Objectives: We sought to evaluate whether socioeconomic status influences outcome after first-time single aortic or mitral valve replacement.Setting: National Heart Valve registry.Design and Patients: Between 1 January 1986 and 31 December 2001, 51 844 consecutive patients who underwent primary aortic or mitral valve replacement were registered on the United Kingdom (UK) Heart Valve Registry. Data included age, gender, valve position, type of valve implant, postcode, follow-up time, date and cause of death. The Carstairs deprivation score (1991 Census data for the UK) was used to stratify cases by level of social deprivation according to postcodes.Results: Both 30-day and 1-year survival/mortality rates were similar across all socioeconomic levels. However, long- term survival rate (up to 15 years) was significantly higher in the least deprived socioeconomic level than in the two most deprived levels. There was an 18% lower survival rate amongst women in the most deprived levels (35.9%, 95% CI: 32.4 to 39.4) versus the least deprived level (43.7%, 95% CI: 38.1 to 49.2, p < 0.004). In men, survival in the most deprived levels (39.5%, 95% CI: 36.4 to 42.5) was 7% lower than in the least deprived level (42.7%, 95% CI: 37.7 to 47.7, p < 0.005). Biological valve, mitral position, female gender, and low socioeconomic status were all associated with long- term mortality.Conclusions: A disadvantaged social background has a negative influence on long-term survival after aortic or mitral valve replacement, especially among women.

OBJECTIVE:South Asian patients in the UK have a higher mortality rate after coronary artery bypass grafting (CABG) than Caucasian patients. As coronary artery size has been shown to correlate to outcome from bypass grafting, it has been suggested that smaller coronary arteries in South Asians as compared to Caucasians could contribute to a poorer outcome in the Asian population. We aimed to measure coronary artery size and disease in matched South Asian and Caucasian men undergoing first time coronary artery bypass grafting. METHODS:Coronary arteriograms from 53 matched first generation South Asian and Caucasian men were examined. The patients had no history of myocardial infarction, coronary revascularisation, familial dyslipidaemia, diabetes or renal disease. They were individually matched for age, height, weight, body mass index and body surface area. Thereafter, coronary artery diameters and significant (> or =50%) diameter stenoses were measured in a blinded fashion using quantitative coronary angiography (QCA). RESULTS:In South Asian men, diameters of the left main stem (LMS) and the proximal left anterior descending, the circumflex and the right coronary arteries were 4.6+/-0.9 mm, 3.5+/-0.8 mm, 3.4+/-0.8 mm and 3.5+/-0.8 mm, respectively. The corresponding arterial diameters among Caucasian men (4.5+/-0.9 mm, 3.5+/-0.7 mm, 3.5+/-0.8 mm and 3.8+/-0.8 mm) did not differ from those in South Asians. There was no difference in the number of significant coronary artery stenoses between the two groups and no difference in bypass and cross-clamp times or in adverse outcome (one from each group died after coronary artery bypass grafting). CONCLUSION:Proximal coronary artery size and number of significant coronary stenoses did not differ between matched pairs of South Asian and Caucasian men using strict inclusion/exclusion criteria.

BACKGROUND:Patients with diabetes have an increased incidence and severity of ischemic heart disease, which leads to an increased requirement for coronary revascularization. Comparative information regarding mode of revascularization--coronary artery bypass graft surgery surgery (CABG) or percutaneous coronary intervention (PCI)--is limited, mainly confined to a subanalysis of the Bypass Angioplasty Revascularization (BARI) trial, suggesting a mortality benefit of CABG over PCI. No prospective trial has specifically compared these modes of revascularization in patients with diabetes.OBJECTIVE:The Coronary Artery Revascularisation in Diabetes (CARDia) trial is designed to address the hypothesis that optimal PCI is not inferior to modern CABG as a revascularization strategy for diabetics with multivessel or complex single-vessel coronary disease. The primary end point is a composite of death, nonfatal myocardial infarction, and cerebrovascular accident at 1 year.METHOD:A total of 600 patients with diabetes are to be randomized to either PCI or CABG, with few protocol restrictions on operative techniques or use of new technology. This gives a power of 80% to detect non-inferiority of PCI assuming that the PCI 1-year event rate is 9%. A cardiac surgeon and a cardiologist must agree that a patient is suitable for revascularization by either technique prior to recruitment into the study. Twenty-one centers in the United Kingdom and Ireland are recruiting patients. Data on cost effectiveness, quality of life, and neurocognitive function are being collected. Long-term (3-5 year) follow-up data will also be collected.

We studied the effect of enhanced external counterpulsation (EECP) in 23 consecutive patients with stable angina pectoris who had a positive dobutamine stress echocardiogram. After EECP, stress-induced wall motion score (WMS) improved by > or =2 grades in 43% of the patients (n = 10); the average improvement was 5.3 +/- 3.8 compared with -0.6 +/- 3.0 in the remaining 13 patients (p = 0.007). The diastolic/systolic augmentation ratio increased by 217% in response to the full course of EECP (p = 0.0002) among patients with improved WMS, and by 71% (p = 0.004) among the other patients; the increase was greater among patients with improved WMS than among patients with no improvement (p = 0.01). After EECP, Canadian Cardiovascular Society angina class improved from 3.1 +/- 0.6 to 2.2 +/- 0.7 (p <0.0001) in the entire group and exercise capacity increased by 73 seconds (p = 0.0002) in patients who were able to exercise (n = 18).

Infectious disease can be linked to social deprivation. We investigated whether postoperative infection with meticillin-resistant Staphylococcus aureus (MRSA) is related to socioeconomic background. Patients were stratified by social deprivation according to postcode. In a consecutive series of 1739 UK residents undergoing isolated coronary artery bypass grafting, 23 (1.3%) were infected with MRSA. We noted a graded relation between incidence of infection and social deprivation. Patients from the most deprived areas had a seven-fold higher infection rate (13 of 579 [2.2%]) than those from the least deprived areas (two of 580 [0.3%]; p=0.0040). Patients with MRSA infection had a six-fold higher mortality rate and a longer hospital stay than patients with no such infection. Our findings suggest that patients from deprived areas might be especially susceptible to postoperative infection with MRSA.

Summary Tracers for myocardial perfusion imaging during stress should not only have high cardiac uptake but they should also have a fast blood clearance to prevent myocardial tracer uptake after the ischaemic stimulus. The present study characterize the early phase of the arterial 99m Tc‐sestamibi (MIBI) time‐activity curve after venous bolus injection at rest, during peak exercise and after dipyridamole infusion. We included 11 patients undergoing angioplasty for one‐vessel disease (rest study) and 20 patients evaluated for the detection of haemodynamic significant coronary stenoses by 99m Tc‐sestamibi single photon emission computed tomography (SPECT) using either bicycle exercise testing (10 patients) or standard dipyridamole testing (10 patients). Arterial blood samples of 1 ml were taken from the left femoral artery (rest study) or the right radial artery (exercise and dipyridamole studies) every 5 s during the first 5 min postinjection. In the exercise and the dipyridamole studies blood sampling were extended to include blood samples every 5 min 5–30 min postinjection. Peak MIBI concentration was lower and decrease in concentration slower after tracer injection during exercise than during dipyridamole stress testing. This may cause an underestimation of perfusion defects during exercise because of MIBI uptake after the ischaemic stimulus. The implications of the study not only refer to the choice of stress modality when using MIBI. This study also underlines the importance of considering early blood clearance in addition to regional myocardial tracerkinetic aspects such as myocardial extraction fraction when new tracers are introduced.

In acute ischaemia, glucose-insulin-potassium administration reduces mortality and beta-adrenoceptor antagonists have favourable effects on the outcome of ischaemic heart disease. The present study was designed to investigate whether insulin (1.4 x 10(-7) M) and the beta-adrenoceptor antagonist, propranolol (10(-5) M), increase hypoxic vasodilation in correspondence with changes in glycolysis. Porcine coronary arteries, precontracted with 10(-5) M prostaglandin F-2alpha, were mounted in a pressure myograph and a microdialysis catheter was inserted in the tunica media. Hypoxic vasodilation, interstitial lactate/pyruvate ratio and interstitial glucose were measured at low (2 mM) and high (20 mM) glucose concentrations. Hypoxia (60 min) caused vasodilation and doubled the lactate/pyruvate ratio. Treatment with insulin quadrupled the lactate/pyruvate ratio during hypoxia, but did not change hypoxic vasodilation. Propranolol blocked isoprenaline-evoked vasodilation, but hypoxic increases in lactate/pyruvate ratio and vasodilation did not change. The combination of insulin and propranolol did not cause further changes compared with each drug added alone, although the combination increased vasoconstriction during reoxygenation. Interstitial glucose fell during hypoxia at an organ bath glucose concentration of 2 mM, and rose at a glucose concentration of 20 mM. Addition of insulin and propranolol alone or in combination had no effect on interstitial glucose concentration. Accordingly, arteries were found to contain only minute amounts of the glucose transporter isoform GLUT4. Our findings suggest that insulin increases arterial glycolysis, but treatment with insulin, propranolol, or both, is not associated with enhanced coronary vasodilation during hypoxia.

Background:Enhanced external counterpulsation (EECP) is a nsoninvasive treatment for angina that acutely augments diastolic pressure and reduces cardiac afterload. However, the mechanism of the sustained clinical benefit seen with this therapy is not known.

OBJECTIVES:To define the ability of early exercise testing and coronary angiography to predict prognosis in young survivors of myocardial infarction (MI).METHODS:255 consecutive patients (210 men) aged 55 years or less (mean 48 years) admitted to hospital (1981-85) were eligible. Of these, 150 patients (130 men) who were able to exercise early after MI and underwent coronary angiography within six months constituted the study group and were followed up for up to 15 years. Survival data up to 18 years was obtained for the whole cohort.RESULTS:Survival at a median of 16 years was 52% for the whole cohort, 62% for the study group, and 48% for the excluded group. From nine years onwards survival deteriorated significantly in the study group compared with an age matched background population. Fifteen years after MI, 121 patients (81%) in the study group had had at least one event (death, MI, revascularisation, cardiac readmission, stroke) leaving 29 (19%) event-free. The number of diseased vessels was the major determinant of time to first event (p = 0.001) and event-free survival (p = 0.04). Exercise duration was also important in the prediction of time to first event (p = 0.003). Death was influenced by a history of prior MI.CONCLUSION:The favourable initial survival was followed by significant deterioration after nine years. This late attrition is an important treatment target. Furthermore, this study supports risk stratification early after MI combining angiography with non-invasive tools.

Chronic low-grade inflammation has been associated with the development of atherosclerosis ( 1 Ross R. Atherosclerosis an inflammatory disease. N Engl J Med. 1999; 340: 115-126 Crossref PubMed Scopus (19694) Google Scholar ). Accordingly, increased levels of various plasma markers of inflammation, including leukocyte count, have been shown to predict coronary and cerebrovascular events ( 2 Danesh J. Collins R. Appleby P. Peto R. Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies. JAMA. 1998; 279: 1477-1482 Crossref PubMed Scopus (1876) Google Scholar , 3 Blankenberg S. Rupprecht H.J. Bickel C. et al. Circulating cell adhesion molecules and death in patients with coronary artery disease. Circulation. 2001; 104: 1336-1342 Crossref PubMed Scopus (496) Google Scholar ). However, markers of inflammation are also elevated in the presence of infections, unspecific inflammation, as well as a variety of diseases and conditions ( 4 Dale D.C. Neutropenia and neutrophilia. in: Beutler E. Lichtman M.A. Coller B.S. Kipps T.J. Seligsohn U. Williams Hematology. 6th ed. McGraw-Hill, New York, New York2001: 823-834 Google Scholar ), and they have been associated with risk factors such as smoking and obesity that may influence outcome in cardiovascular disease ( 2 Danesh J. Collins R. Appleby P. Peto R. Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies. JAMA. 1998; 279: 1477-1482 Crossref PubMed Scopus (1876) Google Scholar ). The importance of increased levels of inflammatory markers for outcome in relation to a major cardiac intervention is not known. We therefore evaluated the association between a single, preoperative, baseline leukocyte count before coronary artery bypass grafting and operative mortality.

Lactate is formed in the coronary arterial wall and in the myocardium as a consequence of ischaemia and infarction. We combined direct measurement of coronary artery diameter and interstitial arterial wall lactate concentration ex vivo in order to ascertain the possible role of lactate in hypoxia‐induced vasodilatation. The wall of porcine coronary arteries, precontracted during an intraluminal pressure of 40 mmHg by addition of prostaglandin F2α, was cannulated using a microdialysis catheter, and exposed to hypoxia for 60 min, followed by 45 min of reoxygenation. The exchange fraction of [14C]lactate over the microdialysis membrane increased from 0.38 ± 0.04 to 0.52 ± 0.05 (P < 0.001) during the study period. Coronary artery diameter increased by 15.5 ± 2.0 % (n= 20) during hypoxia (P < 0.001, compared to normoxic controls) and interstitial lactate concentration rose from 1.07 ± 0.21 to 2.50 ± 0.40 mmol l−1 during hypoxia (P < 0.01) and was unchanged in controls. The increase in coronary artery diameter correlated with the increase in interstitial lactate concentration in the period between 30 and 60 min of hypoxia (r= 0.62; P= 0.02). Dichloroacetate (10−5m), an agent that reduces lactate generation by activating pyruvate dehydrogenase, abolished hypoxia‐induced lactate production, but caused a further increase in coronary arterial diameter (30.2 ± 4.4 %, n= 9; P < 0.001 vs. hypoxia and no dichloroacetate). Under control conditions, the addition of l‐lactate (10−3‐10−2m) increased dose‐dependently coronary arterial diameter by 22.0 ± 4.2 % (n= 5) and interstitial lactate concentration from 0.52 ± 0.04 to 5.70 ± 0.66 mmol l−1 (P < 0.001). There was a correlation between the increase in coronary artery diameter and interstitial lactate concentration (r= 0.60; P= 0.02). The present observations represent the first direct measurements of metabolites by microdialysis in a blood vessel wall. The lactate concentration may affect, but is not essential for, hypoxia‐induced vasodilatation in porcine coronary arteries.

We did an observational study in 2059 patients undergoing coronary artery bypass surgery to assess the effect of haemoglobin concentration on in-hospital mortality. We noted that individuals with a preoperative haemoglobin concentration of 100 g/L or less had a five-fold higher in-hospital mortality rate after surgery than those with a higher haemoglobin concentration, despite having had blood transfusions or the pump primed with blood preoperatively as a routine precaution. Our findings suggest that a low haemoglobin concentration is a marker of disease severity or comorbidity that has a major effect on survival rate.

Background: Although the protective role of collaterals in coronary artery disease (CAD) is well known, the influence of drugs on collateral function remains controversial.Hypothesis: We aimed to investigate prospectively the prevalence of spontaneously visible and recruitable coronary collaterals in consecutive patients with single-vessel CAD and the effect of systemic administration of nitroglycerin on these types of collaterals during percutaneous transluminal coronary angioplasty (PTCA).Methods: Ipsi- and contralateral coronary artery contrast injections were performed before and during PTCA. Simultaneously with balloon occlusion, we measured coronary artery occlusion pressure via the balloon catheter. All measurements were repeated after administration of 0.5 mg of nitroglycerin intravenously.Results: Of 101 consecutive patients, 24% had spontaneously visible and 30% had recruitable collaterals. Contralateral collaterals were five times more frequent than ipsilateral collaterals. Presence of collaterals was highly associated with the degree of coronary stenosis. Coronary occlusion pressure was higher in patients with than in those without collaterals. Collaterals prevented pain and ischemia during PTCA, and in this respect spontaneously visible collaterals were more effective than recruitable collaterals, There was no effect of systemic administration of nitroglycerin on appearance or occlusion pressure of coronary collaterals.Conclusion: Coronary collaterals were found in more than half of patients with single-vessel CAD, as the Prevalence of recruitable collaterals was slightly higher than that of spontaneously visible collaterals. Nitroglycerin did neither recruit nor augment coronary collaterals.

OBJECTIVE:To investigate the relationship between admission plasma glucose and 30-day mortality after primary isolated coronary artery bypass grafting (CABG) in nondiabetic patients. RESEARCH DESIGN AND METHODS:All nondiabetic patients with admission plasma glucose measurement undergoing primary isolated CABG from 1993 to 1997 were included in this study. RESULTS:In 878 consecutive patients (155 women), overall mortality was 3.4% (95% CI 2.3-4.8). The mortality rate in women (n = 11; 7.1%, 3.6-12.3) was higher than in men (n = 19; 2.6%, 1.6-4.1) (P = 0.01). There was a positive correlation between plasma glucose and 30-day mortality among women only (P = 0.0001). There was a higher mortality rate in the upper two glucose quartiles (11.7%, 5.5-21.0) compared with the lower two quartiles (2.6%, 3.0-8.9) in the female patients (P = 0.03); a plasma glucose of 6.0 mmol/l separated high- and low-mortality groups. Furthermore, women in the upper two glucose quartiles had a fourfold higher mortality rate than men in the similar quartiles (P = 0.002). Among men, there was no difference in mortality rate across glucose quartiles. In a multivariate analysis, admission plasma glucose, history of thyroid disease, left ventricular ejection fraction <0.35, operation bypass time, and perioperative myocardial infarction were independently associated with mortality. CONCLUSIONS:Women with admission plasma glucose < or =6.0 mmol/l and men across the whole range of glucose values had similar mortality rates after CABG. The surplus female mortality was found only in subjects with plasma glucose >6 mmol/l. Further studies are needed to appraise the possible influence of glucose status on outcome from CABG in nondiabetic subjects.

In a consecutive series of 436 Indian Subcontinent Asians and 1,458 Caucasians undergoing primary isolated coronary artery bypass grafting, the mortality rate was twofold higher in Asians than in Caucasians, which resulted mainly from a mortality difference between men in the 2 groups. Diabetics had a higher mortality rate than nondiabetics. and diabetes, 2.5 times more frequent in Asians than in Caucasians, was an independent predictor of death only in Asians and may in part explain the mortality difference.

The purpose of the study was to investigate the influence of preactivation, wall tension and geometry on the reactivity of porcine coronary arteries to nifedipine and extracellular Ca(2+) in vitro. Porcine large coronary arteries were mounted as ring and cylindrical preparations and studied by wire- and balloon-based techniques. The sensitivity and maximal responses to nifedipine were more pronounced in 25 mM K(+) compared to 10 microM prostaglandin F(2alpha)-contracted preparations. Vascular sensitivity to nifedipine and Ca(2+) was enhanced under isometric compared to isobaric conditions. Under isometric conditions in the presence of 25 mM K(+), coronary rings were more sensitive to nifedipine, but less sensitive to Ca(2+) compared to cylindrical segments. In cylindrical segments, circumferential and axial tension increases augmented the extracellular Ca(2+)-dependent spontaneous resting tone and the sensitivity to extracellular Ca(2+). Coronary rings showed no resting tone at various resting tensions. These results suggest that preactivation, wall tension and vessel geometry are important determinants of Ca(2+)-influxes via nifedipine-sensitive voltage-gated Ca(2+) channels. Furthermore, axial wall tension appears to be a modulator of nifedipine-insensitive transmembrane Ca(2+)-influx that may play a role for the tone and reactivity in large coronary arteries.

Objectives. The present study evaluated the impact of recruitable collaterals on regional myocardial perfusion measured by (99m)technetium (Tc)-sestamibi single-photon emission computerized tomography (SPECT) during temporary coronary occlusion and related these estimates to the coronary wedge pressure and electrocardiographic (ECG) ST-segment changes.Background. Clinical variables (angina and ECG changes) and intracoronary flow and pressure recordings have indicated a protective role of recruitable collaterals on myocardial perfusion during percutaneous transluminal coronary angioplasty (PTCA).Methods. Thirty patients (mean age 55 years, SD 9; 20 men) with stable angina pectoris and proximal nonoccluding single-vessel left anterior descending coronary artery (LAD)-stenosis scheduled for PTCA were included. Visualization of recruitable collaterals by ipsilateral and contralateral contrast injection, registration of coronary wedge pressure and injection of Tc-99m-sestamibi during 90-s LAD occlusions were undertaken. A rest perfusion study was performed within four days before PTCA. As an estimate of the severity of regional hypoperfusion during occlusion, an occlusion/rest count ratio was calculated (mean defect pixel count during occlusion divided by mean pixel count in identical regions at rest).Results. The scintigraphic occlusion/rest count ratio was higher in patients with recruitable collaterals (n = 16), 67 +/- 11%, compared to patients without collaterals (n = 14), 60 +/- 6% (p < 0.05). The occlusion/rest count ratio correlated with the coronary wedge pressure (R-2 = 0.34; p < 0.001). The occlusion/rest count ratio was lower, 61 +/- 6%, in patients with ST-segment elevation (n = 23) versus 74 +/- 9% in patients without ST-segment elevation (n = 7) (p < 0.0001).Conclusions. Using Tc-99m-sestamibi SPECT imaging during brief episodes of coronary occlusion, the severity of regional myocardial hypoperfusion was reduced by the presence of recruitable collaterals in a selected patient population with proximal LAD stenoses. Our results demonstrate a protective effect of recruitable collaterals on myocardial perfusion during temporary coronary occlusion. (C) 2000 by the American College of Cardiology.

Background: Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow‐up. Although repeat angiography usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information.