cardiovascular-agents and Syndrome

Chronic coronary syndromes (CCS) and stable angina are a growing clinical burden worldwide. This is of particular concern in the Gulf region given its high prevalence of cardiovascular risk factors, especially diabetes mellitus and smoking. Despite recommendations on the use of first- and second-line anti-anginal medication, management challenges remain. Current guidelines for pharmacologic treatment are not determined by the range of pathophysiological mechanisms of ischaemia and consequent angina, which may occur either in isolation or co-exist. In this article, we highlight the need to improve knowledge of the epidemiology of chronic coronary syndromes in the Middle East and Gulf region, and the need for studies of stratified pharmacologic approaches to improve symptomatic angina and quality of life in the large and growing number of patients with coronary artery disease from this region. We discuss the role of nicorandil, currently recommended as a second-line anti-anginal drug in CCS patients, and suggest that this may be a particularly useful add-on therapy for patients in the Gulf region.

Topics: Angina, Stable; Cardiovascular Agents; Humans; Nicorandil; Quality of Life; Syndrome; Vasodilator Agents

Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.

Topics: Acute Disease; Cardiovascular Agents; Heart Failure; Humans; Randomized Controlled Trials as Topic; Syndrome

Topics: Adult; Androstenes; Anxiety; Blood Volume; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Confusion; Contraindications; Diagnosis, Differential; Fatigue; Female; Hemodynamics; Humans; Leg; Mast Cells; Norepinephrine; Norepinephrine Plasma Membrane Transport Proteins; Posture; Renin-Angiotensin System; Sodium Chloride; Sympathetic Nervous System; Syncope; Syndrome; Tachycardia

The medication used in cardiopulmonary resuscitation (CPR) has by no means yielded the expected prognostic benefit. This review focuses on drugs that are currently under investigation as part of novel therapeutic strategies in CPR and post-resuscitation care.. The main categories of drugs under investigation were identified in position papers regarding gaps in scientific knowledge and research priorities in CPR. The electronic bases of Medline via PubMed and the ClinicalTrials.gov registry were searched. Research terms were identified using the MESH database and were combined thereafter. Initial search terms were "cardiac arrest", "cardiopulmonary resuscitation", "post-cardiac arrest syndrome" combined with "drugs" and also the names of pharmaceutical categories and related drugs.. Novel pharmaceutical approaches rely on a better understanding of the pathophysiology of cardiac arrest and post-resuscitation syndrome. Some medications are targeted primarily towards enhancing the return of spontaneous circulation and increasing survival rates, while others mostly aim at the attenuation of post-arrest myocardial and neurological impairment. Only a few of these therapies are currently being evaluated for clinical use. Despite the remarkable variability in study quality and success in achieving therapeutic targets, results for most therapies seem encouraging and support the continuation of research.. New pharmaceutical modalities are being investigated for future use in CPR. Currently, none has been unequivocally accepted for clinical use, while only a few of them are undergoing clinical testing. This research is likely to continue, in view of the unsatisfactory results of current pharmaceutical therapies and the encouraging results of preliminary studies.

Topics: Cardiopulmonary Resuscitation; Cardiovascular Agents; Heart Arrest; Humans; Hypoxia, Brain; Prognosis; Syndrome; Treatment Outcome

Topics: Animals; Cardiovascular Agents; Heart Arrest; Humans; Hypothermia, Induced; Oxygen Inhalation Therapy; Patient Care Team; Syndrome

Cardiac and kidney diseases are very common, and increasingly coexist. Classification for cardiorenal syndrome and for its specific subtypes has been developed and published recently by a consensus group of the Acute Dialysis Quality Initiative. Cardiorenal syndromes have been classified according to whether the impairment of each organ is primary, secondary or whether heart and kidney dysfunction occurs simultaneously as a systemic disease. The different syndromes were classified into five subtypes. Type-1: acute cardiorenal syndrome: an abrupt worsening of cardiac function leading to acute kidney injury and/or dysfunction. Type-2: chronic cardiorenal syndrome: chronic abnormalities in cardiac function causing kidney injury and/or dysfunction. Type-3: acute renocardiac syndrome: abrupt worsening of kidney function leading to heart injury and/or dysfunction. Type-4: chronic renocardiac syndrome: chronic kidney diseases leading to heart injury, disease and/or dysfunction. Type-5: secondary cardiorenal syndrome: acute or chronic systemic diseases leading to simultaneous injury and/or dysfunction of heart and kidney. The identification of patients and the pathophysiological mechanisms underlying each syndrome subtype will help cardiologists, nephrologists and physicians working on intensive care units to characterize groups of their patients with cardiac and renal impairment and to provide a more accurate treatment for them.

Topics: Acute Disease; Acute Kidney Injury; Biomarkers; Cardiovascular Agents; Chronic Disease; Creatinine; Glomerular Filtration Rate; Heart Failure; Humans; Kidney Failure, Chronic; Renal Agents; Renal Insufficiency; Syndrome

Acute aortic syndromes (AAS) comprise a group of potentially lethal conditions that require prompt recognition, diagnosis as well as acute medical stabilization and surgical intervention. The purpose of this article is to review the relevant variants of AAS presentation, as well as diagnostic and management issues, including adequate long-term medical therapy and follow-up imaging. In this context, the American College of Cardiology and the American Heart Association recently published guidelines on the management of thoracic aortic disease, drawing greater attention to these processes.

Topics: Acute Disease; Angioplasty; Aortic Aneurysm, Thoracic; Aortic Dissection; Aortic Rupture; Aortography; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Echocardiography, Transesophageal; Follow-Up Studies; Humans; Image Processing, Computer-Assisted; Imaging, Three-Dimensional; Magnetic Resonance Angiography; Marfan Syndrome; Multidetector Computed Tomography; Postoperative Complications; Registries; Risk Factors; Stents; Survival Rate; Syndrome; Ulcer

Hospitalization for acute heart failure syndromes (AHFS) is a growing health care burden. Over 1 million hospitalizations occur annually, with a postdischarge mortality and rehospitalization rate of ~45% by 90 days and a financial cost greater than $20 billion. Attempts to improve outcomes through novel therapies have largely failed, suggesting new approaches are needed. We review phase II studies in AHFS to identify opportunities for future development programs.

Topics: Acute Disease; Cardiac Resynchronization Therapy; Cardiovascular Agents; Clinical Trials, Phase II as Topic; Heart Failure; Humans; Randomized Controlled Trials as Topic; Syndrome

Phase 3 clinical trials in acute heart failure are conducted to allow safety and efficacy data to be collected for the evaluation of treatment strategies, including drugs, devices, diagnostics, or nonpharmacological interventions. There are several important features regarding the conduct of phase 3 clinical trials in acute heart failure. This article describes in detail these important aspects of conducting phase 3 clinical trials in an acute heart failure population.

Topics: Acute Disease; Cardiac Resynchronization Therapy; Cardiovascular Agents; Clinical Trials, Phase III as Topic; Heart Failure; Humans; Randomized Controlled Trials as Topic; Syndrome

Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease, and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse, and abnormal cardiac nociception can also present as angina of cardiac origin. For nonacute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing can help diagnose endothelial-dependent and -independent microvascular dysfunction. Lifestyle modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on the pathophysiology, diagnosis, and treatment of stable, non-ACS anginal chest pain.

Topics: Age Factors; Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Diagnosis, Differential; Diagnostic Imaging; Electrocardiography; Exercise Test; Female; Humans; Male; Myocardial Revascularization; Risk Factors; Sex Factors; Syndrome

Co-existent cardiac and renal dysfunction is increasingly recognized as both a predictor and mediator of poor outcomes in patients with advanced heart failure. Novel therapies, including adenosine receptor antagonists, are currently under development for the treatment of 'cardiorenal syndrome'.. To review the pathophysiologic rationale for using rolofylline, a selective adenosine 1 receptor antagonist, in patients with cardiorenal syndrome; and to provide a critical overview of safety and efficacy data from clinical studies.. We reviewed published data on the pharmacology of rolofylline, and used this to inform a comprehensive summary of preclinical and clinical trials. Cardiac and renal effects, and safety data with a particular reference to seizures, are highlighted.. Rolofylline facilitates diuresis and preserves renal function in patients with acute decompensated heart failure and renal dysfunction. Pilot data also suggest beneficial effects on symptoms and short-term outcomes. The risk of seizures may be minimized by excluding high-risk patients.

Topics: Adenosine A1 Receptor Antagonists; Animals; Cardiovascular Agents; Clinical Trials as Topic; Dose-Response Relationship, Drug; Heart Failure; Humans; Renal Insufficiency, Chronic; Syndrome; Xanthines

Several therapies commonly used for the treatment of acute heart failure syndromes (AHFS) present some well-known limitations and have been associated with an early increase in the risk of death. There is, therefore, an unmet need for new pharmacologic agents for the early management of AHFS that may improve both short- and long-term outcomes.. To review the recent evidence on emerging pharmacologic therapies in AHFS.. A systematic search of peer-reviewed publications was performed on MEDLINE, EMBASE and Clinical Trials.gov from January 1990 to August 2007. The results of unpublished or ongoing trials were obtained from presentations at national and international meetings and pharmaceutical industry releases. Bibliographies from these references were also reviewed, as were additional articles identified by content experts.. Cumulative data from large studies and randomised trials suggest that therapies with innovative mechanisms of action may safely and effectively reduce pulmonary congestion or improve cardiac performance in AHFS patients.. Some investigational agents for the management of AHFS are able to improve haemodynamics and/or clinical status. In spite of these promising findings, no new agent has demonstrated a clear benefit in terms of long-term clinical outcomes compared to placebo or conventional therapies.

Topics: Adenosine; Cardiovascular Agents; Endothelin-1; Etiocholanolone; Heart Failure; Hemodynamics; Humans; Hydrazones; Natriuretic Peptide, Brain; Perhexiline; Pyridazines; Randomized Controlled Trials as Topic; Simendan; Sodium-Potassium-Exchanging ATPase; Syndrome; Vasodilator Agents

As for other critically ill diseases, two key factors may markedly improved morbidity and mortality of acute heart failure syndromes (AHFS): early initiation of treatment and tailored therapy. Early initiation aims to stop the negative cascade of heart dysfunction. Tailored therapy should be based on the level of systolic blood pressure at admission and fluid retention. Indeed, EFICA and OPTIMIZE-HF showed that patients with high systolic blood pressure have a left ventricular systolic function that is likely preserved and those with low systolic blood pressure have a lower left ventricular ejection fraction and frequent signs of organ's hypoperfusion. Among the proposed treatments, non-invasive ventilation is the only treatment that was consistently proven to be beneficial on morbidity and mortality in almost all types of AHFS. Concerning pharmacological agents, actions should be taken to increase the use of vasodilators and reduce the use of diuretics.

Topics: Acute Disease; Algorithms; Cardiotonic Agents; Cardiovascular Agents; Clinical Trials as Topic; Continuous Positive Airway Pressure; Diuretics; Heart Failure; Humans; Stroke Volume; Syndrome; Systole; Treatment Outcome; Vasoconstrictor Agents; Vasodilator Agents; Ventricular Dysfunction, Left

Acute Heart Failure Syndromes (AHFS) is a common admission diagnosis associated with high mortality and hospital readmissions. Given the mixed results of recent clinical trials, the early management of AHFS remains controversial.. To review the recent evidence regarding current and investigational therapies for the early management of AHFS.. A systematic search of peer-reviewed publications was performed on MEDLINE and EMBASE from January 1990 to August 2006. The results of unpublished or ongoing trials were obtained from presentations at national and international meetings and pharmaceutical industry releases. Bibliographies from these references were also reviewed, as were additional articles identified by content experts.. Criteria used for study selection were controlled study design, relevance to clinicians and validity based on venue of publication and power analysis.. Although all current intravenous therapies for the early management of AHFS appear to improve hemodynamics, this may not always translate into short-term clinical benefit.. The results of the trials conducted to date in AHFS have generally been disappointing. There is, therefore, an unmet need for new therapeutic approaches for the early management of AHFS that may improve the short-term and long-term outcomes.

Topics: Cardiac Output, Low; Cardiovascular Agents; Clinical Trials as Topic; Humans; Prognosis; Syndrome

Use of molecular tools to diagnose and treat aortic disease, in particular, aortic aneurysms and aortic dissections, is still in its infancy, with great advancements expected in the future. Currently under investigation are the genetic markers linked to aortic disease that may help to identify patients at risk for their development prior to clinical presentation. In addition, specific gene defects may be identified that can assist in the understanding of the basic mechanisms contributing to development of aortic disease. Biomarkers are under investigation that can be used to monitor the development, progression, and possible response to therapy for aortic aneurysms and acute aortic syndromes. Equally important, further investigations into the molecular mechanisms involved in aortic pathology will result in increased understanding of the disease etiology and will lead to development of alternate therapies for these diseases prior to their catastrophic development. With advances in molecular technology, the molecular diagnosis and treatment of aortic diseases will begin to expand at a rapid rate and provide unique, improved therapies.

Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Aortic Diseases; Aortic Dissection; Biomarkers; Cardiovascular Agents; Genetic Predisposition to Disease; Genetic Therapy; Humans; Molecular Diagnostic Techniques; Risk Factors; Signal Transduction; Syndrome

Stable angina pectoris is a manifestation of ischemic heart disease which frequently leeds to acute coronary syndrome. The patient has a short effort or stress situation induced retrosternal pain which is easing after the elimination of its cause, or taking nitroglycerin. Several new data have appeared in the literature about the pathogenesis and diagnosis of stable angina pectoris. Due to the international guidelines using the new drugs and revascularisation techniques, the primary and secondary prevention of stable angina pectoris was improved.

Topics: Acute Disease; Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Humans; Myocardial Ischemia; Syndrome

The management of bradycardia-tachycardia syndrome (BTS) includes bradycardia and tachyarrhythmia therapy. At present, the treatment for symptomatic bradycardia in BTS patients is permanent cardiac pacing. The pharmacological treatment of atrial tachyarrhythmias comprises of rhythm and rate control, and prevention of thromboembolism. Patients with BTS often require both pacemaker and drug therapy. This article reviews the interactions of pacing and drug therapies in BTS. Drugs that alter cardiac electrophysiological properties may influence pacemaker indications, pacing mode selection, efficacy of pacing algorithms and pacing performance. Pacing by preventing drug-induced bradycardia increases the safety of pharmacotherapy and, thus, allows the intensification of those treatments. Pacing therapy and antiarrhythmic drugs used together as a hybrid therapy have a synergistic effect in the prevention of atrial tachyarrhythmias. Atrial-based pacing may reduce atrial tachyarrhythmia burden, allowing reduction of rhythm and rate control. Contemporary pacemakers' memory functions may help guide rhythm and rate control, as well as anticoagulation pharmacotherapy.

Topics: Bradycardia; Cardiac Pacing, Artificial; Cardiovascular Agents; Humans; Pacemaker, Artificial; Syndrome; Tachycardia

Patients presenting with acute coronary syndromes without ST elevation on their electrocardiogram continue to contribute an important healthcare burden. Medical treatments to control symptoms include nitrates and beta-blockers. Morphine is a very effective analgesic although its use may be associated with adverse outcomes. Oral antiplatelet therapies including aspirin and clopidogrel form a cornerstone of prognostically modifying therapy. Similarly, the intravenous IIb/IIIa antagonists have emerged as having an important role in patients undergoing coronary intervention. Low molecular weight heparins are more convenient to use than unfractionated heparin and may be more effective. Care should be taken to avoid mixing the two antithrombins as this contributes to increased bleeding risk. Statins can impact on short-term outcomes when given during the acute admission; and this benefit is augmented if high doses are used.

Topics: Acute Disease; Cardiovascular Agents; Coronary Disease; Humans; Syndrome

Topics: Arteriosclerosis; Cardiovascular Agents; Cardiovascular Diseases; Embolism; Endocarditis, Bacterial; Eye Diseases; Giant Cell Arteritis; Humans; Medical History Taking; Ocular Hypertension; Retinal Vein Occlusion; Syndrome

Management of acute coronary syndromes has been the focus of increased interest in recent years. This has come about with the recognition that the majority of patients who present to the hospital with chest pain have unstable angina or non-Q-wave myocardial infarction (MI). Further, sensitive biochemical markers of myocardial necrosis, such as troponin and creatine kinase, have improved early diagnosis. Markers of inflammation such as C-reactive protein (CRP), although not in wide clinical practice, may provide an early and important marker of prognosis. The current approach to management of acute coronary syndromes is careful risk stratification so as to select appropriate medical therapies and to guide the clinician to appropriate interventions such as angiography or percutaneous coronary intervention (PCI). Established therapies such as aspirin, heparin, intravenous nitrates, and, in selected patients, beta blockers or calcium antagonists, are being used concomitantly with, or are being supplanted by, newer therapies such as low-molecular-weight heparins and glycoprotein IIb/IIIa inhibitors. The role of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) in patients with acute coronary syndromes is being investigated and shows promise.

Topics: Acute Disease; Adrenergic beta-Antagonists; Algorithms; Angina, Unstable; Biomarkers; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Heparin, Low-Molecular-Weight; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Infarction; Nitroglycerin; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Randomized Controlled Trials as Topic; Risk; Risk Factors; Severity of Illness Index; Syndrome; Troponin I

The clinical entities of unstable angina, non-Q wave myocardial infarction, and Q wave myocardial infarction share the same pathogenesis and, because of this, are linked under the heading of acute coronary syndromes. Prompt reperfusion in the early phase of acute ST segment elevation myocardial infarction, with thrombolysis or percutaneous transluminal coronary angioplasty, now has an established place in the treatment of this condition. However, thrombolysis has been disappointing and may be harmful in the treatment of unstable angina and non-Q wave myocardial infarction. While traditional therapy with morphine, oxygen, nitrates, aspirin, heparin, and beta blockers may be indicated in the treatment of all types of acute coronary syndromes, recent studies have led to advances in the treatment of unstable angina/non-Q wave myocardial infarction patients. In these patients, enoxaparin (a low molecular weight heparin) and the platelet glycoprotein IIb/IIIa receptor antagonists may be particularly effective.

Topics: Acute Disease; Cardiac Catheterization; Cardiovascular Agents; Coronary Disease; Heparin, Low-Molecular-Weight; Humans; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Syndrome; Thrombin

Topics: Acute Disease; Angina, Unstable; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Thrombosis; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Middle Aged; Myocardial Infarction; Syndrome

The coronary circulation is controlled by the central nervous system, circulating hormones and local vascular mechanisms. The importance of local regulatory mechanisms has only recently been recognized. The endothelium is in a strategical anatomical position within the blood vessel wall located between the circulating blood and vascular smooth muscle cells. It can respond to mechanical and hormonal signals from the blood; of particular importance is the fact that it is a source of mediators which can modulate the contractile state and proliferative responses of vascular smooth muscle cells, platelet function and coagulation as well as monocyte adhesion. Important relaxing factors are nitric oxide and prostacyclin and a putative hyperpolarizing factor. Nitric oxide also inhibits smooth muscle proliferation and, together with prostacyclin, platelet adhesion and aggregation. Bradykinin-induced nitric oxide production is regulated by angiotensin converting enzyme located on the endothelial cell membrane; indeed, the enzyme not only activates angiotensin I into angiotensin II, but also inactivates bradykinin. Endothelin-1 and thromboxane A2 and prostaglandin H2 are contracting factors produced by the endothelium. In contrast to thromboxane A2 and prostaglandin H2 which activate platelets, endothelin has no direct effects on these cells, but has proliferative properties in vascular smooth muscle. Under physiological conditions, the endothelium plays a protective role as it prevents adhesion of circulating blood cells, keeps the vasculature in a vasodilated state and inhibits vascular smooth muscle proliferation. In disease states, however, endothelial dysfunction contributes to enhanced vasoconstrictor responses, adhesion of platelets and monocytes and proliferation of vascular smooth muscle cells, events all known to occur in coronary artery disease. Nitrates substitute in part for deficient endogenous nitric oxide, while angiotensin converting enzyme inhibitors increase the bradykinin induced nitric oxide and prostacyclin production. The newly developed endothelin antagonists allow specific blocking of the effects of endothelin. Pharmacological correction of endothelial dysfunction may be important to treat coronary artery disease and its complications.

Topics: Acute Disease; Blood Platelets; Cardiovascular Agents; Coronary Disease; Endothelium, Vascular; Humans; Muscle, Smooth, Vascular; Myocardial Contraction; Nitric Oxide; Risk Factors; Syndrome

This review discusses the circadian phase dependency in the anti-anginal effects and in the pharmacokinetics of drugs used in the treatment of coronary heart diseased patients. beta-receptor blocking agents seem mainly to reduce ischaemic events during daytime hours and are of therapeutic value in the morning hours which are the hours of high cardiovascular risk. Calcium channel blockers seem to be less effective in reducing ischaemic event during the night and early morning. However, the galenic formulation and the type of calcium channel blocker may play an important role. Whereas the effects of the anti-ischaemic properties of oral nitrates are well established, their influence of the circadian organization of cardiovascular events needs to be clarified. Only limited data are available concerning the circadian phase dependency in the dose-response relationship of anti-anginal drugs. Such data would be valuable for a better understanding of the need of a time-specified drug treatment which is based on the circadian phase dependency of cardiovascular events such as coronary infarction and angina pectoris attacks.

Topics: Acute Disease; Adrenergic alpha-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Chronotherapy; Coronary Disease; Humans; Myocardial Ischemia; Nitrates; Syndrome

The growing size of trials on primary and secondary prevention of acute coronary syndromes characterised by very broad inclusion criteria may seem logical to 'trialists', who reason that the the broader the inclusion criteria, the easier it is to recruit large numbers of patients in a short period of time and the more widely applicable are the results of the study. However, large trials with very broad inclusion criteria raise two grounds for concern for physicians. The first is that the broader the inclusion criteria for enrollment in a trial in order to prove a statistically significant benefit, the greater the heterogeneity of the study population which is likely to include both susceptible and non-susceptible patients to the tested treatment. The second is that this method of assessment rapidly increases the number of treatments that produce a statistically-significant improvement in prognosis within the same broad group of patients. On the contrary, the identification of potential responders to a specific treatment can provide a personalised form of medical care suited to the needs of each individual patient with an optimal cost-benefit ratio. This approach, however, represents a major challenge as it can only be based on the identification of homogeneous subgroups of patients with common risk factors for the development of acute coronary syndromes or of their recurrence. This challenge can only be overcome by a strong commitment in funding studies on the multiple causes of acute coronary syndromes.

Topics: Acute Disease; Adult; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Europe; Humans; Syndrome; United States

Topics: Aged; Animals; Anti-Bacterial Agents; Anticonvulsants; Cardiovascular Agents; Chloroquine; Drug-Related Side Effects and Adverse Reactions; Hormones; Humans; Motor Endplate; Myasthenia Gravis; Neuromuscular Junction; Penicillamine; Postoperative Complications; Psychotropic Drugs; Respiratory Insufficiency; Synaptic Transmission; Syndrome

Recently heart failure with preserved ejection fraction (HFpEF) has emerged as a huge epidemic. Increasing evidence shows the role of energy deficiency in the pathophysiology of HFpEF. In the current study, we hypothesize that the use of metabolic modulator perhexiline would correct myocardial energy deficiency and improve exercise capacity and diastolic abnormalities in patients with this syndrome.

Topics: Cardiovascular Agents; Clinical Protocols; Double-Blind Method; Heart Failure; Humans; Outcome Assessment, Health Care; Perhexiline; Stroke Volume; Syndrome

The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected populations. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes (ACSs) in a largely indigent county hospital setting.. Patients admitted for ACS were randomized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit. Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines. Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence-based practice goals.. One hundred forty consecutive patients were randomized. A similar proportion of patients returned for study follow-up in both groups at 3 months (54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group; P = 0.97). Among those completing the 3-month visit, a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 (69%) of the usual care patients compared with 35 (57%) of those in the intervention group (P = 0.43). There was no statistical difference in implementation of therapeutic lifestyle changes (smoking cessation, cardiac rehabilitation, or exercise) between groups. Prescription rates of evidence-based therapeutics at 3 months were similar in both groups.. The implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence-based secondary prevention treatment goals. Despite initially high rates of evidence-based treatment at discharge, adherence with follow-up appointments and sustained implementation of evidence-based therapies remains a significant challenge in this high-risk cohort.

Topics: Acute Disease; Algorithms; Cardiovascular Agents; Coronary Care Units; Coronary Disease; Female; Follow-Up Studies; Guideline Adherence; Humans; Male; Middle Aged; Retrospective Studies; Syndrome; Treatment Outcome

The aim of this study was to examine the effect on symptoms in patients with induced cardioinhibitory carotid sinus syndrome (ICSS) when treated or not treated with a pacemaker.. Sixty patients with a history of syncope or pre-syncope and ICSS were randomized to receive a permanent pacemaker (P group, n = 30) or no pacing (NP group, n = 30). ICSS was defined as a ventricular pause (i.e. asystole) lasting 3 s or more in response to carotid sinus stimulation. The patients were seen at 3 and 12 months and at symptoms. At 12 months, the rate of syncope in the NP group was 40% (n = 12) compared with 10% (n = 3) in the P group (P = 0.008). The majority (11 of 12) of the syncope recurrences in the NP group occurred during the first 3 months. Pre-syncope occurred in two patients (7%) in the NP group and in eight (27%) in the P group. Ten patients (33%) with recurrent syncope in the NP group later crossed-over to receive pacemaker implant.. A history of syncope or pre-syncope, plus ICSS, was a strong predictor of subsequent syncope or pre-syncope. Most of the new symptoms occurred within 3 months. Pacemaker treatment effectively reduced syncope and/or resulted in milder symptoms.

Topics: Aged; Cardiac Pacing, Artificial; Cardiovascular Agents; Carotid Sinus; Female; Humans; Male; Middle Aged; Pacemaker, Artificial; Recurrence; Regression Analysis; Syncope; Syndrome; Tilt-Table Test; Treatment Outcome

To address the existing gaps in knowledge about long-acting nitroglycerine (LA-NTG) and provide recommendations to address these issues.. Approved LA-NTG questionnaire that included 17 questions related to the role of LA-NTG in the management of angina and chronic coronary syndrome (CCS) was shared with 150 expert cardiologists from different regions from India. Results of these survey questionnaires were further discussed in 12 regional level meetings. The opinions and suggestions from all the meetings were compiled and analyzed. Further, recommendations were made with the help of attending national cardiology experts and a consensus statement was derived.. This is the first consensus on LA-NTG, summarizing the clinical evidence from India and suggesting recommendations based on these data. The experts recommended early use of LA-NTG as a first-line antianginal therapy in combination with beta-blocker since it improves exercise tolerance in patients with CCS. A strong consensus was observed for using LA-NTG in patients with co-morbid hypertension, diabetes, chronic kidney disease and post-percutaneous coronary intervention angina. As a part of cardiac rehabilitation, LA-NTG allows patients with angina to exercise to a greater functional capacity.. A national consensus was observed for several aspects of LA-NTG in the management of angina and CCS. The clinical experience of the experts confirmed an extremely satisfied patient perception about the efficacy of LA-NTG.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; India; Nitroglycerin; Percutaneous Coronary Intervention; Syndrome

Topics: Angina Pectoris; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiac Rehabilitation; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Complementary Therapies; Coronary Angiography; Coronary Artery Disease; Coronary Stenosis; Drugs, Chinese Herbal; Humans; Male; Medicine, Chinese Traditional; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Stents; Stroke Volume; Syndrome; Tai Ji

Topics: Cardiology; Cardiovascular Agents; Chronic Disease; Consensus; Coronary Artery Disease; Evidence-Based Medicine; Humans; Myocardial Revascularization; Practice Guidelines as Topic; Syndrome; Treatment Outcome

Topics: Aged; Angioplasty, Balloon, Coronary; Angioscopy; Biopsy; Cardiovascular Agents; Coronary Aneurysm; Coronary Angiography; Coronary Artery Disease; Coronary Thrombosis; Drug-Eluting Stents; Female; Humans; Myocardial Infarction; Neointima; Percutaneous Coronary Intervention; Predictive Value of Tests; Prosthesis Design; Risk Factors; Sirolimus; Syndrome; Thrombectomy; Tomography, Optical Coherence; Treatment Outcome; Ultrasonography, Interventional

Over the last 2 decades, early treatment for patients presenting with acute heart failure syndromes (AHFS) has changed very little. Despite strikingly different underlying disease pathophysiology, presenting signs and symptoms, and precipitants of AHFS, most patients are treated in a homogeneous manner with intravenous loop diuretics. Inhospital studies of new therapies have produced disappointingly neutral results at best. Patients continue to be enrolled in trials long after initial therapy, at a time when vital signs have improved, symptoms have changed, and initiating pathophysiologic processes, such as myocardial and renal injury, have already begun. The "one-size-fits-all" approach to inhospital AHFS trials have been recognized as one potential contributor to the disappointing trial results seen to date. Studies designed to tailor the therapeutic approach to ascertain which treatment modalities are most effective depending on patient phenotypes have not been previously conducted in AHFS because this objective is not traditional in clinical trial design. Utilizing Bayesian adaptive designs in trials of early AHFS provides an opportunity to personalize therapy within the constraints of clinical research. Bayesian adaptive design is increasingly recognized as an efficient method for obtaining valid clinical trial results. At its core, this approach uses existing information at the time of trial initiation, combined with data accumulating during the trial, to identify treatments most beneficial for specific patient subgroups. Based on accumulating evidence, the study then "adapts" its focus to critical differences between treatments within patient subgroups. Bayesian adaptive design is ideally suited for investigating complex, heterogeneous conditions such as AHFS and affords investigators the ability to study multiple treatment approaches and therapies in multiple patient phenotypes within a single trial, while maintaining a reasonable overall sample size. Identifying specific treatment approaches that safely improve symptoms and facilitate early discharge in patients who traditionally are admitted, often for prolonged periods of time, are necessary if we aim to reverse the disappointing trend in clinical trial results. In this study, AHFS clinical researchers and biostatisticians with expertise and experience in designing "personalized medicine" trials describe the development of a Bayesian adaptive design for an emergency department-based AHFS trial.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Bayes Theorem; Cardiovascular Agents; Clinical Trials as Topic; Emergency Service, Hospital; Epidemiologic Research Design; Female; Heart Failure; Humans; Male; Middle Aged; Syndrome; Time Factors; Young Adult

Noncompaction myocardium (NCM) is a genetic heterogeneous primary cardiomyopathy which affects both children and adults and can be either isolated or combined with other congenital heart disorders. It has common pathogenesis of symptoms but is distinguished by pronounced clinical polymorphism. We have observed 25 adult patients (15 men, 10 women aged from 20 to 62 years, mean age 42.9+/-13.3 years) with NCM syndrome. Heart failure have been found in 96% of patients (functional class [FC] I in 7, II - in 6, III in 7, and IV - in 4 patients). Ninety two percent of patients have ventricular extrasystoles, 32% - atrial fibrillation, 28% - FC I-III angina. Mean end diastolic left ventricular dimension is 6.5+/-0.8cm, ejection fraction 29.7+/-13.0%, mean pulmonary artery pressure - 42.6+/-13.5 mm Hg. Intracardiac thrombosis have been found in 24% of patients. In 7 patients morphological study of myocardium has been performed. NCM syndrome was diagnosed at initial investigation just in 1 case. We distinguished the following clinical masks (variants of diagnosis) of NCM: 1) clinically not manifest, is revealed at accidental examination (4%); 2) exists under mask of "idiopathic" rhythm disturbances (8%); 3) has a mask of ischemic heart disease; 4) is revealed in patients with acute or subacute myocarditis (12%); 5) has a mask of dilated cardiomyopathy (52%); 6) NCM in patients with other primary cardiomyopathies (hypertrophic, restrictive, genetic myopathy, arrhythmogenic right ventricular dysplasia). Combination of NCM with congenital heart defects has been found in 20% of patients. In 56% of cases myocarditis was diagnosed (it was viral in no less than 44%). Only in 32% of patients it is possible to consider presence of isolated NCM syndrome. This paper contains discussion of problems of diagnostics (including morphological) and treatment in the presented group of patients, significance of myocarditis for development of decompensation, role of NCM in patients with other primary cardiomyopathies, possibility of compensatory (secondary) character of NCM in severe systolic dysfunction.

Topics: Adult; Arrhythmias, Cardiac; Biopsy; Cardiomyopathies; Cardiovascular Agents; Diagnosis, Differential; Disease Management; Electrocardiography; Female; Heart Defects, Congenital; Heart Failure; Heart Function Tests; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Myocarditis; Myocardium; Prognosis; Syndrome; Tomography, Spiral Computed; Treatment Outcome

We present analysis of a case history of a patient with rare congenital heart disorder - Bland-White-Garland syndrome. The 25 years old women was first diagnosed with this disorder during an examination in the cardiological department of the Moscow clinical hospital No83. The paper contains discussion of difficulties of diagnosis and peculiarities of management of adults with this pathology as well as of a problem of the choice of further therapeutic approaches.

Topics: Adult; Benzazepines; Cardiovascular Agents; Cardiovascular Surgical Procedures; Coronary Angiography; Coronary Vessel Anomalies; Coronary Vessels; Female; Heart Failure; Humans; Ivabradine; Metoprolol; Mitral Valve Insufficiency; Multidetector Computed Tomography; Prognosis; Pulmonary Artery; Syndrome; Treatment Outcome

Topics: Adult; Cardiovascular Agents; Female; Giant Cell Arteritis; Humans; Immunosuppressive Agents; Male; Polyarteritis Nodosa; Syndrome; Systemic Vasculitis; Takayasu Arteritis; Thromboangiitis Obliterans; Vasculitis

Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the "Post-Cardiac Arrest Syndrome" and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on "clinical judgment" might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics.

Topics: Advanced Cardiac Life Support; Algorithms; Cardiopulmonary Resuscitation; Cardiovascular Agents; Combined Modality Therapy; Critical Care; Diuretics; Glasgow Outcome Scale; Heart Arrest; Hemodynamics; Humans; Hypnotics and Sedatives; Hypothermia, Induced; Hypoxia, Brain; Intensive Care Units; Life Support Systems; Monitoring, Physiologic; Myocardial Revascularization; Neuromuscular Blockade; Seizures; Syndrome

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Drug-Eluting Stents; Everolimus; Humans; Hypersensitivity; Myocardial Infarction; Paclitaxel; Prosthesis Design; Sirolimus; Syndrome; Thrombosis; Treatment Outcome

Topics: Cardiovascular Agents; Humans; Liver Diseases; Liver Transplantation; Living Donors; Organ Size; Propranolol; Somatostatin; Syndrome

The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry.. The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005.. Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI.. Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

Topics: Adrenergic beta-Antagonists; Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Calcium Channel Blockers; Cardiovascular Agents; Chemoprevention; Drug Prescriptions; Female; Follow-Up Studies; France; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Registries; Stents; Syndrome

Since the introduction of drug-eluting stents (DESs), patterns of revascularization strategies for patients with non-ST-segment elevation acute coronary syndromes have not been assessed. We studied 82,924 patients from the CRUSADE Initiative who presented with non-ST-segment elevation acute coronary syndromes and underwent coronary angiography at 365 United States hospitals that had capabilities for surgical (coronary artery bypass grafting [CABG]) and percutaneous (percutaneous coronary intervention [PCI]) revascularization from January 2002 to June 2005. Temporal trends in the use of PCI, CABG, and medical management without revascularization were analyzed with respect to the introduction of DESs. In total, 73,577 patients (89%) had >50% stenosis in > or =1 coronary artery, and there was a significant increase in the use of PCI (vs CABG or medical management without revascularization) during the study period (38.3% vs 52.5%). By quarter 2 of 2005, 80% of patients who underwent PCI received a DES. In total, 18,462 of 25,068 patients (73.6%) with 3-vessel disease (3VD) underwent revascularization and use of CABG decreased for these patients (48.9% to 39.9%, p <0.001), whereas use of PCI increased (51.1% to 60.1%, p <0.001). Factors significantly associated with use of PCI for patients with 3VD who underwent any revascularization included previous PCI, previous CABG, cardiology inpatient care, care at an academic hospital, renal insufficiency, and previous congestive heart failure. In conclusion, coinciding with the introduction of DESs, there has been a significant increase in the use of PCI and, in those patients with 3VD, a decrease in the use of CABG with a shift toward increasing use of PCI. Long-term implications of this shift remain uncertain, especially in patients with 3VD.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Databases, Factual; Female; Humans; Male; Middle Aged; Patient Selection; Retrospective Studies; Risk Factors; Stents; Syndrome; United States

Drug-eluting stents (DES) present a slightly higher incidence of stent thrombosis compared to bare metal stents and some cases of DES thrombosis are described in the literature. Therefore, there is consensus in recommending treatment with clopidogrel for at least 6 months in addition to life-long aspirin administration. We describe a case of very late paclitaxel-eluting stent thrombosis despite 21 months of clopidogrel treatment, which occurred just 2 weeks after its withdrawal, causing an acute coronary syndrome that was promptly resolved with an urgent invasive strategy. In our experience, paclitaxel-eluting stent thrombosis can occur several months after stent implantation despite prolonged clopidogrel treatment.

Topics: Acute Disease; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clopidogrel; Coronary Angiography; Coronary Thrombosis; Humans; Male; Middle Aged; Myocardial Ischemia; Paclitaxel; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Prosthesis Design; Stents; Syndrome; Ticlopidine; Time Factors; Treatment Outcome

To examine the relation between treatment intensity and level of risk in routine hospital care of patients with acute coronary syndromes (ACS), and to identify independent predictors of use or omission for each of eight evidence-based treatments.. Retrospective cohort study of patients fulfilling case definition for ACS in whom absolute risk of adverse outcomes was quantified (as low, moderate, or high risk) using formal prediction rules, and for whom treatment eligibility was determined using expert-agreed criteria.. 3912 consecutive or randomly selected patients admitted to 21 hospitals in Queensland, Australia between 1 August 2001 and 31 December 2005.. The proportions of eligible patients receiving treatment varied inversely with risk level in regard to reperfusion therapies of fibrinolytic therapy or primary angioplasty (low risk, 88.3%; moderate risk, 61.9%; high risk, 18.2%; P < 0.001), heparin (91.4%; 83.7%; 72.8%; P < 0.001) and early invasive intervention (33.6%; 24.0%; 18.5%; P < 0.001). Significantly more low- and moderate- than high-risk patients received beta-blockers (87.0%; 88.5%; 79.1%; P < 0.001), lipid-lowering agents (87.3%; 84.8%; 65.8%; P < 0.001), and referral to cardiac rehabilitation (51.8%; 46.0%; 34.4%; P < 0.001) at discharge. The most frequent independent predictors of treatment omission in all patients included increasing age (5 of 8 treatments), previous ACS or atrial tachyarrhythmias (4 of 8), and past history of cerebrovascular accident or congestive heart failure (3 of 8).. In routine care of ACS, eligible patients at high risk receive treatment less frequently than those at low and moderate risk. Reforms in professional education, routine use of risk stratification tools, guideline recommendations tailored to population-specific reductions in absolute risk, and better hospital networking with standardised triage and referral procedures for invasive procedures may help reduce selection bias in the delivery of indicated care.

Topics: Aged; Angina, Unstable; Cardiovascular Agents; Cohort Studies; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Reperfusion; Myocardial Revascularization; Retrospective Studies; Risk Assessment; Syndrome; Treatment Outcome

Topics: Angina, Unstable; Biomarkers; Cardiology Service, Hospital; Cardiovascular Agents; Humans; Myocardial Infarction; Myocardial Revascularization; Risk Assessment; Syndrome

We describe a postpartum woman who, after an uneventful pregnancy, developed posterior reversible encephalopathy syndrome after spinal anesthesia, complicated by postdural puncture headache.

Topics: Adult; Anesthesia, Spinal; Brain Edema; Brain Ischemia; Cardiovascular Agents; Cesarean Section; Diffusion Magnetic Resonance Imaging; Female; Humans; Magnesium Sulfate; Magnetic Resonance Angiography; Post-Dural Puncture Headache; Postpartum Period; Pregnancy; Syndrome; Treatment Outcome; Vasospasm, Intracranial

Patients' beliefs about their disease may affect their willingness to engage in preventive health behaviors. We sought to determine whether men and women with acute coronary syndrome differ in their perceptions of the severity of cardiac-related illness while controlling for the clinical severity of their condition.. All patients with acute coronary syndrome discharged from a university hospital during a 3-year period were mailed a questionnaire, and medical records were abstracted. The questionnaire assessed perceived severity of cardiac-related illness (5-point scale from "very mild" to "very severe"), symptom frequency, type of acute coronary syndrome event, number of medications, Duke Activity Status Index (DASI), time since most recent cardiac event, Charlson Comorbidity Index, and demographic information. A logistic regression model was constructed with perceived severity of heart disease as the dependent variable. Gender was the key independent variable while controlling for the other patient and disease variables.. The 490 respondents (1217 surveys sent, 40.3% response rate) included 348 men and 142 women who were similar with regard to race and type of acute coronary syndrome event experienced. Women were older, less educated, had a lower DASI score, had more symptoms, and were taking more medications. However, they perceived their cardiac disease as being no more severe than the men. The significant predictors in the regression model of perceived severity included gender, DASI, number of symptoms, type of acute coronary syndrome event, and comorbidity. Female gender was associated with lower perceived severity (odds ratio 0.30-0.80).. Women rate their cardiac disease as less severe than do men when controlling for other measures of cardiac disease severity.

Topics: Acute Disease; Adult; Aged; Angina, Unstable; Attitude to Health; Cardiovascular Agents; Comorbidity; Cross-Sectional Studies; Culture; Female; Gender Identity; Hospitals, University; Humans; Male; Michigan; Middle Aged; Myocardial Infarction; Patient Acceptance of Health Care; Self Concept; Severity of Illness Index; Surveys and Questionnaires; Syndrome; Women

Oral antiplatelet agents (OAAs) can prevent further vascular events in cardiovascular disease. How prior use or recent discontinuation of OAA affects clinical presentation of acute coronary syndromes (ACS) and clinical outcomes (death, myocardial infarction [MI]) is unclear.. We studied and followed up for up to 30 days a cohort of 1358 consecutive patients admitted for a suspected ACS; of these, 930 were nonusers, 355 were prior users of OAA, and 73 had recently withdrawn OAA. Nonusers were at lower risk, more frequently presented with ST-elevation MI on admission, and more frequently had Q-wave MI at discharge than prior users (36.6% versus 17.5%, P<0.001; and 47.8% versus 28.2%, P<0.001, respectively). However, there was no difference regarding the incidence of death or MI at 30 days between nonusers and prior users (10.3% versus 12.4%, P=NS). In addition, prior users experienced more major bleeds within 30 days compared with nonusers (3.4% versus 1.4%, respectively; P=0.04). Recent withdrawers were admitted on average 11.9+/-0.8 days after OAA withdrawal. Interruption was primarily a physician decision for scheduled surgery (n=47 of 73). Despite a similar cardiovascular risk profile, recent withdrawers had higher 30-day rates of death or MI (21.9% versus 12.4%, P=0.04) and bleedings (13.7% versus 5.9%, P=0.03) than prior users. After multivariate analysis, OAA withdrawal was found to be an independent predictor of both mortality and bleedings at 30 days.. Among ACS patients, prior users represent a higher-risk population and present more frequently with non-ST-elevation ACS than nonusers. Although patients with a recent interruption of OAA resemble those chronically treated by OAA, they display worse clinical outcomes.

Topics: Acute Disease; Administration, Oral; Aged; Aspirin; Cardiovascular Agents; Cohort Studies; Drug Therapy, Combination; Electrocardiography; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Paris; Platelet Aggregation Inhibitors; Prospective Studies; Risk Factors; Syndrome; Thrombosis; Treatment Outcome; Withholding Treatment

Topics: Acute Disease; Adrenergic beta-Antagonists; Angina Pectoris; Angina, Unstable; Anticoagulants; Cardiac Catheterization; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Electrocardiography; Fibrinolytic Agents; Humans; Myocardial Infarction; Nitrates; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Prognosis; Randomized Controlled Trials as Topic; Risk Factors; Syndrome; Thrombolytic Therapy; Time Factors

The role of systemic hypertension in acute coronary syndrome (ACS) has not been well studied. We studied consecutive subjects admitted to the University of Michigan Health System (Ann Arbor, Michigan) with symptoms of ACS. Data were collected using a standardized form. This observational study is currently ongoing; we collected data from May 1999 to December 2000 for 979 subjects, 890 of whom also had 6-month follow-up data. Hypertensives represented 64.4% (n = 630) of the total population. In general, hypertensive patients were older than normotensives (66.3 vs 59.9 years, p <0.0001), more often women (38.7% vs 26.9%, p = 0.0002), and had more comorbidities, such as previous myocardial infarction (47.9% vs 33.8%, p <0.0001), congestive heart failure (25.7% vs 12.0%, p <0.0001), and diabetes (36.9% vs 17.8%, p <0.0001). At admission, hypertensives had higher systolic blood pressure. Hypertensives had fewer electrocardiographic abnormalities indicating ischemic changes (67.9% vs 76.3%, p = 0.01) and had fewer incident of acute myocardial infarction (AMI) (70.7% vs 76.1%, p = 0.07) than normotensives. There was consistency over different levels of admission systolic blood pressure. Hypertensives received more oral cardiovascular drugs, and had undergone more invasive procedures. The lower rate of AMI in hypertensives seemed to be related to the higher frequency of a history of percutaneous coronary intervention and coronary artery bypass grafting. However, at 6-month follow-up, age- and gender-adjusted odds ratios for adverse events were equivalent in hypertensives and normotensives, suggesting no continuing differential treatment benefit for hypertensives in the months after the initial ACS episode.

Topics: Acute Disease; Age Distribution; Aged; Biomarkers; Cardiovascular Agents; Comorbidity; Coronary Disease; Creatine Kinase; Electrocardiography; Female; Follow-Up Studies; Humans; Hypertension; Male; Michigan; Middle Aged; Myocardial Infarction; Odds Ratio; Reference Values; Regression Analysis; Sex Distribution; Syndrome; Troponin I

Topics: Acute Disease; Angina, Unstable; Angioplasty, Balloon, Coronary; Atrial Fibrillation; Cardiology; Cardiovascular Agents; Clinical Trials as Topic; Congresses as Topic; Coronary Artery Bypass; Coronary Disease; Echocardiography; Europe; Heart Failure; Humans; Myocardial Infarction; Stents; Syndrome; Thrombolytic Therapy

A 68 year old woman developed a sudden decrease in her visual acuity in both eyes with several central scotomas. Funduscopy demonstrated a motted alteration of the retinal pigment epithelium in both maculae. The fluorescein angiography showed a choroidal ischemia at the macular level in both eyes.. The patient was diagnosed of acute macular neuroretinopathy. This entity is included among the so-called <>. However, it is important to determine which of these diseases each patient suffers in order to determine if treatment is necessary, the visual prognosis and the possibility of recurrences.

Topics: Acute Disease; Aged; Cardiovascular Agents; Choroid; Female; Humans; Ischemia; Macula Lutea; Pigment Epithelium of Eye; Retinal Diseases; Scotoma; Syndrome; Visual Acuity

The Halifax County MONItoring of trends and determinants in CArdiovascular disease (MONICA) Project found that between 1984 and 1988, the proportion of myocardial infarctions (MIs) that were fatal within 28 days remained constant, but declined between 1989 and 1993. The objective was to investigate association among case fatality, treatment and case severity of MI in hospitalized patients.. The MONICA MI register contains data on demographics, health history, in-hospital investigations, interventions and treatment, and vital status at 28 days after onset of symptoms for all MIs occurring in residents of Halifax County, aged 25 to 74 years. Logistic regression analysis was used to estimate trends in the use of cardioactive drugs and revascularization procedures. A case severity score was developed from patient characteristics at time of admission. Case fatality was calculated as the proportion of MIs that were fatal within 28 days.. Between 1984 and 1988, a large increase (OR 1.3) occurred in the use of angiotensin-converting enzyme (ACE) inhibitors, acetylsalicylic acid (ASA), thrombolysis and percutaneous transluminal coronary angioplasty (PTCA); a minor increase occurred in use of calcium channel blockers (OR=1.29, 99% CI 1.19 to 1.40); beta-blocker use decreased; case fatality remained constant and case severity score increased. From 1989 to 1993, ACE inhibitor use increased (OR=1.4, 99% CI 1.27 to 1.55); minor increases occurred in use of ASA and beta-blockers, and in PTCA and coronary artery bypass grafting; case severity did not change and case fatality decreased.. While use of beneficial treatment increased between 1984 and 1988, MI case fatality did not decrease, probably because case severity increased. Between 1989 and 1993, case severity remained constant, and the further increase in the use of beneficial therapy was associated with a decline in case fatality.

Topics: Acute Disease; Adrenergic beta-Antagonists; Adult; Aged; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Bypass; Diagnosis, Differential; Drug Utilization; Female; Hospital Mortality; Hospitalization; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Myocardial Revascularization; Nova Scotia; Risk Factors; Severity of Illness Index; Syndrome; Thrombolytic Therapy

Topics: Acute Disease; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Humans; Syndrome

An electrophysiological study and a provocative test of coronary artery spasm was attempted in a 68-year-old man who was having syncopal attacks and chest pain. His electrocardiogram had the characteristics of Brugada syndrome and ventricular fibrillation (VF) was induced by programmed electrical stimulation. ST-segment elevation became exaggerated by procainamide, which could not prevent the induction of VF. Coronary angiography revealed no stenotic lesions, and spasm in the left coronary artery was induced by intracoronary administration of acetylcholine with similar chest pain to that experienced before. Under treatment with diltiazem and flecainide, which suppressed the induction of VF, the patient experienced no recurrence of symptoms despite persistent ST-segment elevation. No previous reports have described coronary spasm associated with Brugada-type ECG abnormalities, and patients with syncope should be evaluated carefully.

Topics: Acetylcholine; Aged; Anti-Arrhythmia Agents; Calcium Channel Blockers; Cardiovascular Agents; Chest Pain; Coronary Angiography; Coronary Vasospasm; Diagnosis, Differential; Diltiazem; Electric Stimulation; Electrocardiography; Electrophysiology; Flecainide; Humans; Male; Syncope; Syndrome; Vasodilator Agents; Ventricular Fibrillation

The CD40 ligand (CD40L) on activated T cells and platelets may be activating matrix metalloproteinases, inducing procoagulant activity, and be involved in the pathogenesis of acute coronary syndromes by promoting plaque rupture in atheroma.. To study the role of CD40L-CD40 interaction in coronary disease, we analyzed levels of soluble (s) and membrane-bound CD40L in the peripheral blood from 29 patients with stable angina, 26 with unstable angina, and 19 controls. Our main findings follow. (1) Patients with unstable angina had significantly raised serum levels of sCD40L when compared with patients with stable angina and controls. (2) Platelets could release large amounts of sCD40L when stimulated ex vivo with the thrombin receptor-agonist peptide SFLLRN in both patients and controls. (3) Platelets in patients with unstable angina were characterized ex vivo by decreased intracellular levels and decreased SFLLRN-stimulated release of sCD40L, which may possibly represent a higher percentage of degranulated platelets in these patients. (4) T cells in patients with unstable angina had enhanced surface expression of CD40L and increased release of sCD40L on anti-CD3/anti-CD28 stimulation in vitro when compared with patients with stable angina and controls. (5) Recombinant CD40L and serum from patients with unstable angina who had high sCD40L levels induced enhanced release of monocyte chemoattractant peptide-1 from mononuclear cells, a CC-chemokine involved in the pathogenesis of atherosclerosis.. This first demonstration of enhanced levels of soluble and membrane-bound forms of CD40L in angina patients, with particularly high levels in patients with unstable angina, suggests that CD40L-CD40 interaction may play a pathogenic role in both the long-term atherosclerotic process and in the triggering and propagation of acute coronary syndromes.

Topics: Acute Disease; Aged; Angina Pectoris; Angina, Unstable; Blood Platelets; Cardiovascular Agents; CD4-Positive T-Lymphocytes; CD40 Antigens; CD40 Ligand; CD8-Positive T-Lymphocytes; Cell Membrane; Chemokine CCL2; Cholesterol; Coronary Disease; Cytoplasmic Granules; Female; Humans; Male; Membrane Glycoproteins; Metalloendopeptidases; Middle Aged; Peptide Fragments; Platelet Activation; Rupture, Spontaneous; Smoking; Solubility; Syndrome; Triglycerides; Vasculitis

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Disease; Drug Evaluation; Electrocardiography; Epoprostenol; Exercise Test; Female; Humans; Iloprost; Male; Middle Aged; Syndrome

Topics: Aminopyrine; Asthma; Bronchodilator Agents; Cardiovascular Agents; Drug Therapy; Humans; Methenamine; Muscle Relaxants, Central; Syndrome; Theophylline

Topics: Anesthetics; Anesthetics, Local; Cardiovascular Agents; Drug Hypersensitivity; Humans; Lidocaine; Procaine; Syndrome

Topics: Anticoagulants; Cardiovascular Agents; Deoxyribonuclease I; Muscle Relaxants, Central; Streptodornase and Streptokinase; Streptokinase; Syndrome; Thromboembolism

Topics: Cardiovascular Agents; Dihydroergotoxine; Ergot Alkaloids; Neck Injuries; Oxytocics; Syndrome; Whiplash Injuries

Topics: Cardiovascular Agents; Ergot Alkaloids; Neck; Neck Pain; Osteochondritis; Oxytocics; Syndrome

Topics: Cardiovascular Agents; Ergot Alkaloids; Gastrointestinal Diseases; Syndrome

Topics: Cardiovascular Agents; Central Nervous System Diseases; Muscle Relaxants, Central; Muscle Spasticity; Spasm; Syndrome

Topics: Cardiovascular Agents; Central Nervous System Diseases; Humans; Muscle Relaxants, Central; Muscle Spasticity; Syndrome