R W Hautvast

Medisch Centrum Alkmaar, Alkmaar, North Holland, Netherlands

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Publications (33)257.73 Total impact

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    ABSTRACT: Third-generation, permanent-polymer-based drug-eluting stents with novel, flexible designs might be more easily delivered than previous generations of stents in complex coronary lesions, but might be less longitudinally stable. We aimed to assess the safety and efficacy in all-comer patients of two third-generation stents that are often used clinically, but that have not yet been compared, and one of which has not previously been assessed in a randomised trial. In this investigator-initiated, single-blind, multicentre, randomised, two-arm, non-inferiority trial, patients aged 18 years and older who required a percutaneous coronary intervention with implantation of a drug-eluting stent were recruited from four study sites in the Netherlands. We randomly assigned patients by independently managed computer-generated allocation sequences in a 1:1 ratio to receive either cobalt-chromium-based zotarolimus-eluting stents (Resolute Integrity, Medtronic, Santa Rosa, CA, USA) or platinum-chromium-based everolimus-eluting stents (Promus Element, Boston Scientific, Natick, MA, USA). Patients and analysts were masked to the allocated stent, but treating clinicians were not. The primary endpoint of target-vessel failure was a composite of safety (cardiac death or target-vessel-related myocardial infarction) and efficacy (target-vessel revascularisation) at 12 months, analysed by intention to treat (with a non-inferiority margin of 3·6%). This trial is registered with ClinicalTrials.gov, number NCT01331707. Between Nov 25, 2010, and May 24, 2012, 1811 eligible all-comer patients, with 2371 target lesions, were enrolled in the study. 370 (20%) patients presented with ST-elevation myocardial infarction and 447 (25%) with non-ST-elevation myocardial infarction. 906 patients were assigned to receive zotarolimus-eluting stents and 905 to receive everolimus-eluting stents. Ease of stent delivery was shown by very low numbers of patients requiring treatment other than their assigned study treatment (six [1%] in the zotarolimus-eluting stent group vs five [1%] in the everolimus-eluting stent group; p=0·22). 12-month follow-up results were available for 1810 patients (one patient in the zotarolimus-eluting stent group withdrew consent). The primary endpoint was met by 55 (6%) of 905 patients in the zotarolimus-eluting stent group and 47 (5%) of 905 in the everolimus-eluting stent group. The zotarolimus-eluting stent was non-inferior to the everolimus-eluting stent (absolute risk difference 0·88%, 95% CI -1·24% to 3·01%; upper limit of one-sided 95% CI 2·69%; non-inferiority p=0·006). We noted no significant between-group differences in individual components of the primary endpoint. Definite stent thrombosis occurred in three (0·3%) patients in the zotarolimus-eluting stent group and six (0·7%) patients in the everolimus-eluting stent group (p=0·34). Longitudinal stent deformation was seen only in the everolimus-eluting stent group (nine [1·0%] of 905 vs 0 of 906, p=0·002; nine of 1591 [0·6%] everolimus-eluting stents implanted became deformed), but was not associated with any adverse events. Both stents were similarly efficacious and safe, and provided excellent clinical outcomes, especially in view of the large number of patients who presented with acute myocardial infarctions. Boston Scientific, Medtronic.
    The Lancet 10/2013; · 39.21 Impact Factor
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    ABSTRACT: Drug-eluting stents (DES) are increasingly used for the treatment of coronary artery disease. An optimized DES performance is desirable to successfully treat various challenging coronary lesions in a broad population of patients. In response to this demand, third-generation DES with an improved deliverability were developed. Promus Element (Boston Scientific, Natick, MA) and Resolute Integrity (Medtronic Vascular, Santa Rosa, CA) are 2 novel third-generation DES for which limited clinical data are available. Accordingly, we designed the current multicenter study to investigate in an all-comers population whether the clinical outcome is similar after stenting with Promus Element versus Resolute Integrity. DUTCH PEERS is a multicenter, prospective, single-blinded, randomized trial in a Dutch all-comers population. Patients with all clinical syndromes who require percutaneous coronary interventions with DES implantation are eligible. In these patients, the type of DES implanted will be randomized in a 1:1 ratio between Resolute Integrity versus Promus Element. The trial is powered based on a noninferiority hypothesis. For each stent arm, 894 patients will be enrolled, resulting in a total study population of 1,788 patients. The primary end point is the incidence of target vessel failure at 1-year follow-up. DUTCH PEERS is the first randomized multicenter trial with a head-to-head comparison of Promus Element and Resolute Integrity to investigate the safety and efficacy of these third-generation DES.
    American heart journal 04/2012; 163(4):557-62. · 4.65 Impact Factor
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    ABSTRACT: The nurse practitioner may be the ideal healthcare worker to create a new environment and may facilitate in the process of expediting discharge and improving patient safety. They can play an intermediary role between the consultants, nurses and patients, thereby combining the aspects of care (nursing) and cure (physicians). We describe the contribution and role of the nurse practitioner in a teaching hospital and provide an overview of the changes in care and cure that were facilitated by two nurse practitioners in the treatment of cardiac surgery patients or non-complicated acute coronary syndrome patients. The nurse-led clinic for postoperative patients has registered 1967 patients in the past 10 years. These patients were transferred at a mean of 5.5 days after their bypass operation. All patients had an uneventful clinical course in our hospital and were discharged alive. The period between discharge and outpatient clinic visit could be set at 4 weeks. The post-acute coronary syndrome (ACS) group included 1236 patients. Mortality in this patient cohort was 4% while 0.4% of these patients experienced a re-myocardial infarction. Additional surgery was needed in only 2% of these stable post-infarction patients. The mean length of stay was 5.9 ± 14.5 days. This observational study confirms that a nurse-led postoperative care unit and post-ACS care unit is feasible and effective for the treatment of patients returning from cardiac surgery or transferred after uncomplicated ACS to a general cardiology ward.
    Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 01/2012; 20(1):5-11. · 1.41 Impact Factor
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    ABSTRACT: Proton-pump inhibitors (PPIs) are often prescribed in combination with thienopyridines. Conflicting data exist as to whether PPIs diminish the efficacy of clopidogrel. We assessed the association between PPI use, measures of platelet function, and clinical outcomes for patients treated with clopidogrel or prasugrel. In the PRINCIPLE-TIMI 44 trial, the primary outcome was inhibition of platelet aggregation at 6 h assessed by light-transmission aggregometry. In the TRITON-TIMI 38 trial, the primary endpoint was the composite of cardiovascular death, myocardial infarction, or stroke. In both studies, PPI use was at physician's discretion. We used a multivariable Cox model with propensity score to assess the association of PPI use with clinical outcomes. In the PRINCIPLE-TIMI 44 trial, 201 patients undergoing elective percutaneous coronary intervention were randomly assigned to prasugrel (n=102) or high-dose clopidogrel (n=99). Mean inhibition of platelet aggregation was significantly lower for patients on a PPI than for those not on a PPI at 6 h after a 600 mg clopidogrel loading dose (23.2+/-19.5% vs 35.2+/-20.9%, p=0.02), whereas a more modest difference was seen with and without a PPI after a 60 mg loading dose of prasugrel (69.6+/-13.5% vs 76.7+/-12.4%, p=0.054). In the TRITON-TIMI 38 trial, 13,608 patients with an acute coronary syndrome were randomly assigned to prasugrel (n=6813) or clopidogrel (n=6795). In this study, 33% (n=4529) of patients were on a PPI at randomisation. No association existed between PPI use and risk of the primary endpoint for patients treated with clopidogrel (adjusted hazard ratio [HR] 0.94, 95% CI 0.80-1.11) or prasugrel (1.00, 0.84-1.20). The current findings do not support the need to avoid concomitant use of PPIs, when clinically indicated, in patients receiving clopidogrel or prasugrel. Daiichi Sankyo Company Limited and Eli Lilly and Company sponsored the trials. This analysis had no funding.
    The Lancet 09/2009; 374(9694):989-97. · 39.21 Impact Factor
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    ABSTRACT: This study sought to comprehensively identify predictors of stent thrombosis (ST). Given the devastating consequences of ST, efforts should be directed toward risk stratification to identify patients at highest risk for ST. Consecutive patients with angiographic ST were enrolled. Patients who did not suffer from a ST were randomly selected in a 2:1 ratio and were matched for: 1) percutaneous coronary intervention (PCI) indication; 2) same date of index PCI; and 3) same interventional center. Of 21,009 patients treated with either a bare-metal or drug-eluting stent, 437 patients (2.1%) presented with a definite ST. A total of 140 STs were acute, 180 were subacute, 58 were late, and 59 were very late. Undersizing of the coronary stent, Thrombolysis In Myocardial Infarction flow grade <3, present malignancy, presence of intermediate coronary artery disease proximal and distal to the culprit lesion, dissection, lack of aspirin, bifurcation lesions, ejection fraction <30%, and younger age were associated with ST. The lack of clopidogrel therapy at the time of ST in the first 30 days after the index PCI (hazard ratio [HR]: 36.5, 95% confidence interval [CI]: 8.0 to 167.8), between 30 days and 6 months after the index PCI (HR: 4.6, 95% CI: 1.4 to 15.3), and beyond 6 months (HR: 5.9, 95% CI: 1.7 to 19.8) after the index PCI was strongly associated with ST. Important correlates of ST were identified. Discontinuation of clopidogrel, undersizing of the coronary stent, present malignancy, and intermediate (>or=50% to <70% stenosis) coronary artery disease proximal to the culprit lesion were the strongest predictors of ST.
    Journal of the American College of Cardiology 04/2009; 53(16):1399-409. · 14.09 Impact Factor
  • The American journal of cardiology 11/2008; 102(8):1115. · 3.58 Impact Factor
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    ABSTRACT: To assess safety and efficacy of off-site percutaneous coronary intervention (PCI) in The Dutch invasive cardiovascular system. Descriptive single centre registry of elective and emergency PCI. Setting is a Dutch community hospital, 40 km north of Amsterdam, with an adherent population of 400,000 people. A Clinical follow up of Major Adverse Cardiac and Cerebral Events (MACCE) at 30 days post PCI is performed. The total number of participants eligible for PCI was 781 of whom 545 were men and 236 women. During a two-year period 781 PCI's were performed of which 298 were emergency and 483 elective. Acute complications occurred in 2.1% of participants. MACCE-free was 86.9% in the group with AMI and 95.8% in the elective group. Off-site PCI is feasible and safe in The Netherlands on the condition that specific key factors for success are taken into consideration.
    International journal of cardiology 02/2008; 132(1):59-65. · 6.18 Impact Factor
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    ABSTRACT: We investigated whether primary percutaneous coronary intervention (PCI) for patients admitted with an acute ST-segment elevation myocardial infarction could be performed more rapidly and with comparable outcomes in a community hospital versus a tertiary center with cardiac surgery. We started the first PCI with an off-site surgery program in The Netherlands in 2002 and report the results of 439 consecutive patients. In the safety phase, 199 patients presenting with ST-segment elevation myocardial infarction were randomly assigned to treatment at our off-site center versus a more distant cardiac surgery center. In the confirmation phase, 240 consecutive patients were treated in the off-site hospital. Safety and efficacy end points were the rate of an angiographically successful PCI procedure (diameter stenosis <50% and Thrombolysis In Myocardial Infarction grade 3 flow) in the absence of major adverse cardiac and cerebrovascular events at 30 days. The randomization phase showed a 37-minute decrease in door-to-balloon time (p <0.001) with comparable procedural and clinical successes (91% Thrombolysis In Myocardial Infarction grade 3 flow in the 2 groups). In the confirmation phase, the 30-day rate without major adverse cardiac and cerebrovascular events was 95%. None of the 439 patients in the study required emergency surgery for failed primary PCI. In conclusion, time to treatment with primary PCI can be significantly shortened when treating patients in a community hospital setting with off-site cardiac surgery backup compared with transport for PCI to a referral center with on-site surgery. PCI at hospitals with off-site cardiac surgery backup can be considered a needed strategy to improve access to primary PCI for a larger segment of the population and can be delivered with a very favorable safety profile.
    The American Journal of Cardiology 11/2007; 100(9):1353-8. · 3.21 Impact Factor
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    ABSTRACT: BACKGROUND.: Based on experience from other countries, the Medical Centre Alkmaar was granted permission to start the first Dutch PCI programme without on-site cardiac surgery. The cardiology group of the Medical Centre Alkmaar started an off-site PCI programme in 2002 with only primary PCI in the first year and a full PCI programme from November 2003 onwards. We report the first Dutch experience with acute cardiac surgery following a failed PCI procedure in an off-site clinic. PATIENTS.: From October 2002 until February 2007, 2500 patients were treated by PCI in the Medical Centre Alkmaar. These patients were treated for an acute myocardial infarction (33%), acute coronary syndromes (37%) or progressive angina (30%). In this first series of off-site PCI in the Netherlands, the incidence of emergency cardiac surgery following failed PCI was 0.2% All five patients who needed emergency surgery underwent elective PCI for progressive stable coronary artery disease. No emergency surgery was needed for primary PCIs in patients with an acute myocardial infarction. All patients survived emergency surgery following failed PCI. CONCLUSION.: Adherence to the Dutch guidelines of interventional cardiology with protocols describing a close collaboration with cardiac surgeons and an immediate availability of rapid ground transportation are mandatory when performing off-site PCI. This series extends the current expertise of emergency surgery after failed PCI to off-site clinics. With appropriate settings, off-site PCI may not be associated with an increase in the risk of adverse events. (Neth Heart J 2007;15:173-7.).
    Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 06/2007; 15(5):173-7. · 1.41 Impact Factor
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    ABSTRACT: A drug-eluting stent was implanted in four patients, a man aged 67 and a woman aged 42 with acute myocardial infarction, a woman aged 41 with unstable angina pectoris and a man aged 41 with stable angina pectoris. All suffered stent thrombosis after discontinuation (in three cases prematurely) of clopidogrel therapy. Reasons for discontinuation included allergic reaction, a dental procedure and refusal of reimbursement by the insurer. In order to restore stent patency they were treated by percutaneous coronary intervention and all patients suffered irreversible myocardial damage. Combination therapy using acetylsalicylic acid and clopidogrel during and after angioplasty for the prevention of long- and short-term complications is necessary. Stent thrombosis after drug-eluting stent implantation usually occurs within 1-4 weeks following discontinuation ofantiplatelet medication. These cases stress the importance of antiplatelet therapy after stent implantation. Physicians, dentists and patients must be aware of the risk of the early discontinuation ofantiplatelet therapy.
    Nederlands tijdschrift voor geneeskunde 05/2006; 150(15):863-8.
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    ABSTRACT: The impact of patient- and operator-related clinical variables of success and evaluation of subsequent midterm effects of percutaneous treatment of left main coronary stenosis were assessed at a tertiary-referral high-volume angioplasty center in a retrospective observational study. A total of 118 consecutive surgical and nonsurgical patients with protected and unprotected left main (LM) lesions were treated by operators within a preconditioned expert culture. There were 57 protected and 61 unprotected patients, including 13 patients with an acute myocardial infarction (AMI). Mean age was 67 years (range 33-90). The length of the stenotic segment was 4.8 +/- 2.3 mm, mean lumen diameter was 1.1 +/- 0.6 mm, and percentage diameter stenosis was 63.6 +/- 14.6%. There were 7 (5.9%) in-hospital cardiac deaths that presented with AMI and cardiogenic shock. All 7 patients presented with unprotected LM lesions. Average follow-up was 8 months (range 1-36 months). Major adverse cardiac events (MACE) during follow-up comprised 8 (6.8%) cardiac deaths, 3 (2.5%) myocardial infarctions, 8 (6.8%) subjects with coronary bypass surgery, and 16 (13.6%) repeated angioplasties. The total event rate (MACE, n = 43) at the end of the follow-up period was 36.4%. There were more MACE in the unprotected group than in the protected group (41% vs. 31.6%, P<0.05). This study supports prior data on LM angioplasty. LM stenting in AMI showed less favorable in-hospital and late outcome.
    Critical pathways in cardiology 06/2005; 4(2):88-97.
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    ABSTRACT: Glycoprotein IIb/IIIa receptor antagonists, such as abciximab, are used to reduce major adverse cardiac events (MACEs) in patients undergoing percutaneous transluminal coronary angioplasty. The goal of this study was to evaluate the administration of abciximab in relation to lesion complexity and periprocedural complications. A total of 357 patients with 435 de novo lesions were included in this study. Lesions were divided into simple (type A and type B1) and complex (type B2 and type C) lesions according to the American College of Cardiology/American Heart Association Task Force lesion complexity system. Abciximab was given to unstable complex lesions and simple lesions with a periprocedural unstable complicated course. The overall incidence of MACE during the 9-month follow-up period was 17.0%. Patients treated with abciximab had a higher lesion complexity (P < 0.001), dissections (P = 0.014), stents (P < 0.001), and vessels involved (P < 0.001). in addition, the abciximab group was characterized by a higher angina NYHA class (P = 0.005), lower TIMI flow prior to stenting (P = 0.01), and a longer total inflation time (P = 0.006). Despite these clinical differences, the occurrence of MACE within the abciximab group was slightly less than in the group without abciximab (16.2% and 17.3%, respectively). Lesion complexity was directly related to MACE in the group that did not receive abciximab (simple and stable complex lesions; P = 0.04). On the other hand, in subjects treated with abciximab, lesion complexity was not related to a higher incidence of MACE (P = 0.76). The use of abciximab equalizes the difference in outcome between simple and complex lesions. Therefore, abciximab should be advocated especially in unstable and complex percutaneous coronary interventions.
    Catheterization and Cardiovascular Interventions 11/2003; 60(3):339-43. · 2.51 Impact Factor
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    ABSTRACT: Neurostimulation for refractory angina pectoris is often advocated for its clinical efficacy. However, the recruited pathways to induce electroanalgesia are partially unknown. Therefore, we sought to study the effect of neurostimulation on experimentally induced cardiac nociception, using capsaicin as nociception-induced substance. Four different groups of male Wistar rats were pericardially infused with either saline or capsaicin with or without neurostimulation. Group StimCap was infused with capsaicin, and group StimVeh was infused with saline. Both groups were treated with neurostimulation. Group ShamCap was only infused with capsaicin without stimulation, whereas group ShamVeh was only infused with saline. Neuronal activation differences were assessed with cytochemical staining, revealing the cellular expression of c-fos. Pain behavior was registered on video and was quantitatively analyzed. In the StimCap and ShamCap groups, all animals exerted typical pain behavior, whereas in the StimVeh group only moderate changes in behavior were observed. Group ShamVeh animals were unaffected by the procedure. The upper thoracic spinal cord showed high numbers of c-fos-positive cells, predominantly in laminae III and IV in both StimCap and StimVeh groups. Almost no c-fos expression was noticed in groups ShamCap and ShamVeh in these sections of the spinal cord. In groups StimCap and ShamCap a significantly higher number of c-fos-positive cells in comparison with groups StimVeh and ShamVeh were noticed in the periambigus region, the nucleus tractus solitarius, and the paraventricular hypothalamus. In the paraventricular thalamus, periaqueductal gray, and central amygdala, no significant differences were noticed among the first three groups, and the c-fos concentration in these three groups was significantly higher than in group ShamVeh. It is concluded that neurostimulation does not influence capsaicin-induced cardiac nociceptive pain pulses to the central nervous system. Furthermore, capsaicin-induced cardiac pain and neurostimulation may utilize two different pathways.
    Journal of Molecular Neuroscience 03/2003; 20(1):43-52. · 2.89 Impact Factor
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    ABSTRACT: At present, there is no reliable antianginal drug therapy for patients with cardiac syndrome X. Therefore, the effect of electrical neuromodulation on refractory angina pectoris and myocardial perfusion in cardiac syndrome X was assessed. Eight patients (aged 55+/-7 years) with heterogeneous myocardial perfusion and no esophageal abnormalities were included. The subjects were nonresponders to antianginal drug therapy. Angina pectoris attacks and myocardial perfusion dynamics were evaluated by positron emission tomography at baseline and following 4 weeks of (transcutaneous electrical nerve stimulation) TENS. Following TENS there was a reduction of angina pectoris episodes (baseline 20+/-3, TENS 3+/-1; p=0.012), and short acting nitroglycerin intake per week (baseline 10+/-3, TENS 2+/-1; p=0.008). The rate pressure product (mmHg min(-1)) during the cold pressor test (CPT) was reduced during TENS (baseline 12800+/-1200, TENS 11500+/-900; p=0.02). Following TENS, the perfusion reserve ratio between rest and dipyridamole flow increased (baseline 1.59+/-0.15, TENS 1.90+/-0.11 ml min(-1)x 100g; p=0.05). The coronary vascular resistance had a trend towards a reduction (baseline 0.96+/-0.04, TENS 0.85+/-0.06 mmHg min(-1)x 100 g/ml; p=0.06) during CPT. This observation may suggest that neurostimulation improves angina pectoris with a concomitant improvement of myocardial perfusion in cardiac syndrome X.
    European Journal of Pain 01/2003; 7(6):507-12. · 3.07 Impact Factor
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    Mike J L DeJongste, Raymond W M Hautvast, René A Tio
    Journal of the American College of Cardiology 11/2002; 40(8):1541; author reply 1541-2. · 14.09 Impact Factor
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    ABSTRACT: Recent findings imply prognostic significance of intracoronary acetylcholine infusion for endothelial function testing. We evaluated whether routine use of this test in coronary angiography patients is safe. Patients undergoing a first diagnostic coronary angiography were selected to receive intracoronary acetylcholine for endothelial function evaluation. The relation between adverse reactions during infusion and risk factors was analyzed with a logistic regression model. Included in the multiple logistic regression model were the variables with a univariate P value < 0.20. Adverse reactions occurred in 16% (49/299) of the patients. This included two life-threatening events caused by occlusive spasm and flow limitation in the left coronary artery. Other adverse events were chest pain (n = 38), AV block or sinus bradycardia (n = 10), dyspnea (n = 3). Adverse reactions were more likely to occur in patients younger than 60 years of age (relative risk, 5.6 [2.2-14.3]). Intracoronary acetylcholine infusion is safe, but may lead to serious adverse reactions. Care should be taken especially in patients younger than 60 years of age. Routine use of acetylcholine infusion can thus only be justified if it has important prognostic significance. This has to be proven further in large prospective studies.
    Journal of Investigative Medicine 03/2002; 50(2):133-9. · 1.75 Impact Factor
  • Raymond Hautvast, Gillian Jessurun, Rene Tio
    The Lancet 01/2002; 360(9350):2085-6; author reply 2086. · 39.21 Impact Factor
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    G A J Jessurun, R W M Hautvast, R A Tio
    01/2001;
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    ABSTRACT: The present study assessed the reoccurrence of myocardial ischemia after withholding electrical neurostimulation. After randomization, in the study or withdrawal group, spinal cord stimulation (SCS) was set active during the first 4 weeks, followed by 4 weeks of withholding stimulation. In the control group, SCS was switched off during 4 weeks before the end of the study. The control group had no crossover period. Measurements were done at baseline, then after 4 and 8 weeks. The first periods at 4 weeks of each sequence of both groups were compared. In addition, a comparison of clinical variables was performed between the study group 4 weeks after withholding stimulation and the control group 4 weeks following randomization. A total number of 24 patients with refractory angina and an implanted spinal cord stimulator were included in the study (n = 12) and control group. Angina pectoris complaints, nitroglycerin intake, ischemia, and heart rate variability using 48-hour ambulatory electrocardiographic monitoring were assessed. In addition, neurohormonal status and symptom-limited aerobic capacity were evaluated. There was no increase of anginal complaints or ischemia after withholding stimulation. Neurohormonal levels and aerobic capacity were not altered. We conclude that there is no adverse clinical rebound phenomenon after withholding neurostimulation in patients with refractory angina pectoris.
    Pacing and Clinical Electrophysiology 11/1999; 22(10):1432-9. · 1.75 Impact Factor
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    ABSTRACT: Patients with symptomatic small vessel coronary artery disease may be inadequate candidates for revascularization procedures. They may suffer from refractory angina, which does not respond to maximal anti-anginal drug therapy. In addition to patients with end stage coronary artery disease and syndrome X, this newly defined group of subjects with an isolated stenosis of a small coronary artery may benefit from electrical neurostimulation. We describe two patients with intractable angina caused by a significant narrowing of a diagonal branch. This treatment modality should be considered as an alternative method for unsatisfactory revascularization procedures.
    The Journal of invasive cardiology 08/1999; 11(7):435-8. · 1.57 Impact Factor

Publication Stats

1k Citations
257.73 Total Impact Points

Institutions

  • 2009–2013
    • Medisch Centrum Alkmaar
      • Department of Cardiology
      Alkmaar, North Holland, Netherlands
  • 1995–2002
    • Universitair Medisch Centrum Groningen
      • Department of Cardiology
      Groningen, Groningen, Netherlands
  • 1994–1999
    • University of Groningen
      • Department of Cardiology
      Groningen, Province of Groningen, Netherlands
  • 1996
    • Medisch Spectrum Twente
      Enschede, Overijssel, Netherlands