Submitted in fulfilment of the Master’s Degree in Clinical Technology, Durban University of Technology, 2012. / The sirolimus-eluting stent (Cypher) was the first approved drug- eluting stent by the Food and Drug Administration in April 2003. This is a stent that is based on a bare-metal stent and is coated with a layer of polymer incorporating sirolimus and releasing it by diffusion. Drug-eluting stents reduced risk of restenosis and repeat revascularization as compared with bare-metal stents. Clinical data has raised concerns that drug-eluting stents are associated with late untoward events. Objectives: The objective of this study was to test the hypothesis that stenting is safe and effective treatment for coronary artery disease. Methods and Results: Sirolimus-eluting stenting was performed in 30 patients with 34 coronary lesions. Detailed clinical follow-up data was collected by personal interview or telephone contact at 1, 6, 12 and 24 months. Patients were followed for 2 years for the occurrence of angina and cardiovascular events namely death, myocardial infarction, stent thrombosis and target lesion revascularization. The mean age of the cohort was 62.33±10.99 years; 83 percent were male, 6 percent were diabetic, 53 percent had hypertension. In spite of the overall patient and lesion complexity there were no incidences of major adverse cardiac events and all patients remained angina free out to two years. Dual antiplatelet therapy with aspirin and plavix varied from at least four weeks to one year. One patient had a bleeding event. Conclusions: Treatment of lesions with sirolimus-eluting stents is associated with a sustained clinical benefit two years after device implantation.

M.Cur. (Intensive General Nursing) / The incidence of coronary heart disease is still rising due to man's stressful way of life. Angioplasty is a relatively new procedure used to dilate coronary arteries which have been narrowed by sclerosis. This is seen as the 'instant solution' for a select group of patients with coronary artery sclerosis. It fits in well in the fast paced society. Angioplasty is painful and causes anxiety as the patient is awake during the whole procedure. The goal of the study is to determine the patient's experience during angioplasty and to set guidelines for nurses for the preparation of other patients for angioplasty. The Phenomenological method of interviewing was used for data-collection. Interviews were conducted with 9 participants who had had their first experience of angioplasty. Data was subjected to Phenomenological analysis and verified with suitable literature. The conclusions that were reached were used to set guidelines and make suggestions for the counselling of patients for angioplasty.

Coronary Heart Disease (CETO) is one of the most common causes of mortality in industrialised societies, and it has been demonstrated elsewhere that shift workers have an increased risk of developing CHD compared to day-workers. One possible explanation for this increased risk is that a shift worker may show inappropriate postprandial responses to a night-time meal, when their biological clock is not adapted to the night shift. This could lead to an elevation in the circulating levels of certain hormones and metabolites, such as triacylglycerol (TAG) and insulin, which are known to be risk factors for CHD. This thesis investigated the relationships between meal times and postprandial hormone and metabolic responses in simulated and real-life shift-workers. The work is presented as three major clinical trials. In the first of these, a combination of timed bright light and darkness/sleep was used to induce a gradual 9-hour phase advance in 12 healthy subjects, who then underwent a rapid 9-hour phase delay. Three meal study days were arranged, to occur during the baseline condition, immediately after the rapid phase delay, so that the subjects effectively had "simulated jet lag", and two days later. Blood parameters measured included plasma glucose, insulin, proinsulin, C-peptide, non-esterified fatty acids (NEFA), TAG and glucose- dependent insulinotropic polypeptide (GIP). Substantial differences in plasma TAG and NEFA were observed in the postprandial responses when the subjects consumed an identical meal immediately after the rapid phase delay, compared with during the baseline conditions. Two days after the rapid phase delay, subjects showed inteimediate hormone and metabolite levels, suggesting that the biological clock had a major effect on these postprandial responses. In the second study, day and night-time postprandial responses were compared in a simulated shift work environment, and the effectiveness of a number of potentially beneficial procedures was investigated. These included alterations to the content of the meal consiraied prior to the night shift, bright light exposure during the night shift, and a daytime rest period prior to the night shift. As in the first study, significant differences were seen in a number of hormones and metabolites on the night shift. compared with during the day. The content of the previous meal, bright light exposure and a daytime rest period prior to the night shift all had significant effects on the night-time postprandial responses. The most exciting discovery made was that a single 8-hour night-time bright light exposure significantly lowered the TAG postprandial responses on the simulated night shift. As all the work conducted up until this point had utilised simulated conditions, it was important to illustrate that similar differences in postprandial responses at night-time could be demonstrated in "real-life shift workers". Thus, nine midwives were recruited from the Royal Surrey County Hospital, and studied on four occasions. This allowed comparison of postprandial responses on both day and night shifts, and also allowed further investigation of the effect of altering the content of the previous meal. Significant differences were again found in a number of blood parameters when the night-time and day-time responses to the test meal were compared, with the most striking being a delayed NEFA rise on the night shift, compared with during the day. In conclusion, this series of studies have illustrated that the human body responds differently to a meal consumed at night-time, compared with during the day, both in a simulated and a real-life environment. This results in variations in the levels of a number of known CHD risk factors, and may be linked with the elevated CHD risk reported in shift workers. Alteration to the meal prior to the night shift, exposure to bright light during the night shift, and instituting a rest period prior to the night shift, were all shown to be potentially beneficial in reducing the variation between day and night-time responses.

Dietary-derived lipoproteins, chylomicrons (CM) and CM remnants (CMR), have been implicated in the progression of cardiovascular disease. Retinyl esters are currently the most widely used method for monitoring CM metabolism. The availability, however, of a specific antisera to apo B-48, the protein uniquely associated with dietary-derived lipoproteins, has allowed more extensive investigation of CM and CMR metabolism. The effect of habitual, moderate levels of exercise (3 to 4 exercise sessions a week) on the lipaemic response to meals of varying fat content was assessed in young male subjects. Apo B-48, triacylglycerol (TAG) and retinyl ester were used as markers for CM particles. Active subjects had a lower response than an inactive group in all parameters measured over time after the meals. Lipoprotein lipase (LPL) activity levels measured at the end of the postprandial period were higher in the active group. The area under the time-response curves (AUC) for apo B-48 in the inactive group increased with increasing fat content of the meals, whereas the AUC for apo B-48 was the same after each meal in the active group. Validation of a specific ELISA for apo B-48 was carried out. Cross-reactivity of the antisera with low levels of apo B-100, the protein present on endogenous lipoproteins, was ruled out. The assay was specific and sensitive for measuring apo B-48 concentrations in the CM-enriched fractions. The use of the assay in the current format for plasma samples could not be fully assessed due to difficulties with isolating a pure, concentrated sample of apo B-100 and problems with reactivity between the secondary antibody used in the assay and plasma proteins. The assay was useful for showing postprandial patterns of changes in apo B-48 levels in plasma. The effects of meal frequency on the lipaemic response to a high fat test meal challenge were assessed in an intervention study. A nibbling diet was found to cause differences between the response of various parameters after the meal (NEFA-AUC, LPL activity, infranatant-TAG AUC and time to peak) compared with the normal meal frequency. The size and density distribution of CMR in plasma were investigated. Apo B-48 was found in the IDL and LDL fractions in both the postabsorptive and postprandial states. A comparison between the retinyl ester and apo B-48 responses in the postprandial studies showed that the time to peak retinyl ester level was delayed compared to apo B-48 and TAG. The importance of apo B-48 for studying the metabolism of CM and CMR metabolism was demonstrated.

Coronary heart disease (CHD) has traditionally been regarded as a male disease and, because of this, the magnitude of the problem in women is often overlooked. Yet, cardiovascular disease (CVD) and CHD in particular, remains, next to cancer, the leading cause of morbidity and mortality in women. The longstanding emphasis on the problem of CHD in men, has resulted in a widespread tendency to minimise the incidence and severity of the disease in women. Moreover, most epidemiologic studies examining morbidity and mortality from CHD have focused largely on men, producing a significant gender gap in the research. The lack of information on CHD risk factors and prevention of heart disease in women in Britain is of particular concern, given that British women have one of the highest rates of coronary disease in the world. The Marks and Spencer Coronary Risk Factor Study (MSCRFS) is a cross-sectional and prospective study of CHD risk factors in female employees of the Marks and Spencer retail organisation. The present study is confined to an analysis of cross-sectional data from 14,077 women screened between June 1988 and July 1991. The prevalence and distribution of a variety of lipid, lipoprotein, biochemical, anthropometric and lifestyle-related CHD risk factors among women in the United Kingdom is described, together with their key interrelationships. In addition, the metabolic impact of exogenous hormones, specifically oral contraceptives and postmenopausal hormone replacement, is described. This study - the largest of its kind in the UK - provides reference ranges for a wide range of CHD risk factors in women in the UK, and gives a unique insight into the impact of a variety of lifestyle-related factors on CHD risk. There is an enormous potential for reducing the very high risk of CHD among women in the UK, which needs to be addressed. Based on these data, health strategies designed to reduce morbidity and mortality from CHD can be planned and implemented more effectively.

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