Alexander Battler

Aspirin and mortality in patients treated with angiotensin-converting enzyme inhibitors : A cohort study of 11,575 patients with coronary artery disease

OBJECTIVES The purpose of this study was to investigate the significance of the possible negative interaction between aspirin and angiotensin-converting enzyme (ACE) inhibitors. BACKGROUND Several provocative reports have recently suggested that aspirin is unsafe in patients with heart failure and has negative interaction with ACE inhibitors that might attenuate their beneficial effects upon survival. METHODS We analyzed mortality data of 11,575 patients with coronary artery disease screened for the Bezafibrate Infarction Prevention trial. A total of 1,247 patients (11%) were treated with ACE inhibitors. Of them, 618 patients (50%) used aspirin. RESULTS Five-year mortality was lower among patients on ACE inhibitors and aspirin than patients on ACE inhibitors without aspirin (19% vs. 27%; p < 0.001). After adjusting for confounders, treatment with aspirin and ACE inhibitors remained associated with lower mortality risk than using ACE inhibitors only (relative risk [RR] = 0.71; 95% confidence interval [CI] = 0.56 to 0.91). Subgroup analysis of 464 patients with congestive heart failure treated with ACE inhibitors revealed 221 patients (48%) on aspirin and 243 patients not on aspirin. Although clinical characteristics and therapy were similar, patients taking aspirin experienced lower mortality than patients who did not (24% vs. 34%; p = 0.001). After adjustment, treatment with aspirin was still associated with lower mortality (RR = 0.70; 95% CI = 0.49 to 0.99). CONCLUSIONS Among coronary artery disease patients with and without heart failure who are treated with ACE inhibitors, the use of aspirin was associated with lower mortality than treatment without aspirin. Our findings contradict the claim that aspirin attenuates the beneficial effect of ACE inhibitors and supports its use in patients with coronary artery disease treated with ACE inhibitors.

Stimulation of 42/44 kDa mitogen-activated protein kinases by arginine vasopressin in rat cardiomyocytes

Vasoconstrictors, such as angiotensin II (Ang II), are involved in the regulatory mechanisms of post myocardial infarction (MI) hypertrophy. Arginine vasopressin (AVP), may be another vasoconstrictor that influences the mechanisms that lead to post MI hypertrophy. In these studies we investigated the possible activation of the 42/44 kDa mitogen-activated protein kinases (MAPKs), also referred as extracellular signal regulated kinases (ERKs), in cultured cardiomyocytes. Treatment of rat cardiomyocytes with AVP, Ang II and phorbol 12-myristate 13-acetate (PMA) increases the activation of ERKs. The activity of the 42/44 kDa MAPKs was tested using the phosphorylation of: (1) EGF receptor peptide (EGFR-P); (2) myelin basic protein (MBP) immobilized in poly acrylamide gels; and (3) T183 and Y185 residues of these proteins. The activity of the MAPKs, induced by AVP or PMA was inhibited by downregulation of protein kinase C (PKC), by the tyrosine kinase inhibitor genistein and by MAPK kinase (MEK) inhibitor, PD98059. In addition, the AVP-induced stimulation of MAPKs was shown to be mediated through a V1 receptor. We suggest that AVP activates the 42/44kDa MAPKs through a signal transduction pathway that involves stimulation of AVP-V1 receptor, tyrosine kinase, PKC and MEK. These results suggest that AVP may be involved in ERKs dependent regulatory functions of cardiomyocytes growth.

Anomalous origin of the right coronary artery from the left anterior descending coronary artery

This is the first presentation of anomalous origin of right coronary artery (RCA) from mid-left anterior descending (LAD) coronary artery. A 77-year-old male was catheterized because of recent onset of fatigue during exertion. The LAD demonstrated 50-60% narrowing just proximal to the anomalous origin of the RCA. The patient was maintained on oral medication.

Thrombolytic therapy in acute pancreatitis presenting as acute myocardial infarction

In the treatment of patients with suspected acute myocardial infarction, the use of thrombolytic therapy could be coined as ‘the race against time’, as rapid implementation of thrombolysis may save myocardial mass and decrease mortality. In cases having typical clinical presentations and ECG changes, a rapid and accurate therapeutic decision must be made. In patients with atypical clinical signs and ECG recordings, the chronologic urgency may force a decision concerning the use of thrombolysis while the diagnosis is uncertain. In these circumstances, thrombolytic therapy may be dangerous, particularly in cases of aortic dissection, pericarditis and gastrointestinal tract pathology. Gastrointestinal disorders presenting with epigastric pain are an important part of the differential diagnosis of myocardial infarction. In this situation, the ECG

Angiographic Follow-Up of Coronary Artery Ectasia

Of 1,125 patients catheterized over a period of 8 years, 68 (6%) had coronary ectasia. Twenty-five of them were catheterized at least twice and constituted the study group. The time between the first and last catheterization ranged from 2 to 8 years (mean +/- SD = 4.2 +/- 1.6). Coronary ectasia was more frequent in males (88%). The frequency of involvement was: the right coronary (47%), the left circumflex (30%), the left anterior descending (21%) and the left main arteries (2%). Proximal segments were most frequently involved (48%). Diffuse involvement was found in 29%. Severity of ectasia progressed in 6 segments (14%) and 2 new ectatic segments appeared over the follow-up period. During that period, 2 patients had myocardial infarction, 1 of them due to a total occlusion of an ectatic segment. There were no deaths. In conclusion, coronary ectasia has a relatively benign course.

Contribution of stenting to the results of rescue PTCA

Failed thrombolysis in acute myocardial infarction (AMI) is associated with increased mortality. Controversial benefit of rescue percutaneous transluminal coronary angioplasty (PTCA) in these setting has been published. The feasibility, safety, and contribution of stenting to the outcome of AMI patients treated with this strategy is unknown. We studied the angiographic result and clinical outcome of 33 patients with failed thrombolysis referred for rescue angioplasty. Twenty‐three patients had stenting and 10 patients did not have stenting. Both groups had similar clinical and angiographic characteristics. Stent indications were nonoptimal result, 40%; bailout, 40%; elective, 20%. Angiographic success was 100% with stent vs. 91% with balloon alone (P < 0.8). Postprocedure residual stenosis was 1.5% (0%–10%) with stent vs. 18.05% (0%–30%) with balloon alone (P < 0.01). Thirty‐day outcome with and without stent was mortality, 0% vs. 13% (P < 1.0); reinfarction, 10% vs. 0% (P < 0.30); target vessel revascularization, 0% vs. 21% (P < 0.21). The 6‐month mortality was 0% with stent vs. 14% (P < 0.5). We conclude that stenting during rescue angioplasty is feasible, safe, and is associated with better immediate angiographic results. Although no obvious clinical benefit was found, a potential decrease in the revascularization rate was suggested. Cathet. Cardiovasc. Intervent. 47:411–414, 1999.

Prolonged catheter-induced coronary artery spasm mimicking fixed stenosis.

Two cases of prolonged catheter-induced right coronary artery spasm, mimicking fixed stenoses, are presented. In one case, the spasm appeared at the same place in sequential catheterizations. This angiographic finding may be easily misinterpreted as a fixed lesion, leading to unnecessary attempts at angioplasty.

Ischemia detection after myocardial infarction: Diagnostic value of exercise-induced qrs duration changes evaluated by a new computerized method

A new computerized optical scanner was used to measure QRS complex duration during exercise stress testing, both pre- and postdischarge, as a means of ischemia detection after acute myocardial infarction. Thallium stress testing was used as a standard of comparison. Each patient underwent predischarge exercise testing (while receiving anti-ischemic drug therapy) and a postdischarge test 1 month later (without anti-ischemic drug therapy), as well as thallium stress testing within 4 months of infarction. In the population of 68 patients, 42 of the predischarge tests and 43 of the postdischarge tests showed an ischemic response of QRS prolongation. When compared with thallium testing for QRS prolongation criteria, the sensitivity was 95% with a specificity of 77% predischarge and 89% with a specificity of 65% postdischarge. According to ST-T criteria, only 12 of 68 patients were positive for ischemia predischarge; this number increased to 29 postdischarge (predischarge sensitivity 24% and specificity 90%, with postdischarge sensitivity 68% and specificity 87%), when compared with thallium testing. Measuring QRS duration during exercise increased the sensitivity of detection of ischemic patients over that of ST-T criteria by 71% predischarge and 21% postdischarge, with a 22-23% loss of specificity, and was apparently not influenced by anti-ischemic drug therapy.

Aneurysm of the left main coronary artery: progression of dilatation with concomitant deterioration of coronary stenoses

A left main aneurysm is a rare angiographic finding. We describe a 59-year-old male with a large aneurysm in the left main coronary artery. The aneurysm had enlarged in comparison to its diameter of 3.5 years previously, together with a progression of severity of his coronary stenoses.

Single coronary artery originating above the left sinus of Valsalva

We describe a patient with an unusual coronary anatomic variant in which the heart was supplied by a single coronary artery arising above the left sinus of Valsalva.