Background Recent clinical trials have shown that modification of plasma lipoprotein concentrations can favorably alter progression of coronary atherosclerosis, but no data exist on the effects of a comprehensive program of risk reduction involving both changes in lifestyle and medications. This study tested the hypothesis that intensive multiple risk factor reduction over 4 years would significantly reduce the rate of progression of atherosclerosis in the coronary arteries of men and women compared with subjects randomly assigned to the usual care of their physician.Methods and Results Three hundred men (n=259) and women (n=41) (mean age, 56±7.4 years) with angiographically defined coronary atherosclerosis were randomly assigned to usual care (n=155) or multifactor risk reduction (n=145). Patients assigned to risk reduction were provided individualized programs involving a low-fat and -cholesterol diet, exercise, weight loss, smoking cessation, and medications to favorably alter lipoprotein profiles. Computer-assisted quantitative coronary arteriography was performed at baseline and after 4 years. The main angiographic outcome was the rate of change in the minimal diameter of diseased segments. All subjects underwent medical and risk factor evaluations at baseline and

Substitution of MMF for azathioprine may reduce mortality and rejection in the first year after cardiac transplantation.

Left ventricular dysfunction is common in respiratory-distress syndrome, asthma and obstructive lung disease. To understand the contribution of intrathoracic pressure to this problem, we studied the effects of Valsalva and Müller maneuvers on left ventricular function in eight patients. Implantation of intramyocardial markers permitted beat-by-beat measurement of the velocity of fiber shortening (VCF) and left ventricular volume. During the Müller maneuver, VCF and ejection fraction decreased despite an increase in left ventricular volume and a decline in arterial pressure. In addition, when arterial pressure was corrected for changes in intrapleural pressure during either maneuver it correlated better with left ventricular end-systolic volumes than did uncorrected arterial pressures. These findings suggest that negative intrathoracic pressure affects left ventricular function by increasing left ventricular transmural pressures and thus afterload. We conclude that large intrathoracic-pressure changes, such as those that occur in acute pulmonary disease, can influence cardiac performance.

We identified 420 medically treated and 231 surgically treated patients (coronary graft plus myocardial surgery in 30%) who had severe left ventricular dysfunction manifest by an ejection fraction below 0.36 and markedly abnormal wall motion. Compared with medically treated patients, those treated surgically had more severe angina (56.7% vs 29.0% class III or IV; p < .001), less heart failure as predominant symptom (I 1. 1% vs 18.8%; p < .003), more severe coronary disease (66.7% vs 50.2% three-vessel disease; p < .001), a greater concentration of left main coronary artery lesions > 70% (12.6% vs 3.8%: p < .001), and a greater estimated extent of jeopardized myocardium (p < .001). Multivariate regression analysis of survival, which adjusts for the above covariates, showed that surgical treatment prolonged survival (p < .05), although it ranked below severity of heart failure symptoms, age, ejection fraction, and left main stenosis >70% in determining prognosis. Surgical benefit was most apparent for patients with ejection fractions below 0.26 who had a 43% 5 year survival with medical treatment vs 63% with surgery. Surgically treated patients experienced substantial symptomatic benefit compared with medically treated patients if their presenting symptoms were predominantly angina; however, there was no relief of symptoms caused primarily by heart failure. We conclude that patients with predominantly ischemic pain symptoms, despite poor left ventricular function, benefit from surgery; however, operative mortality in this high-risk subset must equal or better the 6.9% obtained in this study. Circulation 68, No. 4, 785-795, 1983. MANY STUDIES have examined the role of coronary surgery in patients with disabling symptoms, advanced coronary vascular lesions, and relatively well-retained myocardial function. However, for patients who have significant left ventricular dysfunction, concerns about increased operative mortality, diminished long-term survival, and irreversibility of myocardial scar have made it difficult to assess the role of coronary surgery in these patients. The NHLBI-sponsored Coronary Artery Surgery Study (CASS) Registry, which enrolled patients from 1974 to 1979, includes many patients with left ventricular dysfunction whose management varied according to local physicians' preferences based on their assessment of patient symptoms and angiographic findings. We retrospectively reviewed those patients who fell below a specific threshold of left ventricular dysfunction and sought to evaluate those variables that determine survival, coronary events, and symptomatic status.

These results contribute to the understanding of the natural history of coronary artery disease and are also of historical interest. The poor survival of patients with three-vessel disease and low ejection fractions continues to emphasize the importance of considering revascularization for these patients.

Background To identify predictors of long-term outcome after balloon aortic valvuloplasty, we analyzed data on 674 adults (mean age, 78±9 years; 56% were women) undergoing

Annual coronary arteriograms have been obtained from all heart transplant recipients at Stanford University Medical Center since 1969. Angiographic lesions in 81 transplant patients exhibiting coronary vascular disease were classified into three categories: type A, discrete or tubular stenoses; type B, diffuse concentric narrowing; and type C, narrowed irregular vessels with occluded branches. The 81 arteriograms showing transplant coronary vascular disease were contrasted with 32 from nontransplant patients with coronary artery disease analyzed in a similar fashion. The nontransplant angiograms showed 178 lesions, all of type A (discrete or tubular) morphology, 75% of which were located in primary epicardial coronary vessels and 25% in secondary branch vessels. In the patients with transplant coronary vascular disease, 349 (76%) of 461 lesions were type A: 57% in primary vessels, 42% in secondary branches and 1.4% in tertiary branches. Of the 112 type B and C lesions (diffuse narrowing, tapering and obliteration), 25% were in primary vessels, 44% in secondary vessels and 31% in tertiary branches (p less than 0.05 for patients with transplant coronary vascular disease versus patients with nontransplant coronary artery disease). Total vessel occlusion was found in proximal or middle vessel segments in 96% and distally in 4% of patients with "ordinary" coronary artery disease versus 49% distally in patients with transplant coronary disease (p less than 0.002). In the presence of total vessel occlusion, collateral vessels were poor or absent in 92% of transplant versus 7% of nontransplant patients with coronary disease (p less than 0.002). Therefore, coronary artery disease in transplant patients represents a mixture of typical atheromatous lesions and unique transplant-related progressive distal obliterative disease that occurs without collateral vessel development.

Complete revascularization (grafts to three or more vessels) in patients with three-vessel coronary disease appears to most benefit those with severe angina and left ventricular dysfunction.