Frederick A. Heupler

Ergonovine maleate provocative test for coronary arterial spasm

Ergonovine maleate was evaluated as a provocative agent for inducing coronary spasm during coronary arteriography. The study group consisted of 98 patients with either mild fixed obstructions of coronary luminal diameter (less than 50 percent) or normal coronary arteriograms. The test was considered positive if the drug precipitated severe coronary spasm. A positive ergonovine test occurred in 10 of 11 patients with Prinzmetals variant angina (P < 0.02). Two of these patients had a transmural myocardial infarction in the distribution of the spastic artery. Ergonovine tests were negative in (1) the 15 control patients with no clinically suspected coronary artery disease (P < 0.001), (2) 63 of 66 patients with angina-like chest pain (P < 0.001), and (3) all 6 patients with myocardial infarction and no history of Prinzmetals variant angina (P < 0.05). No major complications occurred as a result of this test. Thus, ergonovine maleate test is a safe, sensitive and specific method for reproducing coronary spasm in patients with Prinzmetals variant angina and no major coronary obstructions. The results suggest that coronary spasm can be implicated as a cause of myocardial infarction in patients with normal coronary arteriograms who also have Prinzmetals variant angina. Coronary spasm was not demonstrated in patients who had normal coronary arteriograms and a history of myocardial infarction as an isolated clinical event. Also, coronary spasm could not be demonstrated in the majority of patients who had angina-like chest pain and no major coronary obstruction.

Syndrome of symptomatic coronary arterial spasm with nearly normal coronary arteriograms

The clinical manifestations of symptomatic coronary arterial spasm were analyzed in 30 patients whose coronary arteriograms demonstrated no fixed severe obstructions. The study group consisted of 14 men and 16 women (average age, 47 years). Angina at rest was invariable and it was usually typical in quality, location, duration and response to nitroglycerin. Exertional angina occurred in 23 percent and syncope with angina in 33 percent. Spontaneous remission of angina for at least 1 month occurred in 57 percent of patients. Prinzmetals variant angina occurred in 77 percent of patients and only S-T segment depression or T wave changes during angina occurred in 23 percent. Major arrhythmias during ischemia developed in 47 percent. Exericse tests were positive in 24 percent. Myocardial infarction, probably due to coronary spasm, occurred in 7 percent of patients. Isosorbide dinitrate and propranolol were effective therapy in only 39 percent and 6 percent of patients, respectively. Nifedipine, a calcium flux antagonist, was effective in 80 percent of patients. Patients with normal coronary arteriograms who have clinical features suggestive of coronary arterial spasm should be considered for further investigation, including long-term electrocardiographic monitoring and provocative testing for spasm.

Randomized withdrawal from nifedipine: placebo-controlled study in patients with coronary artery spasm.

A multicenter randomized double-blind withdrawal study was conducted to compare the efficacy of nifedipine to that of placebo in vasospastic angina. Following a 2-week single-blind nifedipine baseline period, during which nifedipine was maintained at prestudy levels, 38 patients, 19 taking placebo and 19 continuing nifedipine therapy, either completed a 4-week randomized phase or were prematurely withdrawn because of therapeutic failure. During the randomized phase, an increase in median anginal frequency (2.8 attacks/wk, p less than 0.003) and nitroglycerin usage (0.5 tablets/wk, p less than 0.03) occurred only in the placebo group. The randomized phase was prematurely terminated because of anginal exacerbation in 7 of 19 placebo patients (37%) (only 1 patient receiving nifedipine [p = 0.02] experienced anginal exacerbation). Double-blind therapy was judged effective in 16 patients (84%) receiving nifedipine and in 3 patients (16%) receiving placebo (p less than 0.001). Nifedipine was well tolerated. This study establishes the efficacy of nifedipine in the treatment of variant and validates previous clinical experience.

Infection control guidelines for the cardiac catheterization laboratory: Society guidelines revisited†

In the early years of diagnostic cardiac catheterization, strict sterile precautions were required for cutdown procedures. Thirteen years ago, when the original guidelines were written, the brachial arteriotomy was still frequently utilized, femoral closure devices were uncommon, “implantables,” such as intracoronary stents and PFO/ASD closure devices, were in their infancy, and percutaneous valve replacement was not a consideration. In 2005, the cardiac catheterization laboratory is a complex interventional suite with percutaneous access routine and device implantation standard. Despite frequent device implantation, strict sterile precautions are often not observed. Reasons for this include a decline in brachial artery cutdown, limited postprocedure follow‐up with few reported infections, limited use of hats and masks in televised cases, and lack of current guidelines. Proper sterile technique has the potential to decrease the patient infection rate. Hand washing remains the most important procedure for preventing infections. Caps, masks, gowns, and gloves help to protect the patient by maintaining a sterile field. Protection of personnel may be accomplished by proper gowning, gloving, and eye wear, disposal of contaminated equipment, and prevention and care of puncture wounds and lacerations. With the potential for acquired disease from blood‐borne pathogens, the need for protective measures is as essential in the cardiac catheterization laboratory as is the standard Universal Precautions, which are applied throughout the hospital. All personnel should strongly consider vaccination for hepatitis B. Maintenance of the cardiac catheterization laboratory environment includes appropriate cleaning, limitation of traffic, and adequate ventilation. In an SCAI survey, members recommended an update on guidelines for infection control in the cardiac catheterization laboratory. The following revision of the original 1992 guidelines is written specifically to address the increased utilization of the catheterization laboratory as an interventional suite with device implantation. In this update, infection protection is divided into sections on the patient, the laboratory personnel, and the laboratory environment. Additionally, specific CDC recommendation sections highlight recommendations from other published guidelines.

Measures to Reduce Radiation in a Modern Cardiac Catheterization Laboratory

Background—X-ray use in the catheterization laboratory is guided by the principle of as low as reasonably achievable. In accordance with this principle, we reduced the default fluoroscopic frame rate from 10 to 7.5 frames/s and increased the emphasis on the use of low-dose acquisition starting January 1, 2013. We aimed to study the impact of these measures on the total air kerma during diagnostic catheterization (DC) and percutaneous interventions (PCI). Methods and Results—Propensity matching based on age, sex, body surface area, total fluoroscopy time, and total acquisition time was used to select matched patients for 2012 and 2013, further stratified by DC or PCI. The total air kerma was subsequently compared between 2012 and 2013, separately for DC and PCI. Median total air kerma during DC in 2013 was 625 mGy, which was significantly lower than the corresponding values in 2012 (median, 798 mGy; P<0.001). Similarly, median total air kerma during PCI in 2013 was 1675 mGy, which was significantly less than corresponding values in 2012 (median 2463 mGy, P<0.001). On comparison of air kerma rates between corresponding projections in 2 years, we observed a significant reduction in fluoroscopy- and acquisition-based air kerma rates in 2013, after institution of radiation reduction measures in all projections. Conclusions—With reduction in the default fluoroscopic frame rate and a greater use of low-dose acquisition, there has been a marked reduction in the total air kerma and air kerma rates for DC and PCI.

Guidelines for internal peer review in the cardiac catheterization laboratory

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has proposed guidelines for establishing an internal peer review program in the cardiac catheterization laboratory. The first step is to establish a committee and a data base. This data base should include quality indicators that reflect: physician qualifications, outcomes of procedures, and processes of care. The outcomes must be risk-adjusted to account for the variable severity of illness. Data should be collected by catheterization laboratory personnel and entered into a laboratory-specific computerized data base. These data must be analyzed and organized into profiles that reflect the quality of care. Based on this information, the Committee would institute the following interventions to improve physician performance: education, clinical practice standardization, feedback and benchmarking, professional interaction, incentives, decision-support systems, and administrative interventions. The legal aspects of peer review are reviewed briefly.

Initial coronary air embolus in the differential diagnosis of coronary artery spasm

Angiographic and electrocardiographic manifestations of initial coronary air embolism were seen in 4 patients and in a dog. All 4 patients had angina pectoris, 2 had ST elevation, 1 patient had ST depression and 1 had no electrocardiographic change after the air embolus. Although the initial diagnosis in these 4 patients was coronary artery spasm, a subsequent ergonovine test response for coronary artery spasm was negative in the 3 patients in whom it was performed. In a dog, initial injection of air in a coronary artery produced ST-segment elevation and delayed clearance of contrast material. The angiographic appearance of initial air embolus was similar in the 4 patients and in the dog. The leading edge of contrast material that followed an air embolus stopped abruptly, appeared hazy and blunt, and pulsated back and forth. The air embolus produced temporary cessation of flow in the main artery and its branches. Initial injection of air during coronary arteriography mimics coronary artery spasm by producing a syndrome characterized by angina, ischemic changes on the electrocardiogram, and delayed flow of contrast material. An initial air embolus may be differentiated from true coronary spasm by several distinctive angiographic features.

A new tool for benchmarking cardiovascular fluoroscopes.

This article reports the status of a new cardiovascular fluoroscopy benchmarking phantom. A joint working group of the Society for Cardiac Angiography and Interventions (SCA&I) and the National Electrical Manufacturers Association (NEMA) developed the phantom. The device was adopted as NEMA standard XR 21‐2000, “Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance,” in August 2000. The test ensemble includes imaging field geometry, spatial resolution, low‐contrast iodine detectability, working thickness range, visibility of moving targets, and phantom entrance dose. The phantom tests systems under conditions simulating normal clinical use for fluoroscopically guided invasive and interventional procedures. Test procedures rely on trained human observers. Cathet Cardiovasc Intervent 2001;52:67–72.

A case of fatal West Nile virus meningoencephalitis associated with receipt of blood transfusions after open heart surgery

First identified in the United States in 1999, West Nile virus caused approximately 3,500 infections in the late summer and fall of 2002. The virus is predominantly transmitted by mosquitoes, and the risk of infection through blood product transfusion is believed to be low. We present a case of West Nile virus encephalitis transmitted by red blood cell transfusion at the time of coronary artery bypass grafting that resulted in the patients death. Individuals undergoing procedures with high blood product transfusion requirements, such as cardiac surgery or organ transplantation, may be at higher risk of this nosocomial infection during epidemics.

The Weasel Clause: Excluding Patients From Door-to-Balloon Analyses

Numerous broad-based studies, including that from the U.S. National Registry of Myocardial Infarction ([1][1]), have convincingly shown a direct relationship between door-to-balloon time and in-hospital mortality for patients treated with primary percutaneous coronary intervention for ST-segment