2007 Vol. 4, No. 1
Objective To evaluate the feasibility and efficacy of intravascular optical coherence tomography (OCT) in the assessment of plaque characteristics and drug eluting stent deployment quality in the elderly patients with unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). Methods OCT was used in elderly patients undergoing percutaneous coronary interventions. Fifteen patients, 9 males and 6 females with mean age of 72.6±5.3 years (range 67-92 years) were enrolled in the study. Images were obtained before initial balloon dilatation and following stent deployment. The plaque characteristics before dilation, vessel dissection, tissue prolapse, stent apposition and strut distribution after stent implantation were evaluated. Results Fifteen lesions were selected from 32 angiographic lesions as study lesions for OCT imaging after diagnostic coronary angiography. There were 7 lesions in the left anterior descending artery, 5 lesions in the right coronary artery and 3 lesions in the left circumflex coronary artery. Among them, 12 (80.0%) were lipid-rich plaques, and 10 (66.7%) were vulnerable plaques with fibrous cap thickness 54.2±7.3 |im. Seven ruptured culprit plaques (46.7%) were found; 4 in UA patients and 3 in NSTEMI patients. Tissue prolapse was observed in 11 lesions (73.3%). Irregular stent strut distribution was detected in 8 lesions (53.3%). Vessel dissections were found in 5 lesions (33.3%). Incomplete stent apposition was observed in 3 stents (20%) with mean spacing between the struts and the vessel wall I72±96 mm (range 117-436 mm). Conclusions 1) It is safe and feasible to perform intravascular OCT to differentiate vulnerable coronary plaque and monitor stent deployment in elderly patients with UA and USTEMI. 2) Coronary plaques in elderly patients with UA and USTEMI could be divided into acute ruptured plaque, vulnerable plaque, lipid-rich plaque, and stable plaque. 3) Minor or critical plaque rupture is one of the mechanisms of UA in elderly patients. 4) Present drug eluting stent implantation is complicated with multiple tissue prolapses which are associated with irregular strut distributions. 5) The action and significance of tissue prolapse on acute vessel flow and in-stent thrombus and restenosis need to be further studied.
In vivo visualization of the coronary arteries is the most elegant way to confirm or refute any iatrogenic or patho-logical lesions and their association with any short- and long-term positive or negative results. At this present time, intravascular ultrasound (IVUS) is the standard technique in imaging coronary plaque and plaque volume measurements. However, in this March 2007 issue of the Journal of Geriatric Cardiology, Lu et al. showed us the real world results of optical coherence tomography (OCT) with 1) more than 30% of vulnerable plaques ruptured in elderly patients with unstable angina (UA), 2) intraluminal thrombus in less than 27% patients on treatment, and 3) high tissue prolapse rate after stent implantation (73%).
Objective To investigate the influencing factors for prehospital delay in patients with acute myocardial infarction (AMI). Methods A total of 807 consecutive patients with AMI who presented to the emergency department of Beijing Anzhen Hospital were analyzed. The influence of several potential risk factors on the prehospital delay time (PDT) was evaluated by comparing patients admitted more than 2 hours after onset of chese pain with those admitted within 2 hours after onset. Results Among 807 patients, 402 came to the hospital within 2 hours while the others arrived at the hospital after 2 hours. The median PDT was 130 min. Among the potential variables, advanced age, history of diabetes mellitus, occurrence of symptom at night and use of emergency medical service significantly affected PDT by multivariate analysis. Conclusion Interventions aimed at reducing the prehospital delay in AMI should primarily focus on the awareness of the risk and help-seeking behavior of patients.
Objective To assess the feasibility and safety of transradial approach in Chinese elderly patients undergoing coronary intervention. Methods In this prospective study, 764 elderly patients with coronary artery disease received percutaneous coronary intervention via either a transradial approach (TRA group) or a transfemoral approach (TFA group). The procedural success rate, success rate of artery access, puncture time, fluoroscopy time, dose of contrast, local complications and post-procedural pulmonary embolism were recorded and compared between 2 groups. Results There was no significant difference of the procedural success rate between the TRA group and the TRF group (96.3% vs. 98.2%, P>0.05); there were also no differences of success rate of cannulation, mean fluoroscopy time and mean dose of contrast between the 2 groups. The mean puncture time was longer in the TRA group than in the TFA group (3.8±2.1 min vs. 2.0±3.4 min, P<0.05). However, there were fewer access site-related complications in the TRA group than in the TFA group. Post-procedural pulmonary embolism occurred in 2 patients in the TFA group but none in the TRA group. Conclusion Transradial coronary intervention was feasible and safe in most Chinese elderly patients when performed by experienced operators.
In this issue of the Journal of Geriatric Cardiology, Jing et al. showed off their near perfect results of percuta-neous coronary interventions (PCI) through transfemoral approach (TFA) and transradial approach (TRA) in the elderly Chinese patients. All patients were older than 60 years of age, with an average of 67. In this interventional cardiac laboratory with high operators' expertise level, the results of PCI showed no difference on the length of time for vascular access, fluoroscopy time, procedural success and less complication for TRA. These data favoring TRA were confirmed previously in many studies. In this study, most of the guides used were the Judkins right (JR) and left (JL) with rare exceptions. The majority of the lesions were in the left anterior descending artery (LAD), with smaller number from the left circumflex (LCX) and with the lowest number from the right coronary artery (RCA). The distribu-tion between the non-LAD and LAD lesion was equal at 50/50. However, in the real world, can every operator, expe-rienced and non-experienced alike, duplicate the results of Jing et al. in his own interventional laboratories? The most difficult part of any approach is to have strong guide support, sufficient for stent advancement across the target lesion. So this editorial will discuss how to achieve the same technical results as Jing et al. and focus on the selec-tion and manipulation of guides by TRA.
Objective Heart failure is an epidemic in the elderly, but there is a striking lack of data in this clinically important patient population. We investigated the demographics, cardiac performance, and medication management of a segment of the hospital popula-tion in at least their eighth decade of life. Methods We retrospectively reviewed 75 records of heart failure patients who were 80 years of age or older. Records were reviewed for demographic information, presence or absence of diastolic dysfunction, evaluation of ejection fraction, and medication usage including angiotensin-concerting enzyme (ACE) inhibitors, angiotensin receptor antagonists (ARBs), beta-adrenergic blockers, digoxin, and aldosterone antagonists. Assessment for contra-indications to ACE inhibitor or ARBs use was also performed to assess co-morbidities that limit treatment of heart failure. Results The population of very elderly with heart failure is heterogeneous. We found a higher proportion of females as well as higher rates of diastolic dysfunction in patients aged > 90 years compared to patients between the ages of 80-89 years. Usage of ACE inhibitors, ARBs and beta-adrenergic blockers was strikingly low throughout the very elderly population. While co-morbid conditions limited use of agents in many cases, there was a lack of explicit centra-indication in most patients not on an ACE inhibitor or an ARB. Conclusions Heart failure is not a single disease processes, but a continuum of disease processes that vary with age. The elderly with heart failure are an undertreated population, in part due to the multitude of co-morbidities that affect them. Further prospective studies are needed to better understand the physiology and ideal treatment regiment in this growing population.
Objective To investigate the appropriate waist circumference (WC) cutoff points for central obesity in the middle-aged and elderly Beijing residents by the metabolic syndrome definition of the International Diabetes Federation (1DF). Methods A total of 2,344 Beijing residents aged >40 years were investigated. They answered questionnaires, received physical examinations, and underwent plasma glucose and lipid profile measurement. Those non-diabetic subjects underwent a 75g oral glucose tolerance test. All data were analyzed to calculate the appropriate WC cutoff points for central obesity reaching the diagonsis of MS. Results 1) Both in males and females, the triglyceride (TG), systolic blood pressure, diastolic blood pressure and fasting plasma glucose (FPG) increased linearly with WC, and the high density lipoprotein cholesterol (HDL-C) decreased linearly with WC (PO.05). 2)The prevalence of elevated TG, reduced HDL-C, elevated blood pressure, elevated FBG, or > 2 of these factors increased with WC (P 25 kg/m2 were about 90 cm for men and 80 cm for women. 4) The odds ratio for the presence of two or more metabolic risk factors increased abruptly in men with WC > 90 cm and in women with WC > 80 cm. Conclusions The appropriate WC cutoff point for central obesity was determined to be 90 cm for men and 80 cm for women in the middle-aged and elderly Beijing residents by the metabolic syndrome definition of 1DF.
The metabolic syndrome (MS) is a cluster of interre-lated risk factors of metabolic origin - metabolic risk factors that appear to directly promote the development of ath-erosclerotic cardiovascular disease and increase the risk of development of type 2 diabetes.1 In addition to diabetes, these patients with MS have increased incidence of elevated plasma triglycerides, lower high density lipoproteins (HDL), and higher blood pressure. The association with MS has now been expanded to include small dense, low density lipoprotein (LDL), abdominal/truncal obesity, prothrombotic states with increased levels of plasminogen activator in-hibitor type 1 (PAI-1), microalbuminuria, impaired fasting glucose (insulin resistance syndrome) and proinflammatory states. Although there is no agreement on a universal defi-nition of MS, insulin resistance, impaired fasting glucose or diabetes constitute major criteria for this definition.
Background and objectives Recent studies have shown that abdominal obesity is an important component for the diagnosis of metabolic syndrome (MS) and MS is a high risk factor for cardiovascular disease and diabetes mellitus. The aim of this study was to develop a new formula for screening and diagnosis of MS using the waist circumference (WC) and skin fold thickness at the point A8 (SFA8) on the Erdheim diagram. Methods A total of 358 essential hypertensive patients (189 male and 169 female) with a mean age of 59.0±9.7 years were included; 151 healthy people (79 male, 72 female) with a mean age of 57.3± 12.1 years (similar to hypertensive patients) who were non-hypertensive and non-diabetic served as a control group. All subjects had no evidence of hepatic, renal, or endocrine disease as determined by history, physical examination and screening blood tests. Height, weight, WC, SFA8, blood pressure (BP), fasting plasma glucose, HDL-cholesterol and triglyceride levels were measured in all subjects. Abdominal obesity measured by WC using the Asia-Pacific criteria (IDFA) was applied for meeting the MS definition. The normal value of SFA8 was measured in the non-MS group. Relationships between SFA8 and systolic BP, diastolic BP, fasting plasma glucose, HDL-cholesterol and triglyceride levels were calculated in the control group. A new formula was developed according to high SFA8 and high WC. Results The normal value of SFA8 in non-MS group was 23.6±7.2 mm in male and 26.5±4.6 mm in female, respectively. The value of SFA8 in MS group was 36.7± 7.4 mm in male and 38.9 ± 8.1 mm in female, respectively. The value of WC in MS group and non-MS group were 92.5±3.0 cm and 79.4±6. 1 cm in male and 86.3±6.4 cm and 74.7±5.4 cm in female, respectively. There was a correlation between SFA8 and systolic BP, diastolic BP, fasting plasma glucose, HDL-cholesterol and triglyceride in control group (the correlation coefficients were 0.29, 0.23, 0.25, -0.31 and 0.46, respectively, P 90 cm in male, > 80 cm in female) + high SFA8 (> 30 mm). The sensitivity, specificity, false positive rate, false negative rate, positive predictive value, and negative predictive value of the new formula assessed with the IDFA definition were 94%, 93%, 7%, 6%, 92% and 95%, respectively. The percentage of all patients who met the criteria for MS by conventional definition was 46.2%. The percentage of all patients who met the criteria by the new-definition was 47.0%. There was no difference between the prevalence percentage of the MS according to new criteria and the IDFA criteria in all patients, in male and in female, respectively (P > 0.05). Conclusion This new formula for MS might be useful for easy screening. The advantage over current criteria is the lack of need for laboratory testing.
A 75-year-old male patient received esophageal carci-noma surgery in Oct 2005. The next day of the operation, he had dyspnea, chest discomfort and sweating when he was on some activities. ECG showed ST segment elevation and T wave depression in leads VI "6. Biochemical markers of myocardial necrosis were elevated. A diagnosis of acute myocardial infarction was made. After anticoagulant, antiplatelet and vasodilator therapy, his symptoms relieved in 3 hours. One week before the admission, a visible edema of the left lower extremity occurred. Doppler ultrasound showed thrombotic occlusion of the left superficial femoral vein and popliteal vein. With further anticoagulant and va-sodilator therapy, the edema disappeared. He was admitted to our hospital for further assessment and treatment on Nov 3, 2005. Diagnosis on admission were coronary heart disease, acute myocardial infarction of anterior wall, esophageal car-cinoma after surgery and thrombosis of left lower extremity vein. Blood, urine and stool routine tests, liver and renal functions were normal. Doppler ultrasound showed athero-sclerosis of both lower extremities, severe narrowed inferior part of right superficial femoral artery and unclear image of right posterior tibial artery (occlusion?). Echocardiography showed segmental wall motion abnormalities in distal part of anterior wall of left ventricle and the apex. LVEF (Simpson method) was 48%.......
Approximately 50% of all heart failure patients in the US are above 75 years of age, which is almost similar to most European countries and the Middle and the Far East. Even though aging is an independent molecular process with a multitude of genetic predetermination and biochemical mediations, aging itself does not automatically result in cardiac insufficiency. On the other hand, with increasing age, cardioprotective mechanisms in response to stress are lost, and progressive cardiomyocyte degeneration with replace-ment fibrosis is often seen in older hearts, even though the exact triggers are not completely understood. Older patients with heart failure have distinct features that require special attention in diagnosis as well as therapy. The elderly more frequently suffer from multiple co-morbidities and might have atypical clinical presentations. Several precautions are essential in the treatment of heart failure in the elderly due to co-existing morbidities and the pharmacokinetic and pharmacodynamic changes related to increased age. Also, treatment expectations, compliance, mental status and cognitive function might play a major role regarding optimized treatment and monitoring options in the elderly suffering from heart failure. This review summarizes current issues of heart failure management in the elderly.
Hypertension is a common clinical problem in the elderly worldwide and physicians of all types are likely to encounter patients with hypertensive urgencies and emergencies in these patients. Although various terms have been applied to these conditions, they are all characterized by acute elevations in blood pressure and evidence of end-organ injury. Prompt, but carefully considered therapy is necessary to limit morbidity and mortality. A wide range of pharmacologic alternatives are available to the practitioner to control blood pressure and treat complications in these patients. The management of the elderly patient with hypertensive crises needs to include close monitoring and a gentle decline in blood pressure to avoid catastrophic complications, exacerbation of ischemic myopathy, and vascular insufficiency.
In general, percutaneous coronary intervention (PCI) is contra-indicated in patients with bleeding and those that are easy to bleed because during PCI the patients need full anticoagulation to counter any thrombotic formation caused by introduction and manipulation of devices in the vascular system. The patients who currently bleed may not tolerate any short term anticoagulant effect. The patients who are easy to bleed may have annoying and prolonged bleeds especially at the surgical or vascular access site while on long term antiplatelet drugs such as clopidogrel or aspirin (ASA). These patients in critical situation such as acute myocardial infarction (AMI) or unstable angina may need to undergo PCI, in spite of the fact that the operators have difficulty in predicting the risk of or controlling further bleed-ing before or during PCI. Any patients whose bleeding cannot be controlled after PCI should not undergo PCI because they will succumb from hemorrhagic shock. These patients are listed in Table 1.