenosis following 1 year of Cypher stent implantation is 3.1%. The factors that significantly increase the risk of this complication within the first year are diabetes mellitus and revascularization in the patients operated on. The one-year rate of Cypher stent thromboses is 1.6%. Patients' discontinuation of antiaggregant therapy is the sole factor that significantly increases the rate of their late thromboses in this period. Within the second year of a follow-up, the rate of late Cypher stent thromboses is 1.8%. The risk of this complication is significantly increased by factors, such as a lengthy (more than 3 mm) stented portion, renal failure, and less than 40% left ventricular ejection fraction.     

急性ST段抬高型心肌梗死患者术后碎裂QRS波的影响因素及其与心肌灌注和短期预后的关系分析

摘要 目的：探讨急性ST段抬高型心肌梗死（STEMI）患者术后碎裂QRS波（fQRS）的影响因素,分析其与心肌灌注及短期预后的关系。方法：选取上海中医药大学附属曙光医院宝山分院于2017年4月～2019年4月期间收治的108例STEMI患者的临床资料行回顾性研究,术后均行12导联心电图检查,根据有无fQRS,分成fQRS组（n=52）,非fQRS组（n=56）。比较两组临床资料,经单因素及多因素Logistic回归分析明确患者术后fQRS的影响因素。比较两组心肌灌注情况,心肌灌注采用心肌呈色分级法（MBG）进行分析。随访1年,分析患者主要不良心血管事件发生率,包括心力衰竭、心绞痛、心源性死亡、心源性休克,用于评价短期预后。结果：单因素分析提示,年龄、冠脉血管病变支数、Gensini评分、心绞痛发作至血管开通时间与术后fQRS有关（P＜0.05）。多因素Logistic回归分析显示,年龄、冠脉血管病变支数、Gensini评分、心绞痛发作至血管开通时间为术后fQRS的影响因素（P＜0.05）。fQRS组MBG 3级占比为46.15%,显著低于非fQRS组的76.79%（P＜0.05）。fQRS组不良心血管事件发生率为26.92%,显著高于非fQRS组的10.71%（P＜0.05）。结论：STEMI患者术后fQRS发生的影响因素包括年龄、冠脉血管病变支数、Gensini评分以及心绞痛发作至血管开通时间,且术后fQRS可预测心肌灌注情况及增加不良心血管事件发生率。     

Return to work after coronary artery surgery for angina.

The working habits of 115 consecutive patients who underwent coronary artery vein bypass grafting for angina were assessed. Only 25 patients worked up to the operation. Seven patients were housewives and seven retired. Sixty-eight patients had had to give up work because of their angina pectoris, and most of these had been off work for between six months and two years. After the operation 75 patients returned to full-time work, 59 within two to six months. These 75 patients included 23 of the 25 at work preoperatively and 47 of the 68 unable to work preoperatively. Most patients returned to their original occupation. We conclude that coronary artery surgery, as well as bringing symptomatic relief, increases the patient''s ability to return to and maintain gainful employment.     

Cineangiography of the Coronary Arteries: Clinical,Functional and Anatomic Correlation in Patients with Chronic Chest Pain

Fifty French-Canadian patients presenting with typical or atypical anginal pain were studied by selective cinearteriography and coronary sinus catheterization, with measurement of myocardial function, oxygen and lactate extraction at rest and during isoproterenol infusion. In 28 of 42 patients all three coronary arteries were involved, but angina pectoris also occurred in patients with single mildly stenotic arterial lesions and even in eight patients with normal cinearteriograms. All patients with severe arterial lesions had typical angina, and the longer the duration of angina, the greater the extent, usually, of anatomic disease. Seventy-nine percent of resting electrocardiograms of patients with documented coronary artery disease were abnormal, with recognizable prior infarction in 18. Two-thirds of the patients experiencing pain during the stressful state had abnormal ventricular function. An abnormal arteriovenous lactate difference in response to isoproterenol occurred in patients in all groups.     

Effects of Lifestyle Modification Programs on Cardiac Risk Factors

Medicare conducted a payment demonstration to evaluate the effectiveness of two intensive lifestyle modification programs in patients with symptomatic coronary artery disease: the Dr. Dean Ornish Program for Reversing Heart Disease (Ornish) and Cardiac Wellness Program of the Benson-Henry Mind Body Institute. This report describes the changes in cardiac risk factors achieved by each program during the active intervention year and subsequent year of follow-up. The demonstration enrolled 580 participants who had had an acute myocardial infarction, had undergone coronary artery bypass graft surgery or percutaneous coronary intervention within 12 months, or had documented stable angina pectoris. Of these, 98% completed the intense 3-month intervention, 71% the 12-month intervention, and 56% an additional follow-up year. Most cardiac risk factors improved significantly during the intense intervention period in both programs. Favorable changes in cardiac risk factors and functional cardiac capacity were maintained or improved further at 12 and 24 months in participants with active follow-up. Multivariable regressions found that risk-factor improvements were positively associated with abnormal baseline values, Ornish program participation for body mass index and systolic blood pressure, and with coronary artery bypass graft surgery. Expressed levels of motivation to lose weight and maintain weight loss were significant independent predictors of sustained weight loss (p = 0.006). Both lifestyle modification programs achieved well-sustained reductions in cardiac risk factors.     

Sexual activity after myocardial infarction.

Questionnaires on sexual activity were completed by 161 patients attending an exercise-centred rehabilitation program an average of some 3 years after a myocardial infarction. In almost half the group, sexual activity was unchanged or increased compared with the period before the infarction. In the remainder it was reduced; this group included 29 men who had adopted a more passive sexual role and 26 who were now having angina or ventricular premature beats during intercourse. Although the patients with diminished activity could not be distinguished by means of formal personality test, questionnaires completed by their wives suggested that they were less willing to assume responsibility, had increased difficulty in adjusting to life at home and at work and were more neurotic and depressed than those with normal or increased activity. Furthermore, those with decreased sexual activity had a poorer response to training in terms of attendance, final average jogging distance and gains in physiologic status. Since the frequency of angina and ventricular premature beats was less during intercourse than during standard laboratory exercise, it was concluded that normal sexual relations carry no special risk for the average postcoronary patient; indeed, by enhancing self-esteem and encouraging effective participation in an exercise programm, acceptance of normal sexual activity may improve the prognosis.     

Clinical trends in stent treatment of simple and complex coronary disease

This is a retrospective analysis of a consecutive group of patients from a single medical center who underwent stent implantation. It describes 316 patients who constituted 53% of the angioplasty procedures carried out in a single year. The authors describe the complications and their 1-year follow-up. We aimed to study the short and long-term results of stenting in our centre in relation to multiple clinical and angiographic variables. During 1996, 316 consecutive patients were treated with stent implantation for a total of 381 coronary lesions. The pharmacological protocol methods of stent implantation and patient characteristics were used. Clinical variables were: age 59.1 3 10.7 years, diabetes mellitus 25.3%, hypertension 33.0% and angina pectoris 88.7% (unstable in 44.1%). Previous coronary surgery had been undergone by 9.2%. Multivessel disease was present in 56% of the patients. The indications for stenting were: primary 58.5%, suboptimal results 33.0% and threatened or acute occlusion 8.5%. Angiographic success was 98.9% and clinical success 96.8%. The major in-hospital complications were acute myocardial infarction (2.2%), acute revascularization (0.3%) and major bleeding (0.6%). All occurred within 24 h of revascularization. Repeated angiography was performed in 115 cases (30.2%) at 160.3 3 109.4 days after stent procedure for unstable angina (38.7%), stable angina (26.1%) and other causes (35.2%). The restenosis rate in those catheterized was 38.1%, with an overall clinical restenosis rate of 11.3% during the follow-up period. Restenosis was more prevalent among diabetic patients (17.9 vs 9.15%, P 3 0.02) and patients with prior balloon angioplasty (18.6 vs 9.75%, P 3 0.046). Clinical follow-up was available in 90.8% of the patients for 291 3 112 days. The actuarial survival at the end of the follow-up period was 93.8%. Death/myocardial infarction was associated with unstable angina pectoris (P 3 0.006), hypertension (P 3 0.001), smoking (P 3 0.046) and threatened or acute occlusion (P < 0.001). In the first year of extensive stent use, stenting is associated with high technical and clinical success rates. Long-term results after stent implantation are associated with the occurrence of acute or threatened occlusion, and the in-hospital complications diabetes mellitus and hypertension.     

Influence of preoperative variables upon the results of coronary artery bypass surgery

One thousand ninety-six consecutive patients who received aorta-to-coronary artery bypass vein grafts were followed up to 4 years postoperatively. The early mortality was 1.7%; the 4-year survival rate, computed by actuarial methods, was 93.1%; the incidence of peri-operative myocardial infarction was 1.9%. After 4 years, 94.4% of the patients were free of peri- and postoperative infarcts. Angina pectoris was relieved in 85.7% and eliminated in 62.8% of the survivors. An analysis of the effects of ten preoperative variables on operative results showed that operative risk (early mortality, perioperative myocardial infarction) was not influenced by any of the variables. Late results (4-year mortality, 4-year infarction rate), however, were negatively affected by impaired ventricular function. Symptomatic improvement was more pronounced in men than in women.     

Long-term Prognosis following Ventricular Fibrillation in Acute Ischaemic Heart Disease

Of 160 patients who survived ventricular fibrillation complicating acute ischaemic heart disease, 80 had had a clinically mild coronary attack. Most of the long-term survivors had ventricular fibrillation within 24 hours of the onset of symptoms. The longterm prognosis of the survivors was similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Those patients who survived ventricular fibrillation which occurred within four hours of the onset of symptoms were younger, usually had had a mild coronary attack, and had the most favourable longterm prognosis. The number of episodes of ventricular fibrillation did not affect adversely the long-term prognosis. Of those who at the time of review were eligible to work, 86% were fit to work and 68% were actually at work.     

Risks of discontinuing anticoagulant therapy in a selected group of patients with atherosclerotic heart disease: a prospective study

In 134 patients with coronary artery disease, long-term oral anticoagulant therapy (mean duration, 56 months) for acute myocardial infarction (98 patients), acute coronary insufficiency (25 patients) or severe chronic angina (11 patients) was terminated abruptly in 50 patients (group 1) and gradually in 84 (group 2). The 134 patients represented a homogeneous population of patients with coronary artery disease since most patients older than 75 years and those with conditions known to increase the risks of thromboembolic complications were excluded. The two groups were comparable in terms of sex, age, presence of risk factors, duration of anticoagulant therapy, and presence of angina and abnormal resting electrocardiograms during therapy. Patients were evaluated 6 months after cessation of anticoagulant therapy and, since abrupt withdrawal of therapy did not carry a higher risk than gradual discontinuation, data for groups 1 and 2 were tabulated together.Of the 84 patients with angina at the end of therapy 15 experienced an increase in its severity and this symptom appeared in another patient (relapse rate, 18%). Angina progressed to fatal acute myocardial infarction in four (mortality, 3%) and nonfatal infarction in two; however, all six had extensive coronary artery disease and poor left ventricular function. The results of this study suggest that neither abrupt nor gradual cessation of anticoagulant therapy is associated with an inordinate exacerbation of heart disease.     

中性粒细胞／淋巴细胞比值与药物支架内再狭窄关系

目的：探讨经皮冠状动脉支架植入术前中性粒细胞／淋巴细胞比值（Neutrophil-to-LymphocyteRatio,NLR）与患者药物支架（DrugElutingStent,DES）植入后发生支架内再狭窄（In—StentRestenosis,ISR）的关系。方法：回顾性分析2012年01月至2012年10月间有DES植入史并再次入院接受冠脉造影的92例患者（平均年龄65．22±9．73岁）的血液学检查、既往冠脉造影结果及再次冠脉造影结果。根据DES植入前的NLR的四分位点将所有入选患者分为3组：最低三分位组（n=31,0．91-1．83）,中间三分位（n=30,1．87—2．63）,最高三分位（n=31,2．66—4．67）,比较3组间ISR发生率有无差异。结果：再狭窄发生在最低NLR三分位的有3例（9．68％）,发生在中间NLR三分位组的有2例（6．67％）,而有4例（12．90％）发生在NLR最高三分位组（P=0．714）,3组之间的差异无统计学意义。结论：因稳定或不稳定型心绞痛而植入药物支架的患者,其术前NLR同支架术后ISR的发生无明显相关性。NLR不能作为DES植入后发生再狭窄的预测指标。     

A Survey of Cardiac Infarctions: Hospital Experience

A study of patients with cardiac infarction, treated in hospital between 1950 and 1954 and followed up to the present, is reported. One hundred and forty-two patients suffered 169 attacks. In 95 attacks, the patients received anticoagulant therapy, with 15 acute deaths. Fifty-six were not so treated; among these there were 21 deaths. The rate of survival was best in younger patients with their first episode of infarction, without preexisting hypertension, cardiac failure, or systolic blood pressure persistently below 100. Angina preceding infarction disappeared in one-half of the subjects after the episode; half the survivors suffered recurrent myocardial infarction within five years. Moderate hypertension had no effect upon immediate or 10-year survival. No patient received long-term anticoagulant therapy. Of the survivors of acute infarction, 16 died in the first year after the acute attack, nine in the second year, nine in the third, six in the fourth and five in the fifth. At the end of five years, 51 subjects had survived 60 episodes. At the end of 10 years, 43 living patients had sustained 45 myocardial infarctions.     

MYOCARDIAL INFARCTION FOLLOWING CAROTID ENDARTERECTOMY

Myocardial infarction has been the major cause of mortality following operation for cerebrovascular insufficiency. In our institution, a clinical diagnosis of coronary artery disease was made in 37 of 125 (29.6%) consecutive male patients having carotid endarterectomy. Six of these 37 patients developed postoperative myocardial infarction. In contrast, none of the 88 patients without coronary artery disease developed myocardial infarction. A more recently treated group of 20 patients who had undergone carotid artery surgery and had previously undergone coronary artery bypass for angina did not develop postoperative myocardial infarction. These data suggest that in patients with both coronary artery and carotid artery disease, prior or concomitant coronary artery bypass should be considered. Myocardial infarction has been the leading cause of early and late death following operation for cerebrovascular insufficiency.(1) DeBakey(2) found operative mortality in patients having surgery for cerebrovascular insufficiency directly related to the incidence of coronary artery disease. An increased operative mortality due to reinfarction has been found in patients recovering from recent myocardial infarction.(3) Cooley(4) found that in patients having aortocoronary bypass there was no increased operative mortality 30 days after myocardial infarction and this may apply to patients having carotid endarterectomy. Subendocardial postoperative infarction associated with minor T wave changes and slight enzyme elevation had a better prognosis than did transmural infarction causing significant Q waves, sequential ST and T wave changes and marked enzyme elevations.(5) The purpose of this study was to document our experience with myocardial infarction in patients undergoing carotid artery operation for clinical coronary artery disease. Consideration of the role of saphenous vein bypass in those patients with coronary artery disease was the background for this review even though the evidence that myocardial infarction can be prevented with saphenous vein bypass operation is only preliminary at the present time.(6)