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ABSTRACT: Objectives: This study sought to evaluate the safety and feasibility of a magnetic medical positioning system (MPS) to determine the three-dimensional (3D) position and orientation of intracoronary wires and catheters and to guide angiography and percutaneous coronary intervention (PCI). Background: Coronary angiography relies on fluoroscopy for catheter navigation and often fails to accurately portray vessel tortuosity, overlap, and length due to complex anatomy and foreshortening of curved coronary segments. Methods: 40 adult participants underwent coronary angiography and/or PCI with MPS guidance. Two interventional cardiologists independently scored (1 to 5) the accuracy of MPS catheter tracking projected on live fluoroscopy, recorded cine-loops, and 3D vessel reconstructions. Measurements from MPS reconstructions were compared to conventional 2D QCA measurements. Device procedural success was defined as the ability of the MPS enabled catheter to reach the target vessel, perform the intended operations, and be retrieved without major adverse cardiac events. Results: Diagnostic coronary angiography was performed in 19 patients (47.5%) and PCI in 21 (52.5%). MPS procedural success was achieved in 36 (90%) of the cases. MPS accuracy was highest with the MPS superimposed on live-fluoroscopy (4.9±0.2/5) and the 3D vessel reconstruction (4.7±0.5/5). MPS length measurements were more accurate than conventional QCA. Conclusions: This study demonstrates the feasibility and safety of magnetic catheter tracking with 3D positional data during diagnostic angiography and PCI. Catheter position was accurately projected on real-time fluoroscopy, recorded cine-loops, and 3D reconstructions. A magnetic positioning system may serve as a platform for device navigation and positioning during PCI. © 2013 Wiley Periodicals, Inc.
Catheterization and Cardiovascular Interventions 04/2013; · 2.29 Impact Factor
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ABSTRACT: Clinical treatment pathways are useful to ensure that evidence-based medicine is consistently applied in hospital systems and have been shown to improve patient outcomes. Such pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care. In 2011, we published the Columbia University Medical Center/New York Presbyterian Hospital - Clinical Pathways for Acute Coronary Syndromes and Chest Pain. This algorithm includes primary percutaneous coronary intervention for all patients with ST-segment elevation myocardial infarction and an early invasive approach for patients with non-ST-segment elevation myocardial infarction. Since our last chest pain algorithm update, the novel antiplatelet agent ticagrelor has been introduced in the United States, resulting in an important revision of our acute coronary syndrome clinical pathways. Herein, we present our updated chest pain algorithm and provide rationale for the changes that we have made to our protocol.
Critical pathways in cardiology 09/2012; 11(3):107-13.
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ABSTRACT: BACKGROUND: Percutaneous coronary intervention with stent placement for the treatment of patients with cardiac allograft vasculopathy is common, but data regarding stent behavior in this setting is lacking. OBJECTIVES: We investigated mechanisms and potential differences in stent expansion among transplant patients vs. patients with native coronary artery atherosclerotic disease ("controls"). METHODS: We compared pre- and poststent intravascular ultrasound in 12 transplant patients (17 lesions) and 33 control patients (34 lesions) matched according to age (60.1 ± 9.2 years), diabetes mellitus, and lesion location. Planar and volumetric analysis was conducted for every 1 mm at the lesion site as well as the first 5 mm proximal and distal to the stent edge. Focal stent expansion was defined as minimum stent area (MSA) divided by mean reference lumen area. Diffuse stent expansion was defined as mean stent area divided by mean reference lumen area. RESULTS: Transplant patients had more plaque than "controls" prestenting, but similar MSA and focal and diffuse stent expansion afterwards. The increase in mean lumen area correlated with the increase in mean vessel area in both groups, transplant (R = 0.64, P = 0.008) and controls (R = 0.70, P < 0.0001), but correlated inversely with changes in mean plaque area only in the transplant group (R = 0.55, P = 0.027). There were no differences in calcification between the two groups and no axial plaque distribution from the lesion into the reference segments in either group. CONCLUSIONS: The mechanism of stent expansion in transplant vasculopathy appears to be similar to de novo atherosclerosis-i.e., mainly vessel expansion to achieve similar acute results. © 2012 Wiley Periodicals, Inc.
Catheterization and Cardiovascular Interventions 03/2012; · 2.29 Impact Factor
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Benjamin Z Galper,
Jennifer Stant,
Mireya Reilly,
Sondra Walter,
Michael Collins,
Osman Sayan,
Gerald Neuberg,
Leslie Miller,
Jeffery W Moses,
Gregg W Stone,
James Giglio, LeRoy E Rabbani
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ABSTRACT: In 2008, we published our chest pain protocol for the management of acute coronary syndromes (ACS) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which includes primary percutaneous intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2008, there have been changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. In particular, recent data on the novel antiplatelet agent prasugrel, dosing of clopidogrel after PCI, and interactions with clopidogrel and other medicines and substrates, which can lead to decreased platelet response to clopidogrel, have led us to update our ACS clinical pathway. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI, and provide rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care.
Critical pathways in cardiology 03/2011; 10(1):9-16.
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Yong He,
Akiko Maehara,
Gary S Mintz,
Harpreet Bharaj,
Celia Castellanos,
Srinivas Kesanakurthy,
Xiaofan Wu,
Ning Guo,
So-Yeon Choi,
Martin B Leon,
Gregg W Stone,
Roxana Mehran, Leroy E Rabbani,
Jeffrey W Moses
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ABSTRACT: It is not clear whether the thin struts and different alloy of a cobalt chromium stent will cause greater acute stent recoil compared to conventional stainless steel stents. We used postintervention intravascular ultrasound (IVUS) examinations to study 99 patients with 116 stented lesions: 61 Xience/Promus stents (cobalt chromium stent group) and 27 Taxus Liberté and 28 Cypher stents (stainless steel stent group). The IVUS images were obtained before and immediately after stent implantation with only the stent-delivery balloon. The ratio of the IVUS-measured to manufacturer-predicted stent diameter and area was the measure of acute stent recoil and expansion. The baseline patient characteristics, lesion morphology, and procedural details were comparable between the 2 groups. The ratio of the IVUS-measured to manufacturer-predicted stent diameter and area was 0.74 versus 0.73 (p = 0.57) and 0.63 versus 0.63 (p = 0.69), respectively, for the cobalt chromium and stainless steel stents. In conclusion, the acute performance of Xience/Promus was similar to that of previous stainless steel stents, and the thinner cobalt chromium metallic platform did not compromise the radial strength of the stent.
The American journal of cardiology 05/2010; 105(9):1272-5. · 3.58 Impact Factor
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Yanai Ben-Gal,
Giora Weisz,
Michael B Collins,
Philippe Genereux,
George D Dangas,
Paul S Teirstein,
Varinder P Singh, LeRoy E Rabbani,
Susheel K Kodali,
Warren Sherman,
Martin B Leon,
Jeffrey W Moses
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ABSTRACT: To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach.
Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site.
We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach.
Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University - New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%).
The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series.
Catheterization and Cardiovascular Interventions 04/2010; 75(5):708-12. · 2.29 Impact Factor
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George Dangas,
Roxana Mehran,
Giulio Guagliumi,
Adriano Caixeta,
Bernhard Witzenbichler,
Jiro Aoki,
Jan Z Peruga,
Bruce R Brodie,
Dariusz Dudek,
Ran Kornowski, LeRoy E Rabbani,
Helen Parise,
Gregg W Stone
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ABSTRACT: Our aim was to determine whether a 600-mg loading dose of clopidogrel compared with 300 mg results in improved clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
A 600-mg loading dose of clopidogrel compared with 300 mg provides more rapid and potent inhibition of platelet activation.
In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 3,602 patients with STEMI undergoing primary PCI were randomized to bivalirudin (n = 1,800) or unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n = 1,802). Randomization was stratified by thienopyridine loading dose, which was determined before random assignment.
Patients in the 600-mg (n = 2,158) compared with the 300-mg (n = 1,153) clopidogrel loading dose group had significantly lower 30-day unadjusted rates of mortality (1.9% vs. 3.1%, p = 0.03), reinfarction (1.3% vs. 2.3%, p = 0.02), and definite or probable stent thrombosis (1.7% vs. 2.8%, p = 0.04), without higher bleeding rates. Compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin monotherapy resulted in similar reductions in net adverse cardiac event rates within the 300-mg (15.2% vs. 12.3%) and 600-mg (10.4% vs. 7.3%) clopidogrel loading dose subgroups (p(interaction) = 0.41). By multivariable analysis, a 600-mg clopidogrel loading dose was an independent predictor of lower rates of 30-day major adverse cardiac events (hazard ratio: 0.72 [95% confidence interval: 0.53 to 0.98], p = 0.04).
In patients with STEMI undergoing primary PCI with contemporary anticoagulation regimens, a 600-mg loading dose of clopidogrel may safely reduce 30-day ischemic adverse event rates compared with a 300-mg loading dose. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966).
Journal of the American College of Cardiology 10/2009; 54(15):1438-46. · 14.16 Impact Factor
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Xuebo Liu,
Kenichi Tsujita,
Akiko Maehara,
Gary S Mintz,
Giora Weisz,
George D Dangas,
Alexandra J Lansky,
Edward M Kreps, LeRoy E Rabbani,
Michael Collins,
Gregg W Stone,
Jeffrey W Moses,
Roxana Mehran,
Martin B Leon
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ABSTRACT: We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections after drug-eluting stent (DES) implantation.
DES implantation strategies differ compared with bare-metal stenting; coronary dissections after DES implantation have not been well studied.
We studied 887 patients with 1,045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging.
Eighty-two dissections were detected; 51.2% (42 of 82) involved the proximal and 48.8% (40 of 82) the distal stent edge. Residual plaque area (8.0 +/- 4.3 mm(2) vs. 5.2 +/- 3.0 mm(2), p < 0.0001); plaque burden (52.2 +/- 11.7% vs. 36.2 +/- 15.3%, p < 0.0001); plaque eccentricity (8.4 +/- 5.5 vs. 4.0 +/- 3.4, p < 0.0001); and stent edge symmetry (1.2 +/- 0.1 vs. 1.1 +/- 0.1, p = 0.02) were larger; plaque burden > or =50% was more frequent (62.0% vs. 17.2%, p < 0.0001); calcium deposits (52.1% vs. 35.2%, p = 0.03) more common; and lumen-to-stent-edge-area ratio (0.9 +/- 0.2 vs. 1.0 +/- 0.2, p < 0.0001) was smaller in the edge dissection group compared with the nondissection group. Intramural hematomas occurred in 34.1% (28 of 82) of dissections. When compared with nonhematoma dissections, residual plaque and media area (6.4 +/- 2.5 mm(2) vs. 8.9 +/- 4.6 mm(2), p = 0.04) was smaller, and stent edges less asymmetric (1.1 +/- 0.1 vs. 1.2 +/- 0.1, p = 0.009) in the dissection with hematoma group. Independent predictors of any stent edge dissection were residual plaque eccentricity (odds ratio [OR]: 1.4, p = 0.02), lumen-to-stent-edge-area ratio (OR: 0.0, p = 0.007), and stent edge symmetry (OR: 1.2, p = 0.02 for each 0.01 increase).
IVUS identified edge dissections after 9.2% of DES implantations. Residual plaque eccentricity, lumen-to-stent-edge-area ratio, and stent edge symmetry predicted coronary stent edge dissections. Dissections in less diseased reference segments more often evolved into an intramural hematoma.
10/2009; 2(10):997-1004. · 1.07 Impact Factor
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Leroy E Rabbani,
Srinivas Iyengar,
George D Dangas,
Cindy L Grines,
David A Cox,
Eulogio Garcia,
James E Tcheng,
John J Griffin,
Giulio Guagliumi,
Thomas Stuckey,
Mark Turco,
Jennifer Stant,
Martin Fahy,
Alexandra J Lansky,
Roxana Mehran,
Gregg W Stone
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ABSTRACT: The impact of thienopyridine administration prior to primary stenting in acute myocardial infarction (AMI) has not been well studied. We therefore examined the database from the prospective, multicenter, controlled CADILLAC trial in which 1,036 patients were randomized to bare metal stenting with or without abciximab to determine whether patients who received a thienopyridine prior to bare metal stenting in AMI had superior clinical outcomes. Per operator discretion, 659 patients (63.6%; Th+) received either a 500 mg ticlopidine loading dose (n = 623) or a 300 mg clopidogrel loading dose (n = 40), while 377 patients (36.4%; Th-) received no thienopyridine prior to stent implantation. Baseline and procedural characteristics of the two groups, including abciximab use (52.5% vs 52.8%, P = 0.93) were well matched. Th+ compared to Th- patients had lower rates of core lab assessed TIMI 0/1 flow postprocedure (0.8% vs 2.7%, P = 0.01). Th+ compared to Th- patients also had significantly reduced in-hospital and 30-day rates of ischemic target vessel revascularization (TVR) (1.1% vs 3.2%, P = 0.01 and 1.5% vs 3.8%, P = 0.02, respectively) and major adverse cardiovascular events (MACE) (2.7% vs 5.8%, P = 0.01 and 4.0% vs 6.9%, P = 0.03, respectively), results that remained significant after covariate adjustment. In conclusion, in this large prospective, controlled trial, patients receiving a thienopyridine prior to primary stenting in AMI were less likely to have TIMI 0/1 flow postprocedure and experienced reduced in-hospital and 30-day rates of ischemic TVR and MACE compared to those not administered a thienopyridine prior to stent implantation.
Journal of Interventional Cardiology 06/2009; 22(4):378-84. · 1.18 Impact Factor
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ABSTRACT: Transplant allograft vasculopathy (TAV) was a leading cause of death in cardiac transplant recipients after the first year of transplantation. Whether drug-eluting stents (DESs) performed better than bare-metal stents (BMSs) for the treatment of patients with discrete epicardial stenosis was unknown. The aim was to determine the safety and efficacy of DESs compared with BMSs in the treatment of patients with TAV. Outcomes of 32 patients sequentially treated using DESs for TAV were retrospectively reviewed and compared with a historic cohort of 35 patients treated sequentially with BMSs for TAV. Patients treated with DESs were also compared with age- and gender-matched cardiac transplant controls to determine differences in survival. After adjustment for baseline risk factors, there was no difference in 1-year survival between patients treated with DESs or BMSs for TAV. Restenosis rates at 1 year were 49% in lesions treated using BMSs and 19% in those treated using DESs. Compared with an age- and gender-matched control group of cardiac transplant patients who did not have discrete obstructive epicardial TAV, patients who required treatment with DESs for epicardial obstructive disease had significantly worse survival. In conclusion, treatment of patients with TAV with DESs did not seem to alter the natural deleterious history of this disease process.
The American journal of cardiology 04/2009; 103(5):659-62. · 3.58 Impact Factor
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Neil Goyal,
Jennifer Stant,
Francesca Esposito,
Gina Piri,
Michael Collins,
Osman Sayan,
Gerald Neuberg,
Leslie Miller,
Jeffery W Moses,
Gregg W Stone,
James Giglio, LeRoy E Rabbani
[show abstract]
[hide abstract]
ABSTRACT: In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. Since 2003, there have been numerous changes in the adjunctive pharmacotherapeutic armamentarium for PCI in both the STEMI and non-STEMI ACS context. We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
Critical pathways in cardiology 01/2009; 7(4):211-22.
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ABSTRACT: Percutaneous coronary intervention (PCI) to palliate cardiac allograft vasculopathy (CAV) has been associated with high restenosis rates, possibly related to increased inflammation associated with this disease. Whether markers of immunologic rejection are associated with restenosis in this population is unknown. The goal of the study was to determine the predictors of restenosis after PCI for CAV.
Records were reviewed retrospectively from a single, high-volume cardiac transplant center. Clinical, angiographic, and immunologic data were collected on all patients postorthotopic heart transplantation (OHT) that had subsequent PCI. Restenosis was defined as greater than 50% stenosis at the previous intervention site.
PCI was successfully performed on 62 de novo lesions in 40 patients an average of 6.8+/-3.9 years after OHT. Angiographic follow-up data was available for 79%, with an average follow-up of 1.54+/-1.22 years. The 1-year restenosis rate was 49% (64% for balloon percutaneous transluminal coronary angioplasty and 33% for coronary stenting [P=0.09 for difference]). The frequency of immunoglobulin (Ig)G antibody to major histocompatibility complex (MHC) class I antigen was highly associated with risk of restenosis (hazard ratio [HR] 11.33, P=0.01). Greater stenosis severity and smaller target vessel diameter were also predictors of restenosis as in the nontransplant population.
The findings suggest that in patients postPCI for CAV, humoral allo-immunity may contribute to restenosis and that IgG antibodies to MHC class I antigen may help predict the risk of restenosis after PCI in this population.
Transplantation 07/2005; 79(11):1581-7. · 4.00 Impact Factor
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ABSTRACT: We assessed the clinical impact of an interdisciplinary, cardiac nurse practitioner-facilitated chest pain (CP) initiative that stresses an early invasive approach for patients with CP with acute coronary syndromes in traditionally underserved patient populations, including females, blacks, Hispanics, and patients older than 60 years.
Two groups of patients were identified: Pre-CP initiative (December 1999-February 2000) and post-CP initiative (December 2000-February 2001).
Analysis of 714 patients revealed significantly more cardiac diagnoses post-CP initiative (61% pre-CP initiative vs. 73% post-CP initiative, P = 0.002), including in patients with myocardial infarction (MI) who were older than 60 years, females, and Hispanics. There was a significant increase in rates of cardiac catheterizations within 1 week of admission (10.5% vs. 20.4%, P <0.001), including in Hispanics. For rates of coronary artery stenting and/or bypass grafting (CABG), there was also a significant increase post-CP initiative (2.5% vs. 10.1%, P = 0.0005), as well as for Hispanics. Length of stay was significantly reduced for patients older than 60 years (8.3 vs. 5.8 days, P = 0.002).
Establishment of an interdisciplinary, cardiac nurse practitioner-facilitated CP initiative is associated with improvement in several clinical processes and outcomes: increased cardiac disease diagnosis in females, Hispanics, and patients older than 60 years; increased rates of cardiac catheterizations in Hispanic patients, increased rates of coronary artery stenting and/or CABG, particularly in Hispanic patients; and decreased length of stay in patients older than 60 years. These data support a targeted interdisciplinary CP initiative as a strategy to systematically enhance access to cardiovascular diagnosis in underserved patient populations.
Critical pathways in cardiology 03/2005; 4(1):3-9.
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ABSTRACT: This prospective study was designed to characterize the time course and variability of hemostatic and fibrinolytic risk factors over the course of a menstrual cycle in normal premenopausal women. Plasminogen activator inhibitor (PAI-1), tissue plasminogen activator, von Willebrand factor, fibrinogen, and fibrin D-dimer predict risk of coronary heart disease. Yet there is limited information describing the status of endogenous hormone concentrations and hemostatic and coagulation factors in premenopausal women. Twenty premenopausal women, mean age 34 +/- 7 yr, underwent testing over a cycle to measure endogenous hormones and hemostatic factors: estradiol and progesterone, FSH, LH; PAI-1, tissue plasminogen activator, von Willebrand factor, fibrin D-dimer, and fibrinogen as well as lipids: total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, and triglycerides. There was cyclical variability in estradiol (P < 0.01) and progesterone (P < 0.001) during the follicular and luteal phases. Moreover, there was intra- and interindividual cyclical variation in hemostatic risk factors. Measures of PAI-1 (P < 0.01) and D-dimer (P < 0.05) differed during the follicular and luteal phases. As estradiol concentration increased, PAI-I decreased. There was a significant correlation between total cholesterol and PAI-1 (r = 0.56, P < 0.05), low-density lipoprotein-cholesterol and PAI-1 (r = 0.50, P < 0.05) as well as between total cholesterol and fibrinogen (r = 0.61, P < 0.05). There is significant cyclical variability in estradiol, FSH, and progesterone as well as the hemostatic factors, PAI-1 and fibrin D-dimer. Characterization of emerging hemostatic risk factors enhances understanding of normal physiology, provides insight into the relation between estrogen and hemostatic factors, and raises the potential for predicting coronary heart disease even in relatively young women.
Journal of Clinical Endocrinology & Metabolism 01/2005; 89(12):6179-84. · 6.50 Impact Factor
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ABSTRACT: For clinicians plasma C-reactive protein (CRP) levels are the only widely available tests that provide a tangible link between inflammation and atherosclerosis. New AHA/CDC joint guidelines from 2002-03 now include the measurement of CRP as a class IIa recommendation for stratifying patients with known cardiovascular disease (CVD) at a moderate (10-20%) 10-year event risk and a class IIb recommendation for patients without known CVD [1]. While the association of CRP and atherosclerosis is by now accepted, the molecular biology behind the association is evolving rapidly into a fascinating story. While some of the story remains obscure, this review aims to bridge the clinical and basic science and identify what is known about the role of this ancient molecule in atherosclerosis. The review covers CRP's interaction with atherosclerosis' major ingredients and cell types including the endothelium, monocytes and neutrophils, lipoproteins and the complement system. Taken together, the clinical and basic science leave the tantalizing impression that CRP has a fundamental role in atherogenesis, and hint at a more complex immunomodulatory effect which transforms the acute inflammatory response to vascular injury into the chronic inflammation seen in atherosclerosis.
Journal of Thrombosis and Thrombolysis 05/2004; 17(2):95-105. · 1.48 Impact Factor
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ABSTRACT: Heart failure is a major public health concern for which treatment options have continued to evolve. While specific therapies such as beta blockers and angiotensin converting enzyme inhibitors have been shown to decrease hospitalizations and improve survival, the benefits of anticoagulation are less clear. Clinical guidelines detailing the appropriate use of anticoagulation for the management of atrial fibrillation and embolic stroke exist, but similar recommendations for their use in isolated cardiac dysfunction are lacking. Epidemiologic studies have documented increased risk of thrombus formation and stroke occurrence in patients with cardiomyopathy that is inversely related to ejection fraction. However, it remains at the clinician's discretion to determine at what degree of left ventricular dysfunction the potential benefits of stroke reduction outweigh the risks of undesirable bleeding with anticoagulation. This paper summarizes the pathophysiology of thrombus formation in heart failure patients; reviews previous studies and current recommendations for anticoagulation; provides a clinical rationale for anticoagulation when conclusive data are lacking; and discusses ongoing clinical trials designed to clarify these issues.
Journal of Thrombosis and Thrombolysis 05/2004; 17(2):87-93. · 1.48 Impact Factor
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ABSTRACT: The tetracyclines are antimicrobials that also inhibit expression of certain matrix metalloproteinases (MMPs). We conducted a series of experiments to determine if minocycline could inhibit MMP expression and limit human aortic smooth muscle cell (SMC) proliferation and migration. Analysis of SMC proliferation was performed after cells were grown in minocycline-incubated media. SMC migration activity was assayed in a micro-Boyden chamber. Western blotting revealed that minocycline reduced SMC production of MMP-2 in a dose dependent manner. Increasing doses of minocycline progressively reduced SMC proliferation to 49% of control values and limited SMC migration to 15% of control. When administered to rats with balloon injured carotid arteries, intraperitoneal doses of minocycline (70-100 mg/kg) reduced neointima formation by 76%, but were associated with liver toxicity. Higher doses were lethal and lower doses were ineffective. Minocycline, applied to injured arteries in a pluronic gel with a low pH, was also ineffective. In summary, minocycline lowers MMP-2 expression, reduces SMC proliferation and migration, and inhibits neointimal hyperplasia, but its efficacy is limited by systemic toxicity.
Journal of Cardiovascular Pharmacology 11/2003; 42(4):469-76. · 2.29 Impact Factor
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ABSTRACT: We describe the development and institution of an initiative based on a clinical diagnostic algorithm and treatment pathways, facilitated by cardiac nurse practitioners, for the treatment of the diverse group of patients with chest pain who seek treatment at our urban-based institution. We believe that our chest pain initiative incorporates previous strategies of rapid emergency department management with inpatient-based care while providing a framework for outpatient follow-up and secondary prevention. These strategies allow our hospital to meet its goals of providing chest pain patients with standardized, high-quality, and expeditious care, given the challenges faced by an academic urban hospital.
Critical pathways in cardiology 07/2003; 2(2):113-7.
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ABSTRACT: Cardiopulmonary resuscitation (CPR), as described in 1960, remains the cornerstone of therapy for cardiopulmonary arrest. Recent case reports have described CPR in the prone position. We hypothesized rhythmic back pressure on a patient in the prone position with sternal counter-pressure (termed reverse CPR here) would increase intra-thoracic pressure and in turn systolic blood pressure (SBP) during cardiac arrest versus standard CPR.
Six patients from Columbia Presbyterian Medical Center's Cardiac and Medical Intensive Care Units (CICU and MICU) were enrolled. Eligible patients had suffered circulatory arrest and failed standard CPR for at least 30 min. After enrollment the patients received 15 additional min of standard CPR and then reverse CPR for 15 min. The study's primary endpoint, mean SBP, significantly improved from 48 mmHg during standard CPR to 72 mmHg during reverse CPR (mean improvement=23+/-14 mmHg). Mean calculated mean arterial pressure (MAP) was also improved significantly from 32 mmHg during standard CPR to 46 mmHg during reverse CPR (mean improvement=14+/-11 mmHg). The mean diastolic blood pressure (DBP) improved from 24 mmHg during standard to 34 mmHg during reverse CPR (mean improvement=10+/-12 mmHg). This difference did not meet statistical significance. No patients had return of spontaneous circulation.
Reverse CPR generates higher mean SBP and higher mean MAP during circulatory arrest than standard CPR. These novel findings justify further research into this technique.
Resuscitation 07/2003; 57(3):279-85. · 3.60 Impact Factor
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The American Journal of Cardiology 06/2003; 91(10):1248-50. · 3.37 Impact Factor
