Relevance of multivessel disease in the development of in-hospital refractory angina and myocardial infarction in patients with unstable angina

Comparative predictive and diagnostic value of flow-mediated vasodilation in the brachial artery and intima media thickness of the carotid artery for assessment of coronary artery disease severity

BACKGROUND

While recent reports suggest that both flow-mediated vasodilation (FMD) in the brachial artery (BA), endothelium-dependent vasodilatation, and intima media thickness (IMT) in the carotid artery correlate with the extent of coronary artery disease (CAD), it is not clear which modality is a better predictor for CAD severity and whether either of these modalities are superior to conventional ST-segment depression in exercise stress electrocardiogram (ECG). Thus, the goal of the present study was to compare the predictive value of FMD and IMT for CAD severity and to evaluate the diagnostic accuracy.

STUDY

A total of 103 consecutive patients (62+/-9 years, 79 men) with clinically suspected CAD underwent FMD and nitroglycerin-induced dilation (NTG-D) in the BA as well as measurement of carotid artery IMT by using high-resolution ultrasound, and exercise treadmill testing. Coronary stenosis index (CSI) was calculated from coronary angiography.

RESULTS

Seventy-three patients had significant CAD, and 30 patients showed no CAD (NL). FMD was significantly lower and IMT was significantly higher in patients with CAD compared with NL patients (FMD, 3.7+/-3.0% vs. 7.5+/-2.9%; IMT, 1.1+/-0.2 mm vs. 0.7+/-0.1 mm). FMD and IMT correlated to CSI to a similar degree (r=-0.67, r=0.69, respectively), and there was a significant correlation between FMD and IMT. In contrast, NTG-D did not correlate with CSI or IMT. Further, the diagnostic accuracy of FMD and IMT was comparable or even better than that obtained with conventional ST-segment depression during exercise in this cohort.

CONCLUSIONS

FMD in BA and IMT could represent a surrogate diagnostic method for assessment of CAD severity.

Thirty day prognosis of patients with acute pulmonary oedema complicating acute coronary syndromes

OBJECTIVES

To investigate the characteristics of the acute coronary syndromes underlying acute pulmonary oedema and their 30 day prognosis.

PATIENTS

185 consecutive patients with acute coronary syndromes and acute pulmonary oedema admitted to a tertiary care centre.

MAIN OUTCOME AND MEASURES

Clinical, ECG, echocardiographic, enzymatic, and angiographic features were prospectively investigated.

RESULTS

Non-ST segment elevation myocardial infarction (NSTEMI) was the most frequent cause of acute pulmonary oedema (61%) followed by unstable angina (UA; 21%) and ST segment elevation myocardial infarction (STEMI; 18%). In each group, mean age was > or = 70 years, but NSTEMI patients were the oldest and > or = 65% of patients had chronic hypertension. Moreover, patients with NSTEMI and UA were older and had a higher incidence of diabetes, previous myocardial infarction, and moderate to severe mitral regurgitation but a similarly reduced ejection fraction (NSTEMI, 41%; UA, 39%; and STEMI, 39%) and increased incidence of diastolic dysfunction and rate of multivessel disease (94%, 87%, and 86%, respectively). However, patients with STEMI had a higher creatine kinase MB peak concentration (158 v 76 microg/l in the NSTEMI group, p < 0.001) and 30 day mortality (26% v 9% in the NSTEMI group and 8% in the UA group, p < 0.024). Multivariate analysis identified ejection fraction < 40% and a peak creatine kinase MB concentration > 100 microg/l as the main prognostic markers (p < 0.03).

CONCLUSIONS

Acute pulmonary oedema is mostly a complication of elderly hypertensive patients with NSTEMI or UA (82%) and with multivessel disease often associated with mitral regurgitation. On the other hand, the larger infarct size and higher mortality in patients with STEMI with a similarly reduced ejection fraction suggest a more extensive acute systolic loss.