Faculty Bibliography

BACKGROUND: Heavy alcohol consumption is a well-known cause of dilated cardiomyopathy and hypertension, but its effects on coronary atherosclerosis are less well understood. The objective of this study was to compare coronary anatomy and left ventricular dysfunction in patients with and without alcoholism associated with heavy consumption. METHODS: We studied 100 consecutive alcoholic male patients presenting with chest pain to the Department of Veterans Affairs New York Harbor Healthcare System (VA) between 1994 and 2002. Alcoholism was defined as a history of either chronic alcohol-related pancreatitis or liver cirrhosis. Patients were compared to age-matched controls (n = 200) that were known to be nonalcoholic. All patients underwent coronary angiography. RESULTS: Baseline demographic characteristics were similar between the two groups. The prevalence of significant coronary artery disease (CAD) (defined as coronary arterial luminal diameter stenosis > 50%) was lower in the alcoholic group than in the control group (42% vs. 58%; p = 0.013). Among patients with CAD, those with a history of alcoholism had fewer vessels with stenoses (1.6 +/- 0.6 vs. 2.3 +/- 0.7; p < 0.001) than the control group, and were more likely to have single-vessel CAD (64% vs. 8%; p < 0.05). The alcoholic group also had lower mean left ventricular ejection fraction (LVEF) compared to the control group (43 +/- 13% vs. 49 +/- 9%; p < 0.001), and a higher prevalence of left ventricular dysfunction (LVEF < 40%; 37% vs. 13%; p < 0.05). In the alcoholic group, there was a lower prevalence of CAD in patients with left ventricular dysfunction as compared to those without left ventricular dysfunction (21% vs. 49%; p = 0.006). CONCLUSIONS: In a group of male VA patients presenting with chest pain, alcoholism was associated with a lower incidence and a lesser severity of angiographically-defined CAD, but had greater left ventricular dysfunction. There appears to be an inverse relationship between CAD and left ventricular function in patients with a history of heavy alcohol consumption.

Direct thrombin inhibitors (DTI) are emerging as alternative anticoagulants to unfractionated heparin and indirect thrombin inhibitors in patients undergoing percutaneous coronary intervention (PCI). We review the pharmacological properties of these newer antithrombotic agents and evaluate the clinical data demonstrating their use in patients undergoing PCI.

Low-molecular-weight heparins and direct thrombin inhibitors are emerging as alternative anticoagulants to unfractionated heparin in patients undergoing percutaneous coronary intervention (PCI). This paper reviews the pharmacologic properties of these newer antithrombotic agents and evaluates the clinical data demonstrating their use in patients undergoing PCI.

A 21-year-old woman with a history of systemic lupus erythematosus (SLE) presented to the emergency room with a chief complaint of substernal chest pain and palpitations. She had undergone a four-vessel coronary artery bypass graft operation with separate saphenous vein grafts to the left anterior descending (LAD), obtuse marginal (OM) 1 and 2, and distal right coronary arteries (RCA) 8 months prior to admission. The patient underwent angiography of the coronary vessels, which showed severe diffuse disease with a long, 90% narrowing of the vein graft to the LAD and closed vein grafts to OM1 and OM2. The RCA graft showed mild diffuse disease. An intervention was done in which the LAD was stented twice with subsequent TIMI 3 flow. Advances in medical therapy and a better understanding of the disease have contributed to a dramatic improvement in the long-term survival of patients with SLE. However, despite the overall long-term improvement, coronary artery disease remains a major cause of morbidity and mortality with an incidence of approximately nine-fold greater than would be expected for this population

OBJECTIVES: We evaluated the vascular complications after hemostasis with arteriotomy closure devices (ACD) versus manual compression after percutaneous coronary interventions (PCI). BACKGROUND: Previous clinical studies have indicated that ACD can be used for achievement of hemostasis and early ambulation after PCI. This study investigated the safety of ACD in achieving hemostasis after PCI compared with manual compression in a large cohort of consecutive patients. METHODS: A total of 5,093 patients were followed after PCI was performed with the transfemoral approach. Univariate and multivariate analysis were used to identify the predictors of vascular complications with ACD (n = 516) or with manual compression (n = 5,892) as a hemostasis option after sheath removal. RESULTS: The use of ACD was associated with a more frequent occurrence of hematoma compared with manual compression (9.3 vs. 5.1%, p < 0.001). There was also a higher rate of significant hematocrit drop (>15%) with ACD versus manual compression (5.2% vs. 2.5%, p < 0.001). Similar rates of pseudoaneurysm and arteriovenous fistulae were noted with either hemostasis technique. Vascular surgical repair at the access site was required more often with ACD versus manual compression (2.5 vs. 1.5%, p = 0.03). CONCLUSIONS: In this early experience with ACD after PCI, their use was associated with higher vascular complication rates than hemostasis with manual compression