Percutaneous transluminal angioplasty in patients with multivessel coronary disease: how important is complete revascularization for cardiac event-free survival?

The relative influences of revascularization status and baseline characteristics on long-term outcome were examined in 867 patients with multivessel coronary disease who had undergone successful coronary angioplasty. These patients represented 83% of a total of 1,039 patients in whom angioplasty had been attempted with an in-hospital mortality and infarction rate of 2.5% and 4.8%, respectively. Emergency coronary bypass surgery was needed in 4.9%. Of the 867 patients, 41% (group 1) were considered to have complete revascularization and 59% (group 2) to have incomplete revascularization. Univariate analysis revealed major differences between these two groups with patients in group 2 characterized by advanced age, more severe angina, a greater likelihood of previous coronary surgery and infarction, more extensive disease and poorer left ventricular function. Over a mean follow-up period of 26 months, the probability of event-free survival was significantly lower for group 2 only with respect to the need for coronary artery surgery (p = 0.004) and occurrence of severe angina (p = 0.04). The difference in mortality was of borderline significance (p = 0.051) and there were no significant differences between groups 1 and 2 in either the incidence of myocardial infarction or the need for repeat angioplasty. Multivariate analysis identified independent baseline predictors of late cardiac events that were then used to adjust the probabilities of event-free survival. This adjustment effectively removed any significant influence of completeness of revascularization on event-free survival for any of the above end points including the combination of death, myocardial infarction and need for coronary artery surgery. Therefore, late outcome in these patients is not significantly influenced by revascularization status but depends more on baseline patient characteristics.

Does the emergency room electrocardiogram identify patients with suspected myocardial infarction who are at low risk of acute complications?

To determine the early morbidity of patients admitted to the coronary care unit (CCU) with inconclusive evidence of acute myocardial infarction, the prognostic value of the emergency room electrocardiogram (ECG) was examined prospectively in a blinded fashion in 410 patients presenting with acute chest pain. One hundred and forty one patients (34.4%) had an ECG that was normal, showed ST segment changes less than 1 mm, or was unchanged from a previous recording (group 1). The remaining patients (65.6%, group 2) had ECGs considered abnormal. Thirty-nine patients in group 1 and 226 in group 2 had confirmed infarction. There was one CCU death in group 1 (0.7%) versus 27 (10.0%) in group 2 (p less than 0.001) and the overall hospital mortality for group 1 was 2.1% versus 13.0% in group 2 (p less than 0.001). Twenty-eight patients (19.9%) from group 1 suffered complications in the CCU versus 155 (57.6%) from group 2 (p less than 0.001). No life-threatening arrhythmias occurred in group 1 versus occurrence in 47 patients (17.5%) in group 2 (p less than 0.001). The need for acute intervention was also less for group 1 versus group 2 patients, 14 (9.9%) and 85 (31.6%) respectively (p less than 0.001) with no patient requiring electrical cardioversion in group 1. It is concluded that the emergency room ECG can reliably identify a group of low risk patients presenting with suspected myocardial infarction and so help in establishing priority for admission to the CCU. Furthermore, the risk-benefit of thrombolytic therapy in these low risk patients appears unacceptable.

Antiandrogenic steroidal sulfonylpyrazoles

The steroidal sulfonylpyrazole 1 bound to the rat ventral prostate androgen receptor in vitro; it inhibited testosterone propionate induced increases in ventral prostate weight in vivo in the castrated, immature male rat with an ED50 of 15 mg/kg po. Compound 1 lacked androgenic activity in vivo in contrast to the parent steroidal pyrazole 5, which was both androgenic and antiandrogenic. The 2'- and 5'-methylsulfonyl isomers 6 and 6a did not bind to the androgen receptor. Introduction of an alkylsulfonyl at the N-1'-position has served, therefore, to isolate the intrinsic antiandrogenic properties of the steroidal heterocycle free of apparent hormone agonist properties. Structure-activity relationship studies revealed that a methylsulfonyl group at N-1' together with a C-17 alpha-substituent were the optimal combination for in vitro androgen receptor binding, in vivo antiandrogenic potency, and a lack of androgenic activity.

Detection of mild coronary stenoses using the Dynamic Spatial Reconstructor

The accuracy of the Dynamic Spatial Reconstructor (DSR) in the detection of moderate coronary artery stenoses was examined in 20 closed-chest dogs. Twenty-eight hollow plastic cylinders were embolized into the left coronary arteries and produced 25% to 56% reductions in arterial lumina diameter. For each dog, one three-dimensional (3-D) image of the heart was reconstructed from each DSR scan recorded during injection of contrast into the aortic root. Analysis involved blinded visual analysis by four independent observers of multiview projection images computed from the single 3-D image. Postmortem coronary angiograms of the isolated heart were considered definitive for location of the stenoses. Overall sensitivity of detection by DSR was 89% and specificity 81%. Sensitivity of detecting stenoses greater than or equal to 50% was 98%. Receiver operating characteristics (ROC) analysis showed that detection of stenoses in the left coronary arteries is of equal sensitivity and specificity.

Combined percutaneous coronary atherectomy and coronary angioplasty: experience in 19 consecutive patients

Among 82 patients undergoing coronary atherectomy, 19 (23%) underwent this procedure in combination with coronary angioplasty. The most frequently involved vessel was the left anterior descending coronary artery. In 11 patients (58%), attempted atherectomy preceded coronary angioplasty. In 6 of the 11, angioplasty was used after the atherectomy catheter could not be positioned across the lesion; 4 patients underwent "rescue" angioplasty after developing vessel occlusion related to atherectomy and 1 patient had an unsatisfactory result of atherectomy. The success rate of the combined intervention was 82% for these 11 patients. In eight patients (42%), atherectomy was performed after initial angioplasty. In four of the eight, atherectomy was a rescue procedure to manage vessel occlusion by thrombus or intimal dissection and was successful in three. In the other four, angioplasty was performed to establish an easier passage for the atherectomy catheter and was successful in three. Thus, the success rate of the combined intervention was 75% for these eight patients. The overall success rate for all 19 patients was 79%; there was one in-hospital death and one non-Q wave infarction, and one patient required immediate coronary artery surgery. Two other patients underwent coronary artery surgery before hospital discharge. Combined intervention with coronary angioplasty and atherectomy seems to be a relatively safe and effective approach in selected patients when either of these procedures alone is unsuccessful or is accompanied by acute coronary complications.

Angiographic demonstration of spontaneous diffuse three vessel coronary artery spasm

The spontaneous occurrence of diffuse three vessel coronary artery spasm was documented during routine coronary angiography in three patients with a history of variant angina. Quantitative angiographic analysis of 18 arterial segments demonstrated that the mean luminal diameter of 1.47 mm during spasm increased to 2.47 mm after the administration of nitroglycerin (p less than 0.0001). The underlying coronary arteries were normal or near normal. Although multivessel spasm has previously been considered to be uncommon and its spontaneous occurrence during angiography only rarely documented, these cases suggest that it may be more common than previously recognized. In addition to important diagnostic considerations, this phenomenon may have important implications regarding the pathophysiologic role of endothelium in coronary artery spasm.

Percutaneous transluminal angioplasty of left internal mammary artery grafts: two years' experience with a femoral approach

Percutaneous transluminal angioplasty via the femoral approach was attempted through internal mammary artery grafts in 11 patients who presented with distal anastomotic stenoses or distal native coronary artery stenoses and angina pectoris. The procedure was technically successful in 10 patients and no major complications occurred. During follow up there was one late death, but all 10 surviving patients showed functional improvement. Percutaneous transluminal angioplasty seems to be a safe and effective treatment for stenoses of internal mammary artery grafts. This is an effective technique for treating the increasing number of patients who are likely to present with stenoses of these grafts.

Role of carbon monoxide diffusing capacity in the early detection of major bleomycin-induced pulmonary toxicity

Fifteen patients with malignant teratoma and twelve with squamous cancer of the head and neck received treatment with bleomycin. Routine measurements of carbon monoxide diffusing capacity (DLco) were performed. Both groups showed a gradual fall of similar magnitude in their DLco measurements during treatment. No patient in the group with squamous cancer developed clinical or radiological evidence of major pulmonary toxicity. Two of the teratoma patients suffered fatal pulmonary toxicity and their DLco measurements before any signs of major pulmonary toxicity were no different from the measurements of those patients who remained free of major clinical toxicity. The two patients who died both showed a sustained reduction in renal function during chemotherapy which may have been a major risk factor in the development of severe clinical toxicity. The magnitude of the decline in DLco in this series was not a useful predictor of those patients who developed severe and radiological toxicity.

Glucocorticoid/antiinflammatory activities of nonsteroidal phenylpyrazoles in the rat

Six nonsteroidal phenylpyrazoles are described that have significant glucocorticoid and antiinflammatory activities. These agents competed with dexamethasone for the glucocorticoid receptor from the rat thymus, suppressed adrenal weight when administered orally to intact female rats, produced liver glycogen deposition and thymolysis when administered orally to adrenalectomized male rats, and reduced cotton granuloma formation when administered in the cotton pellet. In addition, in the latter model, no systemic activity (thymolysis or reduced body weight gain) was seen with doses up to 500 to 5000 times the dose which reduced granuloma formation. At least one compound was more potent than methylprednisolone in three of the four rat assay systems used. The compounds described are structurally different from conventional steroidal glucocorticoids but possessed potent glucocorticoid activities. However, they exhibited antiinflammatory activity without evidence of systemic activity when administered locally.

Steroidogenesis inhibitors. 1. Adrenal inhibitory and interceptive activity of trilostane and related compounds

Several methylated derivatives of trilostane were prepared. Methylation of C-4 or C-4 and C-17 changes this relatively selective adrenal inhibitor to compounds with increased ovarian/placental inhibitory activity with decreased adrenal inhibitory activity.

Experimental antiulcer drugs.4. 1,3-Disubstituted 2,4,5,6-tetrahydro-4,6,6 -trimethyl-2-phenylcyclopenta[c]pyrrole-4-carboxamides

The synthesis of 1,3-disubstituted 2,4,5,6-tetrahydro-4,6,6-trimethyl-2-phenylcyclopenta[c]pyrrole-4-carboxamides is reported. The derivatives included R1 = R3 = H, R1 = CH2OH with R3 = H (16) or CH3, R1 = CH3 with R3 = CH2OH (17), and R1 = R3 = CH2OH. The monohydroxymethyl derivatives were as active as the parent cyclopentapyrrole, where R1 = R3 = CH3 (1), when administered orally in the pyloric ligated rat. The compounds lacking one or both CH3 groups at C-1 or C-3 were much less active. Compounds 16 and 17 inhibited histamine-induced gastric acid secretion in the dog.

Experimental antiulcer drugs. 2. 2-Substituted 2,4,5,6-tetrahydro-1,3,4,6,6-pentamethylcyclopenta[c]pyrrole-4-carboxamides

Condensation of a 1-substituted 2,5-dimethylpyrrole 6 with 2 mol of 2-amino-2-methylpropionitrile in hot acetic acid yielded a 2-substituted 2,4,5,6-tetrahydro-1,3,4,5,6,6-pentamethylcyclopenta[c]pyrrole-4-carbonitrile (4). Hydrolysis of the nitriles to the amides gave a group of compounds which were active as antisecretory agents in the pyloric-ligated rat. Outstanding in this respect was the 2-phenyl derivative 5b, the most active compound in the series. It did not possess anticholinergic properties. In contrast to the indoles and pyrroles reported earlier, 5b demonstrated marked activity in blocking gastric acid secretion in the histamine-stimulated dog.

Experimental antiulcer drugs. 1. Indole-1-alkanamides and pyrrole-1-alkanamides

The synthesis and gastric antisecretory activity of a series of indole-1-alkanamides and pyrrole-1-alkanamides are presented. A marked elevation of the pH of the gastric secretions of the rat was observed after oral administration of 100 mg/kg of 2,3-dimethylindole-1-acetamide (2), -1-propionamide (8), and -1-butyramide (13). Replacement of either methyl group by a hydrogen atom or an ethyl radical resulted in greatly diminished activity. In the acetamide and propionamide series the 3-hydroxymethyl-2-methyl (14 and 15) derivatives exhibited activity but only when administered by the subcutaneous route. 2,3-Dimethylindole (18) was active and 2,3,4,5-tetramethylpyrrole-1-acetamide was moderately active. A number of the activ compounds were tested in the mouse mydriasis test for anticholinergic activity and found to be inactive. They were also found to be inactive in blocking histamine-induced acid secretion in the dog.