BACKGROUND. Balloon-expandable coronary-artery stents were developed to prevent coronary restenosis after coronary angioplasty. These devices hold coronary vessels open at sites that have been dilated. However, it is unknown whether stenting improves long-term angiographic and clinical outcomes as compared with standard balloon angioplasty. METHODS. A total of 520 patients with stable angina and a single coronary-artery lesion were randomly assigned to either stent implantation (262 patients) or standard balloon angioplasty (258 patients). The primary clinical end points were death, the occurrence of a cerebrovascular accident, myocardial infarction, the need for coronary-artery bypass surgery, or a second percutaneous intervention involving the previously treated lesion, either at the time of the initial procedure or during the subsequent seven months. The primary angiographic end point was the minimal luminal diameter at follow-up, as determined by quantitative coronary angiography. RESULTS. After exclusions, 52 patients in the stent group (20 percent) and 76 patients in the angioplasty group (30 percent) reached a primary clinical end point (relative risk, 0.68; 95 percent confidence interval, 0.50 to 0.92; P = 0.02). The difference in clinical-event rates was explained mainly by a reduced need for a second coronary angioplasty in the stent group (relative risk, 0.58; 95 percent confidence interval, 0.40 to 0.85; P = 0.005). The mean (+/- SD) minimal luminal diameters immediately after the procedure were 2.48 +/- 0.39 mm in the stent group and 2.05 +/- 0.33 mm in the angioplasty group; at follow-up, the diameters were 1.82 +/- 0.64 mm in the stent group and 1.73 +/- 0.55 mm in the angioplasty group (P = 0.09), which correspond to rates of restenosis (diameter of stenosis, > or = 50 percent) of 22 and 32 percent, respectively (P = 0.02). Peripheral vascular complications necessitating surgery, blood transfusion, or both were more frequent after stenting than after balloon angioplasty (13.5 vs. 3.1 percent, P < 0.001). The mean hospital stay was significantly longer in the stent group than in the angioplasty group (8.5 vs. 3.1 days, P < 0.001). CONCLUSIONS. Over seven months of follow-up, the clinical and angiographic outcomes were better in patients who received a stent than in those who received standard coronary angioplasty. However, this benefit was achieved at the cost of a significantly higher risk of vascular complications at the access site and a longer hospital stay.

/pdf/a-comparison-of-balloon-expandable-stent-implantation-with-3adajz0chr.pdf

A Comparison of Balloon-Expandable-Stent Implantation with Balloon Angioplasty in Patients with Coronary Artery Disease

A high degree of heart rate (HR) variability is found in compensated hearts with good function, whereas HR variability can be decreased with severe coronary artery disease, congestive heart failure, aging and diabetic neuropathy. To test the hypothesis that HR variability is a predictor of long-term survival after acute myocardial infarction (AMI), the Holter tapes of 808 patients who survived AMI were analyzed. Heart rate variability was defined as the standard deviation of all normal RR intervals in a 24-hour continuous electrocardiogram recording made 11 +/- 3 days after AMI. In all patients demographic, clinical and laboratory variables were measured at baseline. Mean follow-up time was 31 months. Of all Holter variables measured, HR variability had the strongest univariate correlation with mortality. The relative risk of mortality was 5.3 times higher in the group with HR variability of less than 50 ms than the group with HR variability of more than 100 ms. HR variability remained a significant predictor of mortality after adjusting for clinical, demographic, other Holter features and ejection fraction. A hypothesis to explain this finding is that decreased HR variability correlates with increased sympathetic or decreased vagal tone, which may predispose to ventricular fibrillation.

Decreased heart rate variability and its association with increased mortality after acute myocardial infarction

In a randomized, double-blind five-year trial, we tested the efficacy of simultaneously elevating serum levels of high-density lipoprotein (HDL) cholesterol and lowering levels of non-HDL cholesterol with gemfibrozil in reducing the risk of coronary heart disease in 4081 asymptomatic middle-aged men (40 to 55 years of age) with primary dyslipidemia (non-HDL cholesterol greater than or equal to 200 mg per deciliter [5.2 mmol per liter] in two consecutive pretreatment measurements). One group (2051 men) received 600 mg of gemfibrozil twice daily, and the other (2030 men) received placebo. Gemfibrozil caused a marked increase in HDL cholesterol and persistent reductions in serum levels of total, low-density lipoprotein (LDL), and non-HDL cholesterol and triglycerides. There were minimal changes in serum lipid levels in the placebo group. The cumulative rate of cardiac end points at five years was 27.3 per 1,000 in the gemfibrozil group and 41.4 per 1,000 in the placebo group--a reduction of 34.0 percent in the incidence of coronary heart disease (95 percent confidence interval, 8.2 to 52.6; P less than 0.02; two-tailed test). The decline in incidence in the gemfibrozil group became evident in the second year and continued throughout the study. There was no difference between the groups in the total death rate, nor did the treatment influence the cancer rates. The results are in accord with two previous trials with different pharmacologic agents and indicate that modification of lipoprotein levels with gemfibrozil reduces the incidence of coronary heart disease in men with dyslipidemia.

https://www.nejm.org/doi/pdf/10.1056/NEJM198711123172001?listPDF=true

Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease

http://lib.ajaums.ac.ir/booklist/archives%20of%20neurology_24%20Jan-2_17.pdf

The cardiovascular health study: Design and rationale

Most current models in health psychology assume that stress adversely affects physical health. We re-examined this assumption by reviewing extensive data from the literature and from six samples of our own, in which we collected measures of personality, health and fitness, stress, and current emotional functioning. Results indicate that self-report health measures reflect a pervasive mood disposition of negative affectivity (NA); self-report stress scales also contain a substantial NA component. However, although NA is correlated with health compliant scales, it is not strongly or consistently related to actual, long-term health status, and thus will act as a general nuisance factor in health research. Because self-report measures of stress and health both contain a significant NA component, correlations between such measures likely overestimate the true association between stress and health. Results demonstrate the importance of including different types of health measures in health psychology research.

Health complaints, stress, and distress: exploring the central role of negative affectivity.

The Biology of Human Starvation.

Information now available about the prevalence and incidence of coronary heart disease is seriously deficient because of the lack of standardized and objective methods of collection, tabulation, interpretation, and reporting of survey data. Chief reliance in the objective diagnosis of coronary heart disease rests on the electrocardiogram, a crucial tool in population studies. A classification system for the electrocardiogram in epidemiologic studies has been developed, tested, and herein presented. It is adapted to the usual clinical reading technics of the electrocardiographer. It embodies criteria widely employed and of diagnostic and prognostic import, but no stipulations about interpretation are made. The system permits more valid comparisons of data on heart disease between populations. It is susceptible to modern methods of data processing.

The Electrocardiogram in Population Studies A Classification System

Twenty-year coronary heart disease (CHD) incidence is analyzed for 279 men, CHD-free at the ages of 47 through 57 years and characterized by three examinations before 20 annual follow-up examinations. Sixty men developed CHD, 42 dying or suffering infarction. Among 20 entry characteristics, three had major predictive power, especially for CHD death or infarction: cold pressor test, a high level of serum cholesterol, and systolic blood pressure. Smoking and relative weight seemed unimportant. Major CHD incidence was proportional to cholesterol to the 3.4 power. Five-variable multiple logistic analysis permitted placement of men into deciles of estimated risk differing more than tenfold in CHD incidence. The combination of only cholesterol and systolic pressure was nearly as good. The multiple logistic coefficients applied to five-year data on 1,287 men among whom 182 CHD developed in 182 yielded satisfactory agreement between observed and predicted distributions of CHD cases in classes of estimated risk.

Mortality and Coronary Heart Disease Among Men Studied for 23 Years

Flicker Fusion Frequency: Background and Applications

Relative weight, body fatness (skinfold thickness), blood pressure, and serum cholesterol are reported from 281 Minnesota business and professional men, initially clinically healthy and aged 45 to 55, who were followed by annual examinations since the winter of 1947-48. In 15 elapsed years, coronary heart disease developed definitely in 32 men and possibly in 16 other men. The incidence of coronary heart disease tended to be higher among men above the median at first examination in relative weight, body fatness, systolic and diastolic blood pressure, and serum cholesterol concentration but these segregations were not statistically significant except with serum cholesterol, which was associated with p < 0.001. The data for the last pre-disease year on the men who developed coronary heart disease showed a significant relationship between incidence and systolic blood pressure as well as for cholesterol. Average data over all pre-disease years showed significantly reduced risk among the men in the bottom quar...

Ernst Simonson

Papers

The Biology of Human Starvation.

The Electrocardiogram in Population Studies A Classification System

Mortality and Coronary Heart Disease Among Men Studied for 23 Years

Flicker Fusion Frequency: Background and Applications

Coronary Heart Disease among Minnesota Business and Professional Men Followed Fifteen Years