Heart Disease - Contraindications

Contra-indications to metformin therapy are largely disregarded.

Holstein A, Nahrwold D, Hinze S, Egberts EH

1st Department of Medicine, Klinikum Lippe-Detmold, Germany.

AIMS: To investigate the current metformin treatment practice and in particular to examine the consideration given to its contraindications. METHODS: A cross-sectional analysis of 308 consecutive Type 2 diabetic patients (mean age 66+/-11.3 years) previously treated with metformin on an outpatient basis and admitted to a German general hospital during the period from 1 January 1995 to 31 May 1998 because of acute disease or in order to optimize their diabetes management. All patients underwent a basic investigation comprising a documentation of their medical history, a physical examination, an electrocardiogram, and an extensive laboratory profile; 34% also had acute coronary angiography. RESULTS: On admission to hospital, 73% of the patients were found to have contra-indications, risk factors, or intercurrent illnesses necessitating discontinuation of metformin; 51% of these patients had several of these conditions. As major contra-indications to metformin, renal impairment was present in 19% of all patients, heart failure in 25%, respiratory insufficiency in 6.5%, and hepatic impairment in 1.3%. The risk factors to metformin included advanced coronary heart disease in 51%, atrial fibrillation in 9.8%, chronic alcohol abuse in 3.3%, advanced peripheral vascular disease in 2%, and pregnancy in 0.7%. As intercurrent illnesses, cerebral ischaemia occurred in 9.8% under metformin treatment and malignancies were diagnosed in 6.5%. The patients with contra-indications or requiring caution to metformin were significantly older and had previously been treated with more cardiovascular medication than those without such reservations (P<0.001). CONCLUSIONS: Despite the considerable risk of lactic acidosis in the majority of patients, no cases were observed.

PMID: 10477216, UI: 99404866

Ann Thorac Surg 1999 Jun;67(6):1653-8

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach.

Baumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Katouzian A, Yokoyama T

St. Vincent Medical Center, Los Angeles, California, USA.

BACKGROUND: Cardiopulmonary bypass and cardioplegic arrest result in known physiologic inflammatory, coagulopathic, and embolic states that may result in end-organ damage. Interest in off-pump complete coronary revascularization using sternotomy exposure is therefore increasing. METHODS: Using specific surgical and anesthetic techniques, we have been able to achieve total revascularization using off-pump coronary artery bypass grafting procedures (OP-CAB) through a sternotomy approach. Exposure techniques and local stabilization are tailored to individual vessels and cardiac regions. Vascular control is achieved with silicone-elastomer loops, occluders, and shunts. Poor ventricular function, advanced age, and other comorbid conditions, in and of themselves, were not considered contraindications to OP-CAB. Cardiomegaly or situations of small, intramyocardial, or heavily calcified vessels were relative contraindications to OP-CAB. RESULTS: Of 141 sternotomy OP-CAB cases, 132 (93.6%) were completely off-pump. The mean number of OP-CAB grafts per patient in the cases that were completely off-pump was 3.3 (range, 1 to 6). The 30-day operative mortality was 0%. There were four instances of intraoperative cardiac arrest, precipitated by vascular occlusion of the right coronary artery or manipulating a cardiomegalic heart. Advanced age (> or = 80 years) or profound ventricular dysfunction (ejection fraction < or = 0.25) was present in a considerable percentage of patients (10.6% and 9.9%, respectively). CONCLUSIONS: Off-pump coronary artery bypass grafting is successful for total revascularization in large numbers of patients. Anatomic factors, including cardiomegaly and small, intramyocardial, or heavily calcified vessels are possible contraindications to OP-CAB. Patients at highest risk for undergoing cardiopulmonary bypass, including those of advanced age and having ventricular dysfunction, are precisely the ones in whom OP-CAB may be the most useful.

PMID: 10391270, UI: 99318154

Prescrire Int 1998 Jun;7(35):90-1

Hypotension and coronary events on nifedipine: reassessing nifedipine safety.

Nifedipine administration for hypertensive emergencies can induce neurological and cardiac events due to abrupt hypotension. Nifedipine also increase the risk of coronary events in case of unstable angina or recent myocardial infarction. In hypertensive emergencies, the potential advantages and risks of achieving a rapid fall in arterial pressure should be assessed case by case. In patients with coronary heart disease, nifedipine is contraindicated in case of recent myocardial infarction or unstable angina. Nifedipine is only a second-line choice for stable angina, and should be combined with a betablocker.

Publication Types:

• Review
• Review literature

PMID: 10342928, UI: 99600610

Urologe A 1999 Mar;38(2):124-7

[Sildenafil (Viagra). Tolerance, contraindications, drug interactions].

Sperling H, Michel MC, Rubben H

Urologische Klinik, Universitatsklinikum Essen.

Placebo-controlled studies have clearly demonstrated the efficacy of sildenafil in the treatment of erectile dysfunction. It's tolerability cannot yet be judged definitively based on the available information. Some findings indicate that in addition to established contraindications (allergy against the active ingredient, concomitant nitrate and NO-donor treatment, retinitis pigmentosa) factors such as coronary heart disease, advanced age, impaired liver function and drug interactions require special attention by the prescribing physician to secure drug safety.

Publication Types:

• Review
• Review, tutorial

PMID: 10231931, UI: 99248713

G Ital Cardiol 1998 Nov;28(11):1225-9

[Minimally invasive surgery with the Port-Access method. Preliminary experience].

Vigano M, Minzioni G, Spreafico P, Pasquino S, Ceriana P, Locatelli A, Maurelli M

Divisione di Cattedra di Cardiochirurgia, Centro Ch. Dubost, Pavia.

METHODS: Data from the initial experience of 40 patients operated on with the Port-Access technique are reported. Indication to surgery was mitral disease in 24 patients and coronary stenosis in 16 patients. Mean age was 52 years (range 32-75). Operations performed were: 8 mitral valvuloplasties, 16 valve replacements, 9 single CABG (associated with an MVR in one case), 1 double CABG, 6 triple CABG and one quadruple CABG. Coronary endarterectomy was performed in 5 patients and left atrial isolation was associated with MV surgery in 5 cases. RESULTS: There were no operative deaths and every patient was discharged after a mean postoperative stay of 5.5 days (range 3-30). Postoperative course was complicated in 7 patients: surgical revision was necessary in 4 patients due to bleeding (through the mini-thoracotomy incision in 3 cases), 1 pacemaker was implanted for A-V block, one retained pulmonary catheter was removed through the mini-thoracotomy without the aid of cardiopulmonary bypass and in one case, there was an emergency conversion to median sternotomy due to a ventricular fibrillation unresponsive to usual resuscitative maneuvers a few hours after surgery. Some of these complications can be ascribed to the learning phase of this new technique and should disappear as experience is increased. CONCLUSIONS: Port-Access surgery is a new minimally invasive technique that utilizes a cardiopulmonary bypass with femoral access and a specialized catheter system that provides endoaortic clamping, pulmonary artery venting and myocardial preservation with infusion of cardioplegic solution in the aortic bulb or in the coronary sinus. Major contraindications to this technique are iliac-femoral disease or severe dilatation of ascending aorta. The aim of the Port-Access technique is to combine the aesthetic and functional advantages of the minimally invasive surgery with the wide range of surgical options that cardiopulmonary bypass can afford (to operate on atrioventricular valves and perform all the CABG that the patient need), without the limitations characteristic of the classic minimally invasive direct coronary artery bypass (MIDCAB) technique.

PMID: 9866799, UI: 99084031

Presse Med 1998 Jul 4-11;27(24):1225-7

[Sildenafil: hopeful or unreasonable]?

Cour F

Due to its specific action on the intracavernous mechanism of erection, sildenafil is the first oral treatment for erectile dysfunction therefore much more effective than earlier oral therapies. Patient acceptance is greatly improved with the simple oral dose one hour before sexual activity, avoiding commonly observed dissatisfaction with intracavernal injections or vacuum devices: will its efficiency be the same? Treatment with nitrate derivatives for angina pectoris is the major contraindication. Global management, for the patient and his partner, remains essential for optimal efficacy of this new compound. Considering patient habits and medical prescriptions in France where use of anti-anxiety and anti-insomnia drugs is relatively high but use of vitamins and regenerating drugs relatively low, only the future will tell whether use of sildenafil will remain within 'reasonable' limits. No decision concerning reimbursement by the French Social Security health care scheme has been made to date.

Publication Types:

• Editorial

PMID: 9767783, UI: 98440897

Rev Esp Cardiol 1998;51 Suppl 3:58-61

[Coronary endarterectomy].

Murtra M, Gonzalez I, Igual A

Servicio de Cirugia Cardiaca, Hospital General Universitario Vall d'Hebron, Barcelona.

The technique of coronary endarterectomy, in coronary artery surgery, has been controversial and alternatively indicated or contraindicated by different authors. In this paper coronary endarterectomy is reviewed, including its definition, history and development of different techniques. Early and late results of the main papers in the literature are commented on as well as our results. The surgical technique of endarterectomy in the different coronary artery territories is described with the primary indications and contraindications. Coronary endarterectomy is a valid and well established technique that can provide possibilities of revascularization in patients with extended and diffused coronary artery obstructions, which are unable to be treated with conventional coronary artery bypass grafts. Operative mortality and morbidity are slightly higher, but long-term results, as far as survival and functional class are concerned, are similar to standard coronary artery surgical procedures.

Publication Types:

• Historical article
• Review
• Review literature

PMID: 9717404, UI: 98383132

Schweiz Med Wochenschr 1998 Apr 25;128(17):671-8

[High altitude stay and air travel in coronary heart disease].

Allemann Y, Saner H, Meier B

Departement Innere Medizin, Universitatsspital Bern.

Acute exposure to high altitude produces hypoxia-associated stimulation of the sympathetic nervous system. This response is further enhanced by physical activity and induces an increase in heart rate and blood pressure. Consequently, cardiac work, myocardial oxygen consumption, and coronary blood flow are also increased. During the first 4 days of acute exposure to moderate or high altitude, coronary patients are at greatest risk of untoward events. Gradual ascent, early limitation of activity to a lower level than tolerated at low altitude, pre-ascent physical conditioning and rigorous blood pressure control should all help to minimise the cardiac risk. At altitudes of 2500 to 3000 m or lower, an asymptomatic coronary patient with good exercise tolerance, without exercise induced signs or symptoms of ischemia, and with an ejection fraction of the left ventricle > 50%, is at very low risk. However, several days' acclimatization before high-level activity at moderate or high altitude is recommended. High risk coronary patients should be investigated more carefully and precautionary measures should be more stringent. Left and right cardiac function and pulmonary artery pressure are the most helpful parameters for evaluation and counselling of patients with non-ischemic heart disease who plan to ascend to moderate or high altitudes. When advising patients who intend to fly as passengers in commercial aircraft, it is important to know that in-flight atmospheric pressure conditions in commercial jet aircraft approach altitude equivalents of 1500 to 2400 m. Propeller-driven planes are rarely pressurized but usually fly at altitudes below 3300 m. Relatively strict contraindications for air travel by coronary patients are uncomplicated myocardial infarction within the last 2 weeks, complicated myocardial infarction within the last 6 weeks, unstable angina, thoracic surgery within the last 3 weeks, and poorly controlled congestive heart failure, arrhythmia, or hypertension.

Publication Types:

• Review
• Review, tutorial

PMID: 9622840, UI: 98286043

Ther Umsch 1998 Apr;55(4):235-9

[Sports in the heart rehabilitation group--experiences with ambulatory rehabilitation at home].

Halle M, Huonker M, Schmidt-Trucksass A, Irmer M, Korsten-Reck U, Durr H, van de Loo G, Keul J, Berg A

Abteilung fur Rehabilitative und Praventive Sportmedizin, Medizinische Universitatsklinik, Freiburg.

Regular physical exercise has shown to be beneficial for patients with cardiovascular disease. Therefore cardiac rehabilitation in Germany is continued for years after hospital discharge in outpatient cardiac exercise groups which meet twice a week under the guidance of a physician and a sports instructor. Before participation cardiac patients have to be examined including exercise tests and echocardiography for assessment of contraindications for exercise therapy as well as individual exercise capacity. Patients are assigned to two groups with different levels of exercise intensity according to their symptom-free work-capacity (cutoff level 1 W/kg). During exercise sessions sports-specific forms of exercise such as stretching, aerobic exercise or ball games are accompanied by psychosocial elements such as stress management. This global approach is intended to improve cardiovascular risk factors, cardiac function, and work capacity as well as to stabilize the patient psychologically in order to accelerate social integration. Recently these groups have opened towards patients after cardiac transplantation or with severe heart failure. Therefore, cardiac exercise groups play a central role in cardiac rehabilitation long after the acute cardiac event.

Publication Types:

• Review
• Review, tutorial

PMID: 9610223, UI: 98273143

Ned Tijdschr Geneeskd 1998 Jan 24;142(4):195-7

[Circulatory arrest following sulprostone administration in postpartum hemorrhage].

Beerendonk CC, Massuger LF, Lucassen AM, Lerou JG, van den Berg PP

Afd. Obstetrie-Gynaecologie, Academisch Ziekenhuis, Nijmegen.

In a woman aged 39 cardiac arrest occurred 3.5 hours after administration of 250 micrograms sulprostone directly into the uterine wall for a post-partum haemorrhage after manual removal of the placenta. A long period of resuscitation was necessary. After further evaluation the woman demonstrated specific contraindications to the administration of sulprostone. as formulated by the French authorities: age > 35 years, heavy cigarette smoking, and cardiovascular risk factors. In the Netherlands sulprostone is registered for intravenous administration only. We would strongly advise against administration directly into the uterine wall.

PMID: 9557027, UI: 98217775

Angiology 1998 Apr;49(4):275-8

Entering the ninth decade is not a contraindication for carotid endarterectomy.

Hoballah JJ, Nazzal MM, Jacobovicz C, Sharp WJ, Kresowik TF, Corson JD

Department of Surgery, The University of Iowa Hospitals and Clinics, Iowa City 52242-1086, USA.

The role of carotid endarterectomy (CEA) in stroke prevention is now better defined. However, its role in patients older than 79 years of age is controversial. This group of patients has been excluded in most clinical trials. In this study the authors reviewed their experience with CEA patients >79 years old. The records of all patients older than 79 years of age who underwent a CEA in a recent time period from January 1988 to December 1996 were retrospectively reviewed. Forty-one patients (31 men, 10 women) were identified by computer search. The indication for operation included transient ischemic attack in 12 (29.3%), amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical risk factors included coronary artery disease in 26 (63.4%), hypertension in 22 (53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG monitoring in all patients. General anesthesia was administered in 37 (90%) and regional anesthesia in four (10%). Shunts were used in four (10%) patients. The internal carotid artery was patched in 16 patients (39%). One patient (2.4%) developed a perioperative stroke and only one patient developed perioperative myocardial infarction (MI). None of the patients died within 30 days of surgery. In addition to the one MI case, five patients developed minor complications. The average length of time for stay after CEA was 3.4 days. Patients were followed up for an average of 20.7 months. Six patients died during follow-up. Four of those died from an MI and two from a stroke. The authors conclude that with proper selection of patients, CEA is safe in the octogenarian. Age alone should not be a contraindication for CEA.

PMID: 9555930, UI: 98215215

Aust N Z J Med 1997 Aug;27(4):501-3

The current status of thrombolytic therapy.

Aylward P

Flinders Medical Centre, Adelaide, SA.

Fibrinolytic therapy substantially reduces mortality from acute myocardial infarction. Patient selection is, however, important. The patient must present within 12 hours of the onset of ischaemic symptoms, have definite ECG changes of ST elevation or left bundle branch block and no contraindications. The major contraindications are those for risk of an intracerebral bleed, recent stroke, intracranial tumour or risk of a major systemic bleed. Age and hypertension are not contraindications but may modify the regimen used. Heparin is required with recombinant tissue plasminogen activator but is optional with streptokinase. The recent COBALT trial suggests that the accelerated weight related t-PA regimen given over 90 minutes is more satisfactory than double bolus t-PA. However, in patients under 75 years of age, the two regimens were equivalent. For patients suffering acute myocardial infarction, practitioners should now individualise choice of therapy, rather than give the same cocktail to all patients. The choice of regimen will depend on the cardiac risk, the stroke risk, the bleeding risk and the cost.

Publication Types:

• Review
• Review, tutorial

PMID: 9448905, UI: 98110383

Drugs Aging 1997 Dec;11(6):424-32

Postinfarction use of beta-blockers in elderly patients.

Aronow WS

Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, USA.

beta-Adrenoceptor antagonists (beta-blockers) reduce mortality and recurrent myocardial infarction (MI) in older patients after both Q-wave MI and non-Q-wave MI. The effects of beta-blockers are to: (i) reduce complex ventricular arrhythmias, including ventricular tachycardia; (ii) increase the ventricular fibrillation threshold; (iii) reduce myocardial ischaemia; (iv) decrease sympathetic tone; (v) markedly attenuate the circadian variation of complex ventricular arrhythmias: (vi) abolish the circadian variation of myocardial ischaemia; and (vii) abolish the circadian variation of sudden cardiac death or MI. beta-Blockers reduce mortality in patients with MI and complex ventricular arrhythmias. In addition, they are excellent antianginal agents. Older persons with hypertension who have had an MI should be treated initially with a beta-blocker. beta-Blockers reduce mortality in patients with: (i) diabetes mellitus who have had an MI; (ii) MI and congestive heart failure with an abnormal or normal left ventricular ejection fraction; and (iii) MI and an asymptomatic abnormal left ventricular ejection fraction. Severe congestive heart failure, severe peripheral arterial disease with threatening gangrene, greater than first degree atrioventricular block, hypotension, bradycardia, lung disease with bronchospasm, and bronchial asthma are contraindications to treatment with beta-blockers.

Publication Types:

• Review
• Review, tutorial