Bjørn Jørgensen

Restenosis and clinical outcome in patients treated with amlodipine after angioplasty: results from the Coronary AngioPlasty Amlodipine REStenosis Study (CAPARES).

OBJECTIVES Our intent was to investigate the effect of the dihydropyridine calcium channel blocker amlodipine on restenosis and clinical outcome in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND Amlodipine has sustained vasodilatory effects and relieves coronary spasm, which may reduce luminal loss and clinical complications after PTCA. METHODS In a prospective, double-blind design, 635 patients were randomized to 10 mg of amlodipine or placebo. Pretreatment with the study drug started two weeks before PTCA and continued until four months after PTCA. The primary angiographic end point was loss in minimal lumen diameter (MLD) from post-PTCA to follow-up, as assessed by quantitative coronary angiography (QCA). Clinical end points were death, myocardial infarction, coronary artery bypass graft surgery and repeat PTCA (major adverse clinical events). RESULTS Angioplasty was performed in 585 patients (92.1%); 91 patients (15.6%) had coronary stents implanted. Follow-up angiography suitable for QCA analysis was done in 236 patients in the amlodipine group and 215 patients in the placebo group (per-protocol group). The mean loss in MLD was 0.30 +/- 0.45 mm in the amlodipine group versus 0.29 +/- 0.49 mm in the placebo group (p = 0.84). The need for repeat PTCA was significantly lower in the amlodipine versus the placebo group (10 [3.1%] vs. 23 patients [7.3%], p = 0.02, relative risk ratio [RR]: 0.45, 95% confidence interval [CI]: 0.22 to 0.91), and the composite incidence of clinical events (30 [9.4%] vs. 46 patients (14.5%), p = 0.049, RR: 0.65, CI: 0.43 to 0.99) within the four months follow-up period (intention-to-treat analysis). CONCLUSIONS Amlodipine therapy starting two weeks before PTCA did not reduce luminal loss, but the incidence of repeat PTCA and the composite major adverse clinical events were significantly reduced during the four-month follow-up period after PTCA with amlodipine as compared with placebo.

Postexercise Ischemia Is Associated With Increased Neuropeptide Y in Patients With Coronary Artery Disease

BackgroundNeurohormones may influence vascular tone both during and after exercise. Neuropeptide Y (NPY), which is costored and released with norepinephrine (NE) during sympathetic activity, is a potent vasoconstrictor with a relatively long half-life. We therefore examined its possible association with the ischemic response to exercise in patients with coronary artery disease. Methods and ResultsTwenty-nine male patients with effort-induced angina pectoris underwent a symptom-limited exercise test. In addition to conventional ST-segment analysis, we examined ischemia on the basis of heart rate (HR)-adjusted ST-segment changes through calculation of the ST/HR slope during the final 4 minutes of exercise and of the ST/HR recovery loop after exercise. Blood samples were taken before, during, and after exercise for an analysis of several neurohormones. Mean ST-segment depression was −223±20.2 &mgr;V (P <0.0001) just before the termination of exercise, followed by a gradual normalization, but it remained significant after 10 minutes (−49±8.9 &mgr;V, P <0.0001). At the end of exercise, the ST/HR slope, which reflects myocardial ischemia, was −6.0±0.77 &mgr;V/HR. In most patients, ST-segment levels at a given HR were lower during recovery than during exercise, here referred to as ST “deficit.” Exercise increased the plasma levels of NPY, NE, epinephrine, and N-terminal proatrial natriuretic peptide, but big endothelin remained unchanged. Although NE and epinephrine peaked at maximal exercise, the highest levels of NPY and N-terminal proatrial natriuretic peptide were observed 4 minutes after exercise. The maximal increase in the NPY correlated significantly with ST-segment depression at 3 minutes after exercise (r =−0.61, P =0.0005), the ST deficit at the corresponding time point (r =−0.66, P =0.0001), and the duration of ST-segment depression after exercise (r =0.42, P =0.02). In contrast, no such correlations were found for NE. ConclusionsThe present study has for the first time demonstrated a correlation between plasma NPY levels and the degree and duration of ST-segment depression after exercise in patients with coronary artery disease, which suggests that NPY may contribute to myocardial ischemia in these patients.

A pharmacoeconomic evaluation of results from the coronary angioplasty amlodipine restenosis study (CAPARES) in Norway and Canada

INTRODUCTION The objective of this analysis was to evaluate the health economic benefits of using amlodipine in patients undergoing angioplasty procedures in Canada and Norway. METHODS A decision tree model was constructed to find the total expected cost per patient for a 4-month time period following an initial angioplasty. The model used clinical data from the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES), a prospective, randomized, double blind, placebo-controlled trial conducted to investigate the effects of amlodipine on restenosis and clinical events in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Outcomes of interest to this analysis included MI, repeat PTCA, CABG, and all-cause mortality. Clinical experts from Canada and Norway were enlisted and a modified Delphi study approach was used to quantify healthcare resources consumed for each clinical outcome. RESULTS The use of amlodipine decreased the rates of MI, PTCA, and CABG by 2.0, 4.7, and 2.7%, respectively. The total expected cost per patient using amlodipine was

Effect of percutaneous transluminal coronary angioplasty on exercise in patients with and without previous myocardial infarction

6,398.30 (US

Effects of amlodipine on ischemia after percutaneous transluminal coronary angioplasty: Secondary results of the Coronary Angioplasty Amlodipine Restenosis (CAPARES) Study

4,323) in Canada and kr 59,993.27 (US

Physiologic response to gain and loss in coronary minimal luminal diameter in patients treated with coronary angioplasty : Prediction of restenosis on the basis of exercise capacity

6,846) in Norway. The total expected cost per patient not using amlodipine was

Exercise capacity in heart transplant recipients: Relation to impaired endothelium-dependent vasodilation of the peripheral microcirculation

6,519.37 (US

Luminal loss and restenosis after coronary angioplasty. The role of lipoproteins and lipids

4,405) in Canada and kr 64,292.17 (US

N-terminal proatrial natriuretic peptide in angina pectoris: impact of revascularization by angioplasty

7,337) in Norway. The model demonstrated potential cost-savings over a 4-month follow up period resulting from the improved clinical outcomes for patients using amlodipine with PTCA--

Attenuated physical exercise capacity in smokers compared with non-smokers after coronary angioplasty despite similar luminal diameters

121,071 (US