Robert W. Healy

Coronary Angiography and Acute Renal Failure in Diabetic Azotemic Nephropathy

Thirteen juvenile-onset diabetics with azotemic diabetic nephropathy (mean serum creatinine level, 6.8 mg/dl) being evaluated fro renal transplantation underwent cardiac catheterization with angiography. All were followed for development of acute renal failure. Twelve (92%) developed some evidence of acute renal failure. Two required potassium exchange resin therapy. Six required dialysis acutely. There were no deaths. All patients who received greater than 65 ml/m2 of iodinated contrast developed acute renal failure. No patient with a hemoglobin value greater than 9.9 g/dl required dialysis or potassium exchange resin. The single patients without acute renal failure received less than 50 ml/m2 of iodinated contrast and had the highest hemoglobin value (12.0 g/dl). No cardiac or angiographic variables were predictive of acute renal failure. In this group at high risk for acute renal failure, radiographic contrast procedures should only be done if the information to be obtained is weighed against the potential for injury.

Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection is a rare event that occurs most commonly in young, otherwise healthy women. Approximately 85 cases have been reported in the world literature. Dissection of the left main coronary artery is even less common; only 18 cases have been reported. This review discusses the incidence, presentation, pathogenesis, and management of spontaneous coronary artery dissection. The case of another patient with left main coronary artery dissection is described; to our knowledge, it is the first to be successfully treated by internal mammary artery bypass grafting.

Asymptomatic Coronary Artery Disease: Angiography in Diabetic Patients Before Renal Transplantation: Relation of Findings to Postoperative Survival

Twenty-one juvenile-onset diabetic patients with azotemic nephropathy underwent coronary angiography and left ventriculography before renal transplantation or chronic hemodialysis. Two-year survival of 12 patients with no coronary artery disease (group A) was 88% compared to 22% for nine patients with coronary artery disease (group B) (P less than 0.025). Each group A patient underwent renal transplantation (nine live-related, three cadaveric). Four group B patients received cadaveric allografts. Among group A patients two cadaveric allografts functioned while in group B patients no allografts were successful. In the absence of coronary artery disease, results were similar to those reported for nondiabetic persons. In the presence of coronary artery disease, 62% of the deaths were due to myocardial infarction or sudden death. These results indicate that atherosclerotic coronary artery disease is a major determinant of survival in diabetic patients undergoing chronic hemodialysis or renal transplantation.

Myocardial dysfunction without coronary artery disease in diabetic renal failure

Fifteen patients with diabetes of juvenile onset and azotemic nephropathy were found to have no evidence of significant coronary artery disease after cardiac catheterization, coronary angiography and ventriculography. Three groups were delineated in terms of myocardial function. There were no differences among the groups in age, sex distribution, duration of diabetes, hypertension or azotemia, presence of surgical arteriovenous fistula or blood concentrations of hemoglobin, cholesterol, urea nitrogen, creatinine or uric acid. Some evidence of myocardial dysfunction was found in eight patients (59 percent)—four with diffuse myocardial dysfunction and four with elevation of left ventricular end-diastolic pressure alone. The hypothesis of a diabetic cardiomyopathy is discussed in terms of a spectrum that may include patients with pressure-volume abnormalities alone; patients with increased left ventricular end-diastolic pressure and an abnormal pressure-volume curve; and patients with a diffusely abnormal ventriculogram, decreased ejection fraction, increased left ventricular end-diastolic pressure and an abnormal pressure-volume curve.

Asymptomatic coronary artery disease: angiographic assessment of diabetics evaluated for renal transplantation.

SUMMARY Twenty-one insulin-dependent diabetics with azotemic nephropathy were evaluated for renal transplantation by selective coronary angiography and cine left ventriculography. All had hypertension, retinopathy, neuropathy, and required salt restriction plus diuretics for volume overload. There was no clinical or electrocardiographic evidence of ischemic coronary artery disease in twenty.Ten patients (five males, five females, mean age 29.3 years; mean duration of diabetes 18.9 years; mean serum cholesterol 264 mg%) had no significant coronary artery disease and no ventricular wall motion abnormalities.Nine patients (seven males, two females; mean age 38.7 years; mean duration of diabetes 21.9 years; mean serum cholesterol 239 mg%) had significant coronary artery disease, seven demonstrating focal abnormalities in left ventricular wall motion.Two patients (one male, one female; mean age 36.5 years; mean duration of diabetes 28.5 years; mean serum cholesterol 250 mg%) had no significant coronary artery disease, but demonstrated diffusely abnormal left ventricular wall motion with diminished ejection fraction.Thirty-eight percent had significant coronary artery disease unpredictable by electrocardiographic clinical data. The finding of no significant coronary artery disease in 52% of a group with severe renalhypertensive complications of diabetes is surprising. Two patients may have a demonstrated cardiomyopathy.

Similar result of percutaneous transluminal coronary angioplasty for women and men with postmyocaedial infarction ischemia

Abstract Objectives. The purpose of this study was to determine whether there are gender differences in the outcome of percutaneous transluminal coronary angioplasty performed for postmyocardial infarction ischemia. Background. Although women have a higher mortality rate after myocardial infarction than that of men, they are less frequently referred for coronary angioplasty (and coronary artery bypass graft surgery) than are men, possibly because of expectations of a worse procedural outcome. Methods. We analyzed the morbidity and mortality at coronary angioplasty and during a mean follow-up period of 34.4 months for women and 34.2 months for men in 505 consecutive patients (164 women and 341 men) with postmyocardial infarction ischemia between 1981 and 1989. Results. Compared with men, women had similar procedural success rates (89.6% and 91.2%, respectively), need for coronary artery bypass surgery (3.7% and 2.6%) and mortality rates at coronary angioplasty (0.6% and 0.9%). During the follow-up period there were no significant gender differences in the requirement for coronary artery bypass surgery (3.6% and 4%), repeat angioplasty (18.7% and 17.3%), reinfarction (5.8% and 6%) and death (3.6% and 3.7%) or the combined end points of all four events (26.6% and 26.6%). Women had significantly more recurrent angina than did men (54% vs. 42.5%, p Conclusions. The procedural outcome of coronary angioplasty for postmyocardial infarction ischemia is similar in women and men. Long-term follow-up is also similar except that women experience an increased incidence of recurrent angina, an outcome also reported after bypass surgery. Therefore, concerns over the safety of coronary angioplasty in women should not adversely influence decisions concering referral of women for coronary angioplasty after myocardial infarction complicated by ischemia.

A Patent Infarct-Related Artery Is Associated With Reduced Long-term Mortality After Percutaneous Transluminal Coronary Angioplasty for Postinfarction Ischemia and an Ejection Fraction <50%

BACKGROUND Prognosis after myocardial infarction (MI) is influenced by the presence of post-MI ischemia and possibly the patency of the infarct-related artery. The purpose of this study was to compare long-term outcome (reinfarction and death) in patients with open versus closed coronary arteries after percutaneous transluminal coronary angioplasty performed for MI complicated by persistent ischemia. METHODS AND RESULTS Between 1981 and 1989, 505 patients underwent percutaneous transluminal coronary angioplasty for post-MI ischemia at the Deaconess Hospital. Long-term incidence (mean follow-up, 34 months) of death, nonfatal reinfarction, repeated coronary angioplasty, and coronary bypass surgery was determined for 479 patients and then compared on the basis of the status of the artery, open versus closed, at the end of angioplasty. The 5-year Kaplan-Meier actuarial mortality rate was 4.9% for 456 patients with open infarct-related arteries and 19.4% for 23 patients with closed infarct-related arteries (P=.0008). Multivariate Cox proportional hazards analyses controlling for age, sex, number of diseased vessels, type and location of MI, and year of coronary angioplasty revealed a hazard ratio for death for closed compared with open arteries of 6.1 (95% CI, 1.8 to 20.0). Among patients with ejection fractions <50%, a closed artery was associated with a higher mortality (p=.0014) compared with patients with open arteries. The status of the artery was not associated with a difference in mortality in patients with ejection fractions > or = 50%. CONCLUSIONS As open artery after coronary angioplasty for post-MI ischemia is associated with significantly lower long-term mortality, particularly in patients with ejection fractions <50%.

Significance of location (anterior versus inferior) and type (Q-wave versus non-Q-wave) of acute myocardial infarction in patients undergoing percutaneous transluminal coronary angioplasty for postinfarction ischemia

Predictors of increased risk for recurrent cardiac events and death after acute myocardial infarction include postinfarction myocardial ischemia, anterior location of the infarct, and non-Q-wave versus Q-wave infarction. Although coronary angioplasty is performed in patients with postinfarction ischemia to alleviate symptoms, the outcome according to location and type of infarction and the effect on prevention of subsequent myocardial infarction and death are not known. To determine if location and type of myocardial infarction provide prognostic information in patients with postinfarction ischemia, we analyzed morbidity and mortality during and after coronary angioplasty according to the location (anterior vs inferior) and type (Q-wave vs non-Q-wave) of myocardial infarction in 505 consecutive patients. The incidence of recurrent angina, repeat coronary angioplasty, coronary bypass surgery, reinfarction, and death during long-term follow-up after hospital discharge (mean 34 +/- 19 months) for the 440 patients with an initial successful angioplasty was also compared. During the procedure, there was no difference in the primary success rate or mortality among the different groups; however, more patients with anterior non-Q-wave myocardial infarction underwent emergent bypass grafting after unsuccessful coronary angioplasty (p = 0.001). Multivariate Cox proportional-hazards analyses controlling for age, gender, number of diseased vessels, location, type of infarction, and year of coronary angioplasty revealed that more patients with anterior infarction had > or = 1 cardiac event (repeat angioplasty, coronary artery bypass grafting, reinfarction, or death) than did those with inferior infarction (RR 1.80, 95% confidence interval [Ci] 1.22 to 2.65, p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiorenal Failure: Treatment of Refractory Biventricular Failure by Peritoneal Dialysis

Fifteen patients with New York Heart Association Class IV functional cardiac disability whose mild-to-moderately severe renal failure had produced life-threatening fluid overload underwent dialytic therapy. Ten were dialyzed by the peritoneal route initially and five were switched from hemodialysis to peritoneal dialysis because of hemodynamic instability. All patients improved, resulting in renewed responsiveness to more conservative measures (2), stabilization for cardiac surgery (4), or less-restricted lifestyle out of hospital (9). We recommend consideration of peritoneal dialysis when biventricular and renal failure are refractory to conventional therapy.

Improving Survival After Renal Transplantation for Diabetic Patients with Severe Coronary Artery Disease

After successful renal transplantation, seven diabetic renal failure patients with severe coronary artery disease returned to productive employment. Despite the requirement for additional peripheral vascular or ophthalmologic surgery in four patients, their renal function remained adequate. Following transplantation, diabetic complications included angina in three, myocardial infarction in three, and cerebrovascular accident in two patients. Two patients with adequate renal function died suddenly at 29 and 62 mo. Despite severe coronary artery disease, an increasing number of diabetic dialysis patients may be able to return to work after a successful kidney transplant.