New developments in percutaneous coronary intervention
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7407.150 (Published 17 July 2003) Cite this as: BMJ 2003;327:150All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
In studies we have performed in patients with chronic visceral
ischaemia we have reported that there is absolutely no correlation between
macroscopic arterial anatomy and presence or absence of ischaemia, defined
as an abnormally low gastric intramucosal pH(1). That the symptoms were
caused by the abnormally low intramucosal pH was confirmed by provocative
tests, the return of the pH to normality after vascular reconstruction,
and the accompanying relief of symptoms.
Our findings, which have since been confirmed by other investigators,
demonstrated the difficulty in establishing a diagnosis of chronic
visceral ischameia from arterial anatomy alone. More importantly our study
showed that small vessel disease, such as that seen in diabetes and
hypertension [not seen on an angiogram], and venous outflow obstruction
could particularly important causes of chronic visceral ischaemia even in
the absence of any significant arterial abnormalities.
I had always assumed that angina was caused by an impairment of
arterial inflow and that nitroglycerin relieved patients of their angina
by improving coronary artery perfusion. I have since discovered that
nitroglycerin is predominatly a venodilator (2). How then is it possible
to establish with any certainty whether a coronary arterial stenosis or
even an occlusion is a significant cause of symptoms and require
angioplastic dilation? In the absence of objective bioenergetic
information, such as a low intramyocardial pH, it must be impossible.
Perhaps that is why the cardiac surgeons have found in retrospect that
increased survival is limited to the surgical correction of a few very
specific coronary artery abnormalities.
Many angioplastic dilations must be unnecessary. There is a great
need for a method of obtaining objective bioenergetic information in the
myocardium in routine clinical practice. There is also an urgent need for
a prospective evaluation of the short and long-term risks and benefits of
angioplastic dilations.
1. Bauer JA, Fung HL. Arterial versus venous metabolism of
nitroglycerin to nitric oxide: a possible explanation of organic nitrate
venoselectivity.
J Cardiovasc Pharmacol. 1996 Sep;28(3):371-4.
2. Fiddian-Green RG, Stanley JC, Nostrant T, Phillips D. Chronic gastric
ischemia. A cause of abdominal pain or bleeding identified from the
presence of gastric mucosal acidosis.
J Cardiovasc Surg (Torino). 1989 Sep-Oct;30(5):852-9.
Competing interests:
None declared
Competing interests: No competing interests
myocardial contrast enhancement(MCE) is rapidly developing in the
field of diagnosis.it has been studied for a therapeutic role too.
ultra sound with microbubbles have a potential of delivering or depositing
adherent drugs or genes to targetted organs.also as albumin- coated
microbubbles can directly adhere to sites of endothelial damage ( after
pci for instance ), this may be the method of drug delivery of choice
without use of ultra sound. this if indeed becomes a reality may offer a
cheap alternative to the expensive drug eluting stents.
Competing interests:
None declared
Competing interests: No competing interests
A Patient's Perspective
Medically speaking, in "New Developments in Percutaneous Coronary
Interventions", July 19th 2003, only two procedures are compared. From the
Patient's Perspective, however, there are effectively three as it is the
access route
which, in each case, controls what the patient experiences.
I've had all three and although the Bypass is in a league of its own,
the differences
between the two percutaneous routes - the Femoral Artery ( currently
representing
95% of interventions), and the Radial or Brachial Artery (5%) is very
marked
indeed.
In fact, I was so impressed that I jotted down a few lines. I hope
they will incite
patients to persuade practitioners to reverse the above statistics fast!
If you're up for angiography
Then I urge you to persist
In rejecting access in the groin
And insist upon the wrist!
Competing interests:
None declared
Competing interests: No competing interests