751-5 Rapid Angiographic Progression of “Target” and “Non-target” Stenoses in Patients Awaiting Coronary Angioplasty

Coronary angioplasty (PTCA) is effective therapy for angina pectoris but coronary events occur after successful PTCA which may be caused by both restenosis and progression of mild pre-existing, “non-target”, stenoses. To compare the short-term evolution of “target”versus “non-target”stenoses in patients awaiting PTCA, we prospectively studied 161 consecutive stable angina patients (124 men and 37 women). After diagnostic angiography, “target”stenoses for PTCA and “non-target”lesions were identified. Patients were put on a routine waiting list and followed up regularly until repeat coronary arteriography (mean±SD: 7±3 months). which was performed immediately preceding angioplasty (138 patients) or soon after acute coronary events (23 patients) when these occurred. Stenosis diameters were measured using computerized arteriography. Progression was defined as 2:20% diameter reduction, new total occlusion, or development of “new” stenoses 2:30%. At study entry, diameters of target (n=207) and non-target (n=184) lesions were 68±9% and 38±9%, respectively (p < 0.001). Disease progression occurred in 33 patients (20%). in whom 18 target (9%) and 15 nontarget stenoses (8%) progressed and 7 new lesions (1 total occlusion) developed. Total occlusion developed in 15 of the 18(83%) target and in 6 of the 15 (40%) non-target stenoses; (p=0.03). During follow up, 3 patients (2%) had a myocardial infarction and 20 (12%) developed unstable angina. These events were associated with progression of target stenoses in 10 patients, of non-target stenoses in 7 patients, and with new lesions in one patient. In 5 patients events were not associated with stenosis progression.Thus a similar proportion of target and non-targetlesions progressed rapidly. Targetstenoses, however, were more likely to progress to total occlusion than non-targetlesions. Progression of non-targetstenoses may contribute to recurrence of angina and new coronary events after successful angioplasty and their role should be considered when developing strategies aimed at improving survival after angioplasty

Anaemia and the development of depressive symptoms following acute coronary syndrome: longitudinal clinical observational study

OBJECTIVE: Depressive symptoms are common following acute coronary syndrome (ACS) and predict subsequent cardiovascular morbidity. Depression in acute cardiac patients appears to be independent of clinical disease severity and other cardiovascular measures. One factor that has not been considered previously is anaemia, which is associated with fatigue and adverse cardiac outcomes. This study assessed the relationship between anaemia on admission and depressive symptoms following ACS. DESIGN: Longitudinal clinical observational study. SETTING: Coronary care unit. PATIENTS: 223 patients with documented ACS. MAIN OUTCOME MEASURES: Depressive symptoms measured with the Beck Depression Inventory 3 weeks after admission. RESULTS: Anaemia was defined with WHO criteria and was present in 30 (13.5%) patients. Anaemia predicted raised depression scores 3 weeks later independently of age, gender, marital status, educational attainment, smoking, Global Registry of Acute Cardiac Events (GRACE) risk scores, negative mood in hospital and history of depression (p=0.003). The odds of a Beck Depression Inventory score ≥10 among anaemic patients were 4.03 (95% CIs 1.48 to 11.00), adjusted for covariates. Sensitivity analyses indicated that effects were also present when haemoglobin was analysed as a continuous measure. Anaemia also predicted major adverse cardiac events over the subsequent 12 months. CONCLUSIONS: Anaemia appears to contribute to depression following ACS and is associated with future cardiac morbidity. Studies evaluating the effects of anaemia management will help delineate the role of this pathway more precisely

Differential progression of complex and smooth stenoses within the same coronary tree in men with stable coronary artery disease

Objectives.We sought to compare the evolution of complex and smooth stenoses within the same coronary tree in patients with stable coronary artery disease.Background.Progression of coronary stenosis has prognostic significance and may be influenced by local and systemic factors. Stenosis morphology is a determinant of disease progression, but no previous study has systematically assessed progression of complex and smooth stenoses within the same patient.Methods.We studied 50 men with stable angina who 1) had one complex coronary stenosis and one smooth stenosis in different noninfarct-related coronary vessels at initial coronary angiography, and 2) had a second angiogram after a median interval of 9 months (range 3 to 24). Patients with lesions ≥10 mm long, at a major branching point or with >85% diameter reduction were not included. Coronary lesions were measured quantitatively from comparable end-diastolic frames. Stenosis morphology was determined qualitatively by two independent observers.Results.All patients remained in stable condition during follow-up. Progression, defined as an increase in diameter stenosis by ≥15% was seen in only eight complex stenoses (16%) but in no smooth lesions (p < 0.01). The severity of complex stenoses changed more than that of corresponding smooth stenoses (mean ± 1 SD 5.8 ± 13% vs. −0.06 ± 6%, p < 0.01). On average, the annual rate of growth was 11.4 ± 28% and 1.5 ± 14% for complex and smooth lesions, respectively (p < 0.01).Conclusions.Few coronary stenoses progress rapidly in stable angina. Complex and smooth coronary stenoses progress at different rates within the same coronary tree. Complex stenosis morphology itself is an important determinant of progression of stenosis in patients with apparently clinically stable coronary artery disease

Fear of dying and inflammation following acute coronary syndrome

Aims Many patients are afraid of dying during acute coronary syndrome (ACS), but the origins and biological correlates of these emotional responses are poorly understood. This study evaluated the prevalence of fear of dying, associations with inflammatory responses during ACS, and later heart rate variability (HRV) and cortisol secretion. Methods and results Two hundred and eight patients admitted with clinically verified ACS rated their fear of dying on interview in hospital. Plasma tumour necrosis factor (TNF)α was recorded on admission, and HRV and salivary cortisol were assessed 3 weeks later. Intense distress and fear of dying was experienced by 21.7%, with moderate levels in 66.1% patients. Fear of dying was more common in younger, lower socioeconomic status, and unmarried patients. It was positively associated with plasma TNFα on admission after controlling for sociodemographic factors, clinical risk, and pain intensity (adjusted odds = 4.67, 95% C.I. 1.66-12.65). TNFα was associated with reduced HRV 3 weeks later, adjusting for clinical and sociodemographic factors and medication (P = 0.019), while fear of dying was associated with reduced cortisol output (P = 0.004). Conclusions Intense distress and fear of dying and heightened inflammation may be related manifestations of an acute biobehavioural response to severe cardiac injury, and have implications for prognostically significant biological risk processe

Cardiac syndrome X: Clinical characteristics and left ventricular function Long-term follow-up study

Objectives.Our aim was to study the clinical characteristics and evolution of symptoms and left ventricular function in a clinically homogeneous group of patients with syndrome X (angina pectoris, positive exercise test results and normal coronary arteriograms).Background.The syndrome of angina with normal coronary arteriograms is heterogeneous and encompasses different pathogenetic entities. These characteristics may contribute to the existing controversy concerning the cause of syndrome X.Methods.We studied 99 patients with syndrome X (78 women, 21 men; mean age ± SD 48.5 ± 8 years). All underwent clinical characterization, ambulatory electrocardiographic (ECG) monitoring and echocardiographic assessment of left ventricular function during a follow-up period of 7 ± 4 years.Results.The syndrome was more common in women than in men. Of the women, 61.5% were postmenopausal before the onset of chest pain. All 99 patients had exertional angina, and 41 also had rest angina. The average duration of episodes of chest pain was > 10 min in 53% of patients. Sublingual nitrate was effective for relief of pain in 42% of patients. Transient ST segment depression was observed during ambulatory ECG monitoring in 64 patients and myocardial perfusion abnormalities in 22. During the first stage of the exercise test, 32 patients had an increase > 20 mm Hg in systolic blood pressure and showed an earlier onset of ST depression and shorter exercise time than did patients whose blood pressure increased ≤20%. During follow-up, no deaths or myocardial infarctions occurred, ventricular function was unchanged (shortening fraction 35.4 ± 4% vs. 35.6 ± 3%; heart failure developed in only one patient), systemic hypertension occurred in eight patients and conduction disturbances in four. Symptoms lessened in 11 patients, were variable or unchanged in 64 and worsened in 24.Conclusions.Syndrome X, as defined in this study, occurs predominantly in postmenopausal women. Patients usually have chest pain typical for angina, but conventional antianginal treatment is not often successful. Myocardial perfusion abnormalities occur in a small proportion of patients. Long-term survival is not adversely affected, and deterioration of cardiac function rarely occurs