Lawrence E. Crawford

The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes ☆

OBJECTIVES The purpose of this study was to assess safety and efficacy of enhanced external counterpulsation (EECP). BACKGROUND Case series have shown that EECP can improve exercise tolerance, symptoms and myocardial perfusion in stable angina pectoris. METHODS A multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina, documented coronary artery disease (CAD) and positive exercise treadmill test. Patients were given 35 h of active counterpulsation (active CP) or inactive counterpulsation (inactive CP) over a four- to seven-week period. Outcome measures were exercise duration and time to > or =1-mm ST-segment depression, average daily anginal attack count and nitroglycerin usage. RESULTS Exercise duration increased in both groups, but the between-group difference was not significant (p > 0.3). Time to > or =1-mm ST-segment depression increased significantly from baseline in active CP compared with inactive CP (p = 0.01). More active-CP patients saw a decrease and fewer experienced an increase in angina episodes as compared with inactive-CP patients (p < 0.05). Nitroglycerin usage decreased in active CP but did not change in the inactive-CP group. The between-group difference was not significant (p > 0.7). CONCLUSIONS Enhanced external counterpulsation reduces angina and extends time to exercise-induced ischemia in patients with symptomatic CAD. Treatment was relatively well tolerated and free of limiting side effects in most patients.

Late thrombosis following treatment of in-stent restenosis with drug-eluting stents after discontinuation of antiplatelet therapy

Drug‐eluting stent usage has become commonplace for the percutaneous treatment of de novo coronary lesions, but the safety and efficacy profile for their evolving usage in restenotic lesions is largely unknown. We report three cases of angiographically confirmed drug‐eluting stent thrombosis following treatment of restenotic lesions that occurred late (193, 237, and 535 days) and shortly after interruption of antiplatelet therapy. All three patients suffered ST elevation myocardial infarction, and there was one death. Further studies are necessary to better define the associated risk and ideal duration of antiplatelet therapy necessary in this cohort of patients with restenotic lesions.

Actin regulation and surface catalysis.

The motile behavior of non-muscle cells often differs between healthy and pathological conditions. Two disease processes, cancer and atherosclerosis, are associated with high morbidity and mortality in our society. The cells involved in both the pathogenesis of and me defense against these diseases undergo marked changes in the organization of their actin cytoskeletonl1,2. In response to a signal originating from the extracellular space, from surrounding cells, or as the result of a mutation, diseased cells initiate a process of motion away from their normal location. Local growth inhibitors are lost, and displaced cells undergo unchecked proliferation1. One example of such a phenomenon is the migration of fibroblasts and smooth muscle cells into the vascular intima and their proliferation in patients with atherosclerotic coronary artery disease2. Another example is the proliferation of metastatic cells distant from the site of primary tumor1.

Effects of a 12-Week mHealth Program on Functional Capacity and Physical Activity in Patients With Peripheral Artery Disease

Supervised exercise is beneficial for peripheral artery disease (PAD) patients limited by intermittent claudication (IC). However, supervised exercise for PAD remains widely underutilized. Mobile health (mHealth) provides an intermediate solution between supervised and independent home-based exercise. The purpose of this study was to determine the effects on functional capacity and physical activity patterns of a 12-week mHealth program in PAD patients with IC. Twenty patients were randomized into usual care or a 12-week mHealth intervention consisting of patient education, smartphones, and physical activity trackers. Patient education was disseminated through smartphone and a daily exercise prescription was given based on steps per day. Primary outcomes were 12-week changes in peak VO2 and claudication onset time; and changes in physical activity measured by steps per/day and minutes of exercise per/week. mHealth patients significantly increased peak VO2 from 15.2 ± 4.3 to 18.0 ± 4.8 ml/kg/min (20.3 ± 26.4%; p ≤0.05), while usual care did not change from 14.3 ± 5.4 to 14.5 ± 5.7 ml/kg/min (1.0 ± 6.9%; NS). Comparison of these changes resulted in a significant difference between groups (p ≤0.05) for peak VO2. Claudication onset time significantly increased in mHealth (320 ± 226 to 525 ± 252 seconds; ≤ 0.05), while usual care demonstrated a worsening (252 ± 256 to 231 ± 196 seconds; NS). The comparison of these group changes resulted in a significant difference (p ≤0.05). Neither steps per day or minutes of activity reached significant differences between groups. In conclusion, a 12-week mHealth program in PAD patients with IC can improve peak VO2 and claudication onset time; and mHealth interventions represent a promising alternative therapy for those patients who cannot participate in supervised exercise.

A case of spontaneous coronary artery dissection diagnosed by coronary computed tomography angiography

Abstract Spontaneous coronary artery dissection (SCAD) is an uncommon presentation of acute coronary syndrome (ACS) and is typically diagnosed by invasive coronary angiography. We present a case of SCAD that was diagnosed by coronary CTA after an inconclusive coronary angiogram.

ENDOVASCULAR RECANALIZATION OF SUPERFICIAL FEMORAL ARTERY CHRONIC TOTAL OCCLUSIONS: A MULTI-DISCIPLINARY, SINGLE CENTER EXPERIENCE

Purpose: The endovascular treatment of CTO in peripheral arteries is common, but little comparative effectiveness data exists to guide clinicians as to which treatment approach is better. We sought to compare procedural outcomes of superficial femoral artery (SFA) chronic total occlusion (CTO) endovascular recanalization using a primary wire approach versus a CTO recanalization device. Methods: We retrospectively identified all patients in an integrated, 3-hospital health system who underwent lower extremity (LE) angiography from 2009-2013. Chart abstraction and angiogram review were performed to identify those patients with de novo SFA CTO who underwent attempted endovascular revascularization by either primary wire approach or CTO recanalization device. Outcomes measured included acute procedural success, volume of contrast dye, fluoroscopy time, and total procedure time. Results: A total of 1,611 patients underwent LE angiography during the study period, and 270 patients were included in the final cohort. There was no significant difference in rates of acute procedural success with primary wire approach when compared with CTO recanalization device (84.5% vs. 77.4%, p=0.32). In the adjusted analysis, there was significantly less contrast use with the use of CTO recanalization device. Conclusions: This study suggests that there is limited difference in acute procedural success rates of SFA CTO revascularization with a CTO recanalization device when compared with a primary wire technique. Larger clinical trials are necessary to demonstrate the value of these devices. Correspondence to: W. Schuyler Jones, MD, DUMC, Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NCBox 3330, USA, Tel: (919) 668-8917, E-mail: schuyler.jones@dm.duke.edu