George S. Chrysant

Endovascular brachytherapy for treatment of bilateral renal artery in-stent restenosis

Percutaneous transluminal angioplasty of renal artery stenosis is an attractive alternative to surgical therapy. However, even with endovascular stenting, the overall rate of restenosis is 21%. While brachytherapy for coronary in‐stent restenosis has proven efficacy, its use for renal artery in‐stent restenosis has not been formally evaluated. We report a case of bilateral in‐stent renal artery restenosis treated with endovascular brachytherapy. Cathet Cardiovasc Intervent 2003;59:251–254.

The Treatment of Cardiovascular Disease Continuum: Focus on Pharmacologic Management and RAS Blockade

The cardiovascular disease continuum is a sequence of events, which begins with a host of risk factors consisting of diabetes mellitus, dyslipidemia, hypertension, smoking and visceral obesity. If left untreated, it will inexorably progress to atherosclerosis, CAD, myocardial infarction, left ventricular remodeling, LVH, left ventricular enlargement, and eventually end-stage heart failure and death. Treatment intervention at any stage of its course will prevent or delay its further progression. However, the best results are expected to be achieved when treatment is initiated at the beginning, or at an early stage of its course. A Pub-Med/MEDLINE search was conducted for relevant English language, randomized clinical trials and epidemiologic studies for the years 1995-2009 using the terms, cardiovascular continuum, obesity, hyperlipidemia, diabetes mellitus, hypertension, metabolic syndrome, renal disease, stroke, and blockers of the renin angiotensin system (RAS). A total of 34 pertinent studies were selected for review. This concise review will focus on prevention and the aggressive treatment of the existing cardiovascular risk factors with emphasis on the blockers of RAS, and demonstrate that RAS blockers are the best drugs for its treatment.

Clinical Experience With Angiotensin Receptor Blockers With Particular Reference to Valsartan

The angiotensin II receptor blockers (ARBs), are highly selective for the AT1 subtype and will block the effects of angiotensin II on peripheral vessels. Several short‐ and long‐term studies have shown these agents to be safe and effective antihypertensive drugs. Since monotherapy of hypertension may be ineffective in lowering the blood pressure to goal, the use of an ARB, especially in combination with a diuretic or another medication, is frequently necessary to bring the blood pressure <140/90 mm Hg (<130/80 mm Hg among people with diabetes mellitus or chronic renal failure), according to JNC 7 guidelines. Besides hypertension, the ARBs have been shown to reduce left ventricular hypertrophy in hypertensive patients. Other benefits of these medications, as well as the angiotensin I converting enzyme inhibitors (ACEIs), include a decrease in cardiovascular morbidity and mortality in patients with heart failure, or hypertensive diabetic nephropathy with proteinuria. Some of the beneficial effects noted with the ACEIs and ARBs (congestive heart failure, left ventricular hypertrophy), have also been demonstrated with the use of β blockers alone and in combination with a diuretic. These drugs, i.e., β blockers, ARBs, and ACEIs, seem to exert their beneficial action through the blockade of the renin‐angiotensin‐aldosterone system. The role of this system in cardiovascular remodeling and its blockade will be discussed in this review, which will specifically summarize data with the ARB, valsartan.

Pharmacological and Clinical Profile of Moexipril: A Concise Review

Angiotensin‐converting enzyme (ACE) inhibitors are effective and safe antihypertensive drugs, with the exception of the rare occasion of angioedema. These drugs have demonstrated additional cardiovascular protective effects to their blood pressure lowering, and their combination with the diuretic hydrochlorothiazide potentiates their antihypertensive effectiveness. Moexipril is a long‐acting ACE inhibitor suitable for once‐daily administration, and like some ACE inhibitors, moexipril is a prodrug and needs to be hydrolyzed in the liver into its active carboxylic metabolite, moexiprilat, to become effective. Moexipril alone and in combination with low‐dose hydrochlorothiazide has been shown in clinical trials to be effective in lowering blood pressure and be well tolerated and safe given in single daily doses. In this review, the pharmacological profile of this drug and its clinical usefulness are discussed.

Sacubitril/valsartan: a cardiovascular drug with pluripotential actions

Sacubitril/valsartan is a first-in-class dual action molecule of the neprilysin (NEP) inhibitor sacubitril (AHU-377) and the angiotensin II (Ang II) type 1 (AT1) receptor blocker (ARB) valsartan.

Age Related Hemodynamic Blood Pressure Changes for Cardiovascular Disease and Stroke: A Mini-review

The blood pressure (BP) changes with the advancement of age from the predominant diastolic BP (DBP) in the young to the predominant systolic BP (SBP) in the older person. This shift is due to the stiffening of the large arteries as a result of the ageing process and the replacement of the elastic fibers with collagen fibers resulting in the loss of compliance and the elastic recoil of these vessels. The end result is augmentation in pulse wave velocity (PWV) and widening of pulse pressure (PP). The SBP rises linearly with the advancement of age whereas, the DBP rises up to the age 50 years and begins to decline after the age of 60 years leading to a progressive increase in PP. These hemodynamic changes of BP are frequently associated with an increased incidence in cardiovascular disease (CVD) and strokes. Several studies have shown an inverse relationship between DBP and CVD, whereas no such a relationship has been dem onstrated for stroke. However,recently, an i nverse relationship has been reported between DBP and stroke for subjects 50 years of age or older. The implications of BP changes with age as they are related to CVD and strokes will be discussed in this mini review. It appears from these recent findings that in treating the hypertension in the elderly to reduce CVD and stroke, care should be taken not to allow the DBP to drop below 55-80 mmHg, since below this DBP level the incidence of CVD and strokes increase.

Ancillary techniques in interventional cardiology

BACKGROUND: Directional coronary atherectomy is a new technique of coronary revascularization by which atherosclerotic plaque is excised and retrieved from target lesions. With respect to the rate of restenosis and clinical outcomes, it is not known how this procedure compares with balloon angioplasty, which relies on dilation of the plaque and vessel wall. We compared the rate of restenosis after angioplasty with that after atherectomy. METHODS: At 35 sites in the United States and Europe, 1012 patients were randomly assigned to either atherectomy (512 patients) or balloon angioplasty (500 patients). The patients underwent coronary angiography at base line and again after six months; the paired angiograms were quantitatively assessed at one laboratory by investigators unaware of the treatment assignments. RESULTS: Stenosis was reduced to 50% or less more often with atherectomy than with angioplasty (89% vs. 80%, p 0.001), and there was a greater immediate increase in vessel caliber (1.05 vs. 0.86 mm, p 0.001). This was accompanied by a higher rate of early complications (11% vs. 5%, p 0.001) and higher in-hospital costs (

Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries

11,904 vs.

Double valve replacement in a patient with osteogenesis imperfecta.

10,637; p 0.006). At six months, the rate of restenosis was 50% for atherectomy and 57% for angioplasty ( p 0.06). However, the probability of death or myocardial infarction within six months was higher in the atherectomy group (8.6% vs. 4.6%, p 0.007). CONCLUSIONS: Removing coronary artery plaque with atherectomy led to a larger luminal diameter and a small reduction in angiographic restenosis, though the latter was not statistically significant. However, atherectomy led to a higher rate of early complications, increased cost, and no apparent clinical benefit after six months of follow-up.