Coronary Artery Disease: Agarwal R

Mehta R, Ward RP, Chandra S, Agarwal R, Williams KA, Anonymous00369, Anonymous00370. · Section of Cardiology, University of Chicago, Chicago, Ill 60637, USA. · J Nucl Cardiol. · Pubmed #18513640 No free full text.

Abstract: BACKGROUND: The American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria (AC) were created to guide responsible use of single photon emission computed tomography (SPECT). Clinical applicability of the AC has not been evaluated. METHODS AND RESULTS: Indications for testing were determined in 1209 patients and categorized as having appropriate, uncertain, or inappropriate indications; the specialty of the ordering physician was noted. There were 940 (80%) appropriate, 154 (13%) inappropriate, and 79 (7%) uncertain tests; 36 tests were labeled "no category," as these were ordered for indications not clearly addressed in the AC. Inappropriate studies had more normal and lower summed stress scores, although there remained a high proportion of abnormal SPECT studies in this group (26% of women and 50% of men). Women had lower summed stress scores and more normal tests in the appropriate and inappropriate groups. Studies ordered by anesthesiologists for preoperative evaluation were more likely to be deemed inappropriate than other specialty groups. CONCLUSION: In evaluating the AC in a single-center academic setting, the majority of studies are appropriate, but a large proportion of ordered SPECT studies were categorized as uncertain, inappropriate, or no category. Although the inappropriate studies showed less ischemia than other groups, especially in women, a substantial portion of these studies (32%) were abnormal.

Agarwal R, Bunaye Z, Bekele DM, Light RP. · Division of Nephrology, Department of Medicine, Indiana University School of Medicine, and Richard L. Roudebush VA Medical Center, Indianapolis, IN 46202, USA. · Am J Nephrol. · Pubmed #18239383 No free full text.

Abstract: BACKGROUND: Death and dialysis are competing outcomes in patients with chronic kidney disease (CKD). The factors associated with end-stage renal disease (ESRD) versus death in this population are unknown. The purpose of our study was to evaluate the competing risk of ESRD versus mortality and to evaluate the risk factors associated with these two outcomes. METHODS: We prospectively recruited 220 consecutive patients at a Veterans Administration Medical Center attending a renal clinic who met the definition of CKD (estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) or urine protein/creatinine ratio of >0.22 g/g). Using age, race, proteinuria, eGFR, systolic blood pressure, and coronary artery disease as predictors, we calculated the competing end-points of ESRD or death using a competing Cox regression model. RESULTS: The cumulative incidence for ESRD was 17.6% and death 18.5% during follow-up that lasted up to 7 years. ESRD was predicted by younger age (hazard ratio (HR) 0.91/year), black race (HR 2.75), higher systolic blood pressure (HR 1.02/mm Hg), proteinuria (HR 1.37/log urine protein/creatinine ratio) and low eGFR (0.014/log eGFR ml/min/1.73 m(2)). Death was predicted by older age (HR 1.07/year), lower eGFR (HR 0.43/log eGFR ml/min/1.73 m(2)), proteinuria (HR 1.26/log urine protein/creatinine ratio) and coronary artery disease (HR 2.52). The coefficients were statistically different for age (p < 0.001), log eGFR (p < 0.001) and systolic blood pressure (p = 0.04) for ESRD and death outcomes. CONCLUSIONS: The risk for mortality is similar to the risk of ESRD in the CKD population of veterans seen by nephrologists. Risk factors for ESRD and death appear to differ in this population. Certain clinical and demographic factors may discriminate between the end-points of death or dialysis and may influence decisions about planning for ESRD.

Anayiotos A, Cheng G, Ito Y, Gray J, Agarwal R. · University of Alabama at Birmingham, Alabama 35294, USA. · Stud Health Technol Inform. · Pubmed #15747925 No free full text.

Abstract: Image based Computational Fluid Dynamics (CFD) simulation of the cardiovascular system is increasingly becoming important and its application in everyday medical practice can already be envisaged. The goal of this workshop is to address all the factors involved in the development of a computational framework/software for modelling and analyses of the cardiovascular system and provide examples. The development of such framework, requires integration, management and interpretation of data from several technology areas such as a) feature detection and extraction of arterial geometry from imaging data, b) adaptive grid generation techniques for 3-D asymmetric geometries c) hemodynamic modelling, disparate length-scale model, and fluid-tissue interaction with high-performance computing, d) CFD data validation, e) feature extraction/detection and visualisation algorithms, f) graphical user interface to allow remote visualisation of post processed data. These computational tools are employed to study flow in specific problem sites in the vascular tree such as the carotid, femoral, coronary and abdominal arteries. Such studies provide understanding of the factors involved in the initialisation and evolution of arterial disease due to altered flow conditions (as a result of plaque formation) such as flow separation and reversal, and low and oscillatory wall shear stress. It is also used to study the effect of various clinical procedures such as the implantation of stents, vascular grafts, vascular prostheses and artificial valve implants on local and global hemodynamics. This workshop will address a new emerging paradigm in clinical practice known as predictive medicine for effective surgical planning and post surgical rehabilitation. The workshop will also address the difficulties in the implementation of some of the technology areas in this application with examples of carotid, femoral, and abdominal artery simulations.

Singh SK, Mishra SK, Kumar D, Yadave RD, Agarwal R, Sinha SK. · Department of Cardiology & Cardiothoracic Surgery, Batra Hospital & Medical Research Centre, M.B. Road, New Delhi 110 0062, India. · Asian Cardiovasc Thorac Ann. · Pubmed #12878555 No free full text.

Abstract: To avoid the deleterious effects of cardiopulmonary bypass, total arterial revascularization was performed on the beating heart, using an Octopus stabilizer, in this prospective study of 803 patients without selection bias. Single-vessel disease was present in 71 (9%) patients, double-vessel disease in 204 (25%), and triple-vessel disease in 528 (66%). An ejection fraction < 30% was found in 127 (16%) cases. Angiography was carried out before discharge in 204 (25%) patients. Grafts included left and right internal mammary arteries and the radial artery. There were 2,661 grafts placed with a mean of 3.31 grafts per patient (range, 1 to 6). Operative mortality was 0.5%. There was no postoperative stroke and few incidences of renal impairment, even in patients with chronic renal failure. Blood transfusion was not required in 558 (69%) patients. Mean hospital stay was 5.6 days. Overall angiographic patency was 98.6%. Total arterial revascularization on the beating heart was found to be safe, effective, and reproducible in almost all patients, with excellent short-term patency rates and minimal morbidity.

Cherian KM, Agarwal R, Sankar NM. · M.G.R. Medical University, Madras, India. · Adv Card Surg. · Pubmed #10575487 No free full text.

Abstract: TMLR is effective as an isolated procedure in patients with ungraftable vessels and is a useful adjunct to CABG in patients with diffuse and small-vessel disease requiring endarterectomies. The optimal subset of patients who will benefit from isolated TMLR are those primarily with angina rather than congestive failure, who have protected myocardium and uncompromised left ventricular function.

Manjunath BV, Mullasari SA, Jaiswal PK, Faizal A, Agarwal R, Cherian KM, Srividhya K. · Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai. · Indian Heart J. · Pubmed #10327780 No free full text.

Abstract: Transmyocardial laser revascularisation has emerged as a new therapeutic option for patients with severe diffuse coronary artery disease refractory to conventional modes of therapy. One hundred and two patients underwent isolated transmyocardial laser revascularisation between December 1994 and November 1997. After transmyocardial laser revascularisation, angina class improved from 2.56 +/- 0.8 to 0.8 +/- 0.9 by the end of one year and 54 percent patients were angina-free. Treadmill test workload increased from 3.6 +/- 1.7 METS pre-operatively to 6.0 +/- 3.4 METS (p < 0.005) at the end of one year's follow-up. However, left ventricle ejection fraction by MUGA slightly decreased (p = NS) at the end of one year. We conclude that transmyocardial laser revascularisation provides symptomatic benefit, improves quality of life and objectively improves the exercise tolerance at 12 months post-procedure.

Agarwal R, Ajit M, Kurian VM, Rajan S, Arumugam SB, Cherian KM. · Institute of Cardiovascular Diseases, Madras, Mogappair, India. · Ann Thorac Surg. · Pubmed #10197665 No free full text.

Abstract: BACKGROUND: Transmyocardial revascularization using a high-energy CO2 laser has emerged as a new therapeutic option for patients with severe diffuse coronary artery disease refractory to conventional modes of therapy. METHODS: From December 1994 to September 1997, 102 patients underwent isolated transmyocardial revascularization. The mean age was 56.7 +/- 9.2 years and 92.15% were men. Mean preoperative angina class and ejection fraction were 2.6 +/- 0.7 and 44.7% +/- 10.5%, respectively. Diabetes was present in 49.01% of patients, 32.3% had history of previous myocardial infarction, and 12.7% had undergone a previous coronary artery bypass graft procedure. An average number of 23 +/- 8 channels were created in each patient using an 800-W CO2 laser. RESULTS: The early mortality was 14.7% and univariate predictors of mortality were age more than 55 years, female sex, creatine kinase more than 1,600 IU, absence of intercoronary collaterals, and mean pulmonary artery pressure greater than 21 mm Hg. At 1-year follow-up there was significant improvement in angina class and effort tolerance but no significant change in left ventricular ejection fraction. CONCLUSIONS: We conclude that transmyocardial revascularization provides symptomatic benefit and improves exercise tolerance in a group of patients suffering from disabling angina not amenable to other modes of treatment. The high early mortality can be brought down with strict patient selection criteria. The mechanism of beneficial effects is uncertain and patency of laser channels is controversial, but laser-induced neoangiogenesis is being looked on as a possible explanation.