Medscape Cardiology
- Physicians Get Shrinking Slice of Healthcare SpendingPhys... For a privately insured family of 4, spending increased 5% for physician services compared with 7.6% for inpatient care and 8.6% for hospital outpatient care, according to a Milliman study. Medscape Medical News
- So Long, Plavix, What a Ride! Clopidogrel Patent ExpiresS... Expiration of the clopidogrel patent draws a close to a "fascinating era" in cardiovascular medicine, say experts, having had its largest impact in the ACS and poststenting settings. Yet even as the patent expires there remain some unanswered questions, particularly given the emergence of platelet function and genetic testing for clopidogrel metabolism. Heartwire
- Genetic Study Questions HDL Levels and the Risk of MIGene... The data, from a large-scale genetic analysis, throw cold water on the potential clinical benefits of raising HDL-cholesterol levels to reduce the risk of MI, say investigators. Heartwire
- FDA to Review CV Risk With AzithromycinFDA to Review CV R... News Alerts
- Azithromycin May up Chance of Sudden Cardiac DeathAzithro... In an observational study, during a five-day course of azithromycin therapy, patients had a small, increased chance of dying from sudden cardiac death compared with patients taking amoxicillin. The risk of death was higher among patients with the most baseline cardiovascular risk factors. Heartwire
- Coffee Consumption Linked to Lower Risk for Death Coffee ... Data from a prospective study of more than 400,000 people showed that coffee consumption was inversely associated with both total and cause-specific mortality. Medscape Medical News
- Without Warfarin, Watchman Still Prevents StrokesWithout ... Patients with AF implanted with the left atrial appendage occluder in the earlier PROTECT-AF trial took warfarin the first six weeks; but in warfarin-contraindicated patients, Watchman still protects against stroke, suggests an observational study. Heartwire
- Resuscitation Rates in Out-of-Hospital Arrests Are Woeful... Resuscitation rates in out-of hospital cardiac arrest are woefully low, new US research finds, fueled by poor use of bystander CPR and AED employment, which does show some variability according to the race of the victim. But focusing on the "race thing" oversimplifies the problem, say researchers, who also found that AEDs were located too far away from victims in 75% of cases. Heartwire
- Top 10 Cloud-Based EHRsTop 10 Cloud-Based EHRs CureMD is tops among companies that sell EHRs as online software that physicians access solely through a Web browser, says research firm KLAS. Medscape Medical News
- EuroPCR 2012: Congress of the European Association of Per... Read clinically focused news coverage of key developments from the meeting. Medscape Cardiology
Medical News Today Cardiology
- Some "Good" Cholesterol May Be Bad For Heart It appears that in some cases, high-density lipoprotein (HDL) cholesterol, the so-called "good" cholesterol, does not protect against heart disease, and may even be harmful. A new study suggests a subclass of HDL that carries a particular protein is bad for the heart. Previous studies have shown that high levels of HDL cholesterol are strongly linked to low risk of heart disease...
- Rare DNA Variations May Be Responsible For Differences In... One-letter switches in the DNA code occur much more frequently in human genomes than anticipated, but are often only found in one or a few individuals. The abundance of rare variations across the human genome is consistent with the population explosion of the past few thousand years, medical geneticists and evolutionary biologists report in the advanced online edition of Science...
- For Chronic Kidney Disease Patients, One Type Of Open Hea... One type of open heart surgery is likely safer than the other for chronic kidney disease (CKD) patients, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). Open heart, or coronary artery bypass, surgery can be done two ways: on-pump or off-pump, depending on whether the patient is put on a heart-lung machine...
- Running Marathons - Death Risk Low, Higher Among Men In recent years, the popularity of marathons has grown significantly and although the risk of dying during a marathon or soon after is extremely low - about 0.75 per 100,000 - men are two times more likely to die than women, say researchers at John Hopkins University School of Medicine. In addition, the number of individuals to complete grueling 26...
- Improving Palliative Care For Heart Failure Patients Palliative care for cancer patients in the UK is well established - but the situation is starkly different for those suffering from heart failure. A recent service evaluation led by the University of Hull and Hull York Medical School (HYMS) shows this doesn't have to be the case - particularly if clinicians have the courage to talk about death with their patients...
- Controlling Blood Pressure - Team Based Care Vital High blood pressure was listed as a primary or contributing cause of death for approximately 336,000 Americans in 2007. If all patients with high blood pressure were treated to goal as outlined in current clinical guidelines, it is estimated that 46,000 deaths might be averted each year...
- Palpitations May Mean Looming Atrial Fibrillation The European Journal of Preventive Cardiology reveals that the emergence of palpitations is a risk factor for atrial fibrillation (AF). Findings of a large population study reveal the strongest risk factors for atrial fibrillation in both men and women to be a history of palpitations and hypertension...
- Common Antibiotic Found To Carry Heart Risk Vanderbilt researchers have discovered a rare, but important risk posed by the antibiotic azithromycin, commonly called a "Z-pack." The study found a 2.5-fold higher risk of cardiovascular death in the first five days of taking azithromycin when compared with another common antibiotic or no antibiotics at all. Wayne A. Ray, Ph.D., professor of Preventive Medicine, and C. Michael Stein, M.B.Ch...
- Beijing Olympics Air Pollution Change Impacted On People'... A study featured in the May 16 edition of JAMA shows that changes in air pollution during the 2008 Beijing Olympics were related to changes in biomarkers of systemic inflammation and thrombosis, in addition to measure of cardiovascular physiology in healthy young people...
- Large Population Study Fomds Palpitations Predictive Of F... A large cohort study has found that the strongest risk factors for atrial fibrillation in both men and women were a history of palpitations and hypertension. While hypertension is a well known risk factor for AF, the investigators note that "the impact of self-reported palpitations on later occurrence of AF has not been documented earlier"...
theheart.org - trusted cardiology news and opinions
- Aerobic fitness can offset the risks of parental hyperten... Increasing physical activity can offset the risk of developing hypertension in individuals who have a family history of high blood pressure, with moderate and high levels of physical-activity levels... For complete story visit theheart.org.
- One troponin test to identify low-risk patients fast Patients with chest pain account for approximately 10% of ER presentations and 25% of hospital admissions, yet up to 85% do not have a final diagnosis of ACS. A simple strategy of measuring just... For complete story visit theheart.org.
- "Are we downsizing in vain?" Lead size, venous occlusion ... Is it time to rethink the slimming of pacing and ICD leads? Thinner may not be better for a number of reasons, and one of its supposed advantages may be a myth. For complete story visit theheart.org.
- New renal-denervation systems debut amid excitement, caution Renal denervation—poised to depose TAVI as the hottest thing in interventional cardiology—had its own color-coded track in EuroPCR 2012 this year, with debates, live cases,... For complete story visit theheart.org.
- Next-generation transcatheter aortic valve looks good in ... Early registry data on the Sapien XT transcatheter aortic valve presented at the EuroPCR conference show low mortality and complication rates. For complete story visit theheart.org.
- Strokes down in new TAVI analyses Two registries and one meta-analysis presented Thursday at EuroPCR point to 30-day major stroke rates ranging from 1.2% to 2.9% in two of the studies. For complete story visit theheart.org.
- Genetic study questions HDL levels and the risk of MI UPDATED // The data, from a large-scale genetic analysis, throw cold water on the potential clinical benefits of raising HDL-cholesterol levels to reduce the risk of MI, say investigators. For complete story visit theheart.org.
- FDA to review CV risk with azithromycin The agency recently revised the label of an oral-suspension version of the antibiotic to warn about reports of a potentially fatal heart arrhythmia. For complete story visit theheart.org.
- Simple risk score aids carotid-stenting decisions The factors determining a patient's risk during carotid surgery are fairly well-understood, but predicting the risk of carotid stenting patients has so far not been easy, so researchers mined the... For complete story visit theheart.org.
- TAVI numbers rise in Europe as reimbursement, expertise e... New data unveiled at EuroPCR yesterday are offering a fresh snapshot of just how quickly the number of TAVI procedures is increasing in Europe and where these are taking place. For complete story visit theheart.org.
MedPage Today Cardiovascular
- Devices Dominate Guidelines for Heart Failure (CME/CE) (MedPage Today) -- BELGRADE, Serbia -- Lifestyle is out and devices are in for acute and chronic heart failure management, according to a major revision of European guidelines.
- Lab Notes: Sugar Sours Memory, Fish Oil Trumps (MedPage Today) -- Rats fed a sugary diet forgot how to run a maze they had previously mastered, but the effect was countered by omega-3 fatty acid supplements. Also this week: new hope for Fanconi anemia.
- PodMed: A Medical News Roundup from Johns Hopkins (with a... (MedPage Today) -- This week's topics include stress testing after heart procedures, coffee and mortality, air pollution and markers of inflammation, and laxative-free colonoscopy.
- Biodegradable Stents Hold Up (CME/CE) (MedPage Today) -- The next generation of drug-eluting stents that do a disappearing act, whether with a biodegradable polymer or an entirely bioabsorbable platform, appears to be holding up to conventional stents over the short term.
- Diabetic Nerve Damage Linked to Metabolic Factors (CME/CE) (MedPage Today) -- Targeting the various aspects of the metabolic syndrome may provide a means for preventing the development of diabetic neuropathy, authors of a review suggested.
- 'Parachute' Promising for Heart Failure (CME/CE) PARIS (MedPage Today) -- A percutaneous device that walls off part of the left ventricle to help failing hearts appears to have a big impact on outcomes, pilot study results showed.
- Glitazones Take New Hit for Bladder Ca Risk CHICAGO (MedPage Today) -- British patients followed after starting on glitazone drugs for type 2 diabetes were significantly more likely to develop bladder cancer than those taking sulfonylurea agents.
- Nerve Ablation Safely Lowers BP in CKD (CME/CE) (MedPage Today) -- Catheter-based renal nerve ablation helps lower resistant hypertension, but now researchers have found that it works as well in those with chronic kidney disease, a pilot study showed.
- Bigger BP Drop Goal for Renal Denervation (CME/CE) PARIS (MedPage Today) -- More dramatic blood pressure reductions may be on the horizon for patients with resistant hypertension given the phalanx of renal denervation systems under development.
- Heart Is Focus for Hypertension Meeting NEW YORK CITY (MedPage Today) -- Hypertension specialists will take a closer look at the connection between high blood pressure and the cardiovascular system at this year's meeting of the American Society of Hypertension here, according to the chair of the scientific program committee.
NEJM Cardiology
- Warfarin in Heart Failure Despite major advances in the management of heart failure with angiotensin-converting–enzyme inhibitors, beta-blockers, and resynchronization therapy, there are more than 1 million hospitalizations for heart failure in the United States each year, and mortality remains high. As compared with the…
- Warfarin and Aspirin in Patients with Heart Failure and S... Chronic heart failure is a major cause of illness and death. Heart failure is associated with a hypercoagulable state, formation of left ventricular thrombus, and cerebral embolism. It is also associated with both sudden death and death resulting from progressive heart failure that may be caused by…
- Secondary Prevention after Ischemic Stroke or Transient I... Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations. Stage. A 62-year-old…
- Azithromycin and the Risk of Cardiovascular Death Azithromycin, a broad-spectrum macrolide antibiotic, has been reported to be relatively free of cardiotoxic effects. However, the closely related drugs erythromycin and clarithromycin can increase the risk of serious ventricular arrhythmias– and are associated with an increased risk of sudden…
- Statins: Is It Really Time to Reassess Benefits and Risks? No drug provides health benefits without some degree of risk, and risk–benefit assessments require ongoing review as new data become available. This is certainly the case for the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors — statins — and the risk of new-onset…
- An Electrocardiographic Sine Wave in Hyperkalemia Figure 1.
- Percutaneous Coronary Interventions without On-Site Cardi... Certification to perform catheter-based interventions for coronary artery disease was originally limited to hospitals that had the capability to perform cardiac surgery on site. However, there has been a progressive worldwide trend to allow percutaneous coronary intervention (PCI) to be performed…
- Outcomes of PCI at Hospitals with or without On-Site Card... The potential need for emergency cardiac surgery to treat complications related to percutaneous coronary intervention (PCI) suggests that performance of PCI may be best limited to hospitals with on-site cardiac surgery. Among Grüntzig's first 50 PCI procedures, 10% of patients required emergency…
- Transcatheter Aortic-Valve Replacement for Inoperable Sev... Symptomatic aortic stenosis, if left untreated, is characterized by a high risk of death.– In the randomized Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter aortic-valve replacement (TAVR), as compared with standard therapy, in patients who were not considered to be…
- The Monocyte in Atherosclerosis — Should I Stay or Shou... Generations of evolutionary pressure have honed a human immune system that is well poised to combat infectious challenges. However, the very same system can turn against us when it is activated by certain noxious stimuli, as is the case with cholesterol-laden meals triggering atherosclerosis.…
Topix Cardiology
- Plant City cardiologist leads monthly health walks Once a month, he accompanies his patients, employees and anyone else who cares to join in on a walk through Aldermans Ford Park.
- UMMC welcomes cardiologist Myrna Ellen Alexander Nickens, the first female interventional cardiologist in Mississippi, has joined the University of Mississippi Medical Center faculty as an associate professor of medicine.
- Straight from the heart When cardiologist Dr Arintaya Phrommintikul is not teaching or tending to patients, she's busy looking for more ways to save lives There's an air of satisfaction in the quiet laboratory at Chiang Mai University's Faculty of Medicine, where cardiologist Dr Arintaya Phrommintikul spends much of her time doing a great deal of life-saving but largely ... (more)
- 1,000 participate in mass CPR training session SINGAPORE: Some 1,000 participants from schools and other organisations came together for a mass cardio-pulmonary resuscitation training session at Pasir Ris on Saturday.
- Investing in staff to secure future of sick children Even in the hands of highly skilled surgeons and nurses, this is a life-or-death situation and anything less than optimum staffing levels risks being unsafe.
- Cardiac centre launched MIOT Heart Revive Centre, inaugurated on Friday aims to address the elements critical to reviving the heart, said Prof Dr PVA Mohandas, managing director of the hospital.
- Top honor to cardiologist for advancing heart transplant ... That was the challenge taking shape by the mid-1970s, when Sharon Hunt , MD, was a cardiology fellow at Stanford Hospital .
- Viagra may benefit young patients with heart defects Sildenafil, also known as the erectile dysfunction drug Viagra, may give a boost to underdeveloped hearts in children and young adults with congenital heart defects.
- Barry Stone How inspectors examine your home Q. I don't understand how a home inspector who is not an electrician can evaluate an electrical system; who is not a plumber can evaluate a plumbing system; who is not an HVAC contractor can evaluate a furnace.
- CardioKinetix Announces Positive Two-Year Clinical Data f... CardioKinetix Inc., a medical device company pioneering a catheter-based treatment for heart failure, today announced two-year clinical results for the first-of-its-kind catheter-based Parachute Ventricular Partitioning Device, a Percutaneous Ventricular Restoration therapy for patients with ischemic heart failure.
theheart.org blogs
- FAME or COURAGE: Can we have both? Heartfelt with Dr Melissa Walton-Shirley - Cardiologist, Dr Melissa Walton-Shirley, brings a practice-focused perspective to the major cardiology news and the overlooked cardiology gems.
- Semuloparin for VTE prophylaxis in cancer chemotherapy pa... It's believed that cancer cells secrete prothrombotic substances and known that chemotherapeutic agents are also prothrombotic—so how do we prevent VTE in cancer patients?
- Is dabigatran an appropriate periprocedural anticoagulant... Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- Has AF ablation reached first-line status? Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- Joint PACES/HRS expert consensus statement offers guidanc... Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- HRS 2012 poster highlights: ECGs, PVCs, OSA, Debates in A... Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- Riata lead safety alert at HRS 2012 Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- Turning the AF ablation world upside down--FIRM ablation Trials and Fibrillations with Dr John Mandrola - Dr John Mandrola—electrophysiologist, competitive biker, blogger, and teacher—shares his thoughts on the world of electrophysiology and arrhythmias.
- Choosing wisely for interventionalists: Seth Bilazarian's... FFR, BMS, complete angiography, complete revascularization, radial approach, best patient care, save healthcare dollars, Seth Bilazarian
- "Consent the stent" campaign--long overdue! Heartfelt with Dr Melissa Walton-Shirley - Cardiologist, Dr Melissa Walton-Shirley, brings a practice-focused perspective to the major cardiology news and the overlooked cardiology gems.
Preventive Cardiology
- CLINICAL STUDY: Associations Among Cardiometabolic Risk F... Prev Cardiol. ****;**:**–**.It has been suggested that within the traditional body mass index (BMI) categories there is a heterogeneous pattern of cardiometabolic risk factor clustering. The objective of this research was to determine the associations among obesity, cardiometabolic abnormalities, and cardiovascular disease (CVD) in a large population-based study of Appalachian adults. The study comprised a cross-sectional survey of Appalachian adults residing in 6 communities in Ohio and West Virginia, who were aged 18 years and older (n=14,783, 50.9% women). The authors categorized BMI into normal weight (5.13), or elevated C-reactive protein (>3 mg/L). They found that 25.6% of normal-weight adults displayed clustering of ≥2 cardiometabolic abnormalities; in contrast, 36.8% of overweight/obese adults displayed no clustering. Compared with normal-weight persons without clustering of cardiometabolic abnormalities (referent), the odds ratio of CVD was 1.06 (95% confidence interval [CI], 0.84–1.34) among overweight/obese individuals without cardiometabolic clustering, 2.21 (95% CI, 1.74–2.81) among normal-weight individuals with cardiometabolic clustering, and 2.45 (95% CI, 2.02–2.97) among overweight/obese individuals with cardiometabolic clustering. These results suggest that within the traditional BMI categories, there may be heterogeneity of CVD risk depending on whether there is underlying clustering of cardiometabolic abnormalities.
- Should We Focus on Novel Risk Markers and Screening Tests...
- Should We Focus on Novel Risk Markers and Screening Tests... Editor’s Note: The following Point/Counterpoint articles were derived from a debate presentation sponsored by the American Society for Preventive Cardiology at the March 2010 meeting of the American Heart Association Council on Epidemiology and Prevention, titled “Should We Focus on Novel Risk Marker and Screening Tests to Better Predict and Prevent Cardiovascular Disease?” Dr. James de Lemos presented the pro side, titled “Novel Risk Markers and Screening Tests Will Improve the Prediction and Prevention of Cardiovascular Disease,” and Dr. Donald Lloyd-Jones advocated the con side, titled “Better Implementation of Existing Knowledge Will Save More Lives Than All of the Novel Biomarkers in the World.” The following articles include points from the debate, rebuttal, and questions raised by the audience. We thank all authors for sharing this debate with the readership.
- Biomarkers for Coronary Heart Disease Clinical Risk Predi... Editor’s Note: The following Point/Counterpoint articles were derived from a debate presentation sponsored by the American Society for Preventive Cardiology at the March 2010 meeting of the American Heart Association Council on Epidemiology and Prevention, titled “Should We Focus on Novel Risk Marker and Screening Tests to Better Predict and Prevent Cardiovascular Disease?” Dr. James de Lemos presented the pro side, titled “Novel Risk Markers and Screening Tests Will Improve the Prediction and PRevention of Cardiovascular Disease,” and Dr. Donald Lloyd-Jones advocated the con side, titled “Better Implementation of Existing Knowledge Will Save More Lives Than All of the Novel Biomarkers in the World.” The following articles include points from the debate, rebuttal, and questions raised by the audience. We thank all authors for sharing this debate with the readership.
- Risk Factors for Subclinical Carotid Atherosclerosis Amon... This study characterized the determinants of carotid atherosclerosis in a large contemporary sample of current smokers. Associations between risk factors, carotid intima-media thickness (CIMT), and carotid plaque presence were determined by multivariable regression. Participants included 1504 current smokers (58% female) who were a median (interquartile range) of 44.7 (38–53) years old and smoked 25 (15–40) pack-years; 55% had plaque. Pack-years, age, male sex, nonwhite race, body mass index, systolic blood pressure, small low-density lipoproteins (LDLs), and total high-density lipoproteins were independently associated with CIMT (model R2=0.434, P<.001). Pack-years (odds ratio [OR], 1.14 per 10 pack-years; P=.001), age (OR, 1.75 per 10 years; P<.001), body mass index (OR, 0.91 per 5 kg/m2; P=.035), and small LDLs (OR, 1.11 per 100 nmol/L; P<.001) were independently associated with carotid plaque presence (model χ2=210.7, P<.001). The association between pack-years and carotid plaque was stronger in women (OR, 1.09 per 10 pack-years, Pinteraction=.018).Prev Cardiol. 2010;13:166–171.©2010 Wiley Periodicals, Inc.
- Association of Warfarin Use With CHADS2 Score in 441 Pati... The authors investigated the use of warfarin at hospital discharge in 557 consecutive patients, mean age 76 years, with nonvalvular atrial fibrillation (AF) at a university hospital. Of 557 patients with AF, 116 (21%) had contraindications to warfarin. Of patients eligible for warfarin, warfarin was used in 8 of 30 patients (27%) with a CHADS2 score of 0, in 82 of 132 patients (62%) with a CHADS2 score of 1, in 121 of 175 patients (70%) with a CHADS2 score of 2, in 72 of 77 patients (94%) with a CHADS2 score of 3, and in 27 of 27 patients (100%) with a CHADS2 score of 4 to 6. Warfarin was used in 123 of 168 patients (73%) older than 75 years, in 74 of 79 patients (94%) aged 65 to 75 years, and in 23 of 32 patients (72%) younger than 65 years. Warfarin was used in 80 of 116 patients (69%) with a glomerular filtration rate <60 mL/min/1.73 m2 and in 140 of 163 patients (86%) with a glomerular filtration rate ≥60 mL/min/1.73 m2. There was no significant difference in use of warfarin between men and women and between whites and nonwhites.Prev Cardiol. 2010;13:172–174.©2010 Wiley Periodicals, Inc.
- Is Acute High-Dose Secondhand Smoke Exposure Always Harmf... Prev Cardiol.Long-term exposure to secondhand smoke (SHS) is associated with impaired vascular function. The authors investigated the vascular and blood pressure (BP) reactions to acute SHS exposure. Twenty-five healthy nonsmoking adults underwent a 1-hour exposure to SHS (mean fine particulate matter <2.5 μm level=315±116 μg/m3). Microvascular endothelial-dependent vasodilatation (EDV) (EndoPAT, Itamar Medical, Caesarea, Israel) and aortic hemodynamics/compliance (SphygmoCor, AtCor Medical, West Ryde, Australia) were measured before and after the SHS exposure with BP measured every 15 minutes during and for a 24-hour period before and after the exposure. SHS exposure did not change EDV, aortic hemodynamics, arterial compliance, or 24-hour BP. However, diastolic BP significantly increased during the SHS exposure period by 3.4±5.6 mm Hg. Our brief SHS exposure did not impair microvascular endothelial function or arterial compliance in healthy nonsmoking adults, but brachial diastolic BP increased.Prev Cardiol. 2010;13:175–179.©2010 Wiley Periodicals, Inc.
- Patient-Related Diet and Exercise Counseling: Do Provider... The goal of this research was to evaluate the personal health behaviors of physicians in training and attending physicians in association with patient-related lifestyle counseling. Physicians at a major teaching hospital were surveyed regarding their personal lifestyle behavior, perceived confidence, and frequency of counseling patients regarding lifestyle behaviors. One hundred eighty-three total responses were received. Trainees were more likely to consume fast food and less likely to consume fruits and vegetables than attendings. Attending physicians were more likely to exercise 4 or more days per week and more than 150 minutes per week. Attending physicians were more likely to counsel their patients regarding a healthy diet (70.7% vs 36.3%, P150 minutes per week, being overweight, and reported adequate training in counseling. Only adequate training in counseling was a predictor of strong self-efficacy for counseling in diet. Many physicians lack confidence in their ability to counsel patients regarding lifestyle. Personal behaviors including regular exercise and better training in counseling techniques may improve patient counseling.Prev Cardiol. 2010;13:180–185.©2010 Wiley Periodicals, Inc.
- Subclinical Atherosclerosis: Evolving Role of Carotid Int... Cardiovascular risk factors have utility in risk prediction but have limitations in predicting individual risk. Identifying an individual’s risk remains a challenge. Emerging technologies such as carotid artery ultrasonography and measures of carotid intima-media thickness (CIMT) may be useful in identifying the susceptible patient who may benefit from more aggressive preventive therapy. This screening test is noninvasive, reproducible, inexpensive, and radiation-free. Recent data have improved our understanding of the application of CIMT as a screening tool for cardiovascular disease. CIMT measurement may place an individual into a higher- or lower-risk category, allowing for appropriate institution of preventive strategies.Prev Cardiol. 2010;13:186–197.©2010 Wiley Periodicals, Inc.
- Will Increasing Referral to Cardiac Rehabilitation Improv...
Cardiology Network Forum
- Is America Prospective For Trained Cardiologist? I am a Bangladeshi trained cardiologist. Recently I became successful at finding a residency position in America. I am curious to know, is America prospective for trained cardiologist?
- Cardiologists still earning big bucks, but work frustrati... US cardiologists earned an average of $314 000 in 2011, with the highest earners being cardiologists working in a single-specialty group practice, results from a new physician compensation survey reveal. For these physicians, their average annual salary was $388 000. Despite the numbers, 54% of cardiologists felt they were inadequately compensated, and only 13% considered themselves wealthy. Nearly four in 10 cardiologists said their income is no better than nonphysicians, while 50% said…
- Cardiologists Are Happy(ish), Married Non-Tweeters, Surve... Cardiologists, for the most part, drive Japanese cars, believe in a higher power, and are moderately savvy when it comes to social media. Those are just some of the pearls from a lifestyle survey of physicians conducted by Medscape and published online today. Asked to rank their level of happiness outside of their work on a scale of 1 to 5, the 762 cardiologists who replied to the survey provided an average happiness score of 3.92. That puts them 15th out of the 25 specialties…
- Yale Researcher, Harlan Krumholtz, MD recommends to throw... I absolutely agree w Dr. Krumholz....the lipid theory of atherogenesis is invalid and the treatment guidelines are unsubstantiated now.....lowering VLDL & LDL does not decrease morbidity or mortality. Infection by CNPs (aka Nanobacteria) is the cause of CAD.....it meets all criteria for the endovascular research development of CAD/Heart Disease: They cause pathological calcification, their LPS endotoxin causes inflammation and secondary deposition of Beta-amyloid soft plaque....and CNPs…
- Impact of Changes in Resuscitation Practice on Survival a... Background—Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/tachycardia) improved in several communities after implementing American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Non-shockable" rhythms are now the predominant presentation of OHCA, upon which the benefit of such treatments is…
- Outcomes of PCI at Hospitals with or without On-Site Card... Background Performance of percutaneous coronary intervention (PCI) is usually restricted to hospitals with cardiac surgery on site. We conducted a noninferiority trial to compare the outcomes of PCI performed at hospitals without and those with on-site cardiac surgery. Full Text of Background...…
- Bariatric Surgery versus Intensive Medical Therapy in Obe... Background Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery. Full Text of Background... Methods In this randomized, nonblinded, single-center…
- AED Trainer for iPad Dear colleagues, I wanted to introduce to you a new medical app, which was published recently in the iTunes store by my company Ivor Medical - http://www.ivormedical.com. The app is called AED Trainer and is available for the iPad tablet - http://ivormedical.com/products/aed-trainer-app/The app turns the iPad into a simulator of automatic external defibrillator (AED) with…
- Check Hemoglobin without Pricking Anemia is a major -- and completely preventable -- cause of deaths in childbirth in many places around the world, but the standard test is invasive and slow. In this witty and inspiring talk, TED Fellow Myshkin Ingawale describes how (after 32 tries) he and his team created a simple, portable, low-cost device that can test for anemia without breaking the skin. Myshkin Ingawale is the co-founder of Biosense Technologies, which has built ToucHB, a portable,…
- Five Things You Need To Know When Deciding On A Cholester... Recent news has caused millions of Americans to question whether they should be taking statin drugs, used for lowering cholesterol and preventing heart disease. The Food and Drug Administration (FDA) recently announced safety labeling changes for statins and a prominent cardiologist warned in the New York Times that too many people are taking statin drugs. The concerns affect many people since these blockbuster drugs are practically ubiquitous. Government studies indicate that there…
Cardiology Network Blog Posts
- Deaths Caused By the Failure of Riata and Riata ST Implan... Abstract Background: Riata and Riata ST leads (St. Jude Medical, CA) were recalled in 2011. These leads are prone to externalized conductors. However, it is electrical malfunctions, which may result in serious adverse events, including death. Objective: The purpose of this study was to assess the deaths of Riata and Riata ST patients that have been reported to the FDA in order to determine if they were due to lead malfunction. A similar analysis was…
- CT Angiography for Safe Discharge of Patients with Possib... Background Admission rates among patients presenting to emergency departments with possible acute coronary syndromes are high, although for most of these patients, the symptoms are ultimately found not to have a cardiac cause. Coronary computed tomographic angiography (CCTA) has a very high negative predictive value for the detection of coronary disease, but its usefulness in determining whether discharge of patients from the emergency…
- Infection as the Reversible Cause of Arteriosclerosis ~From AHA Cardiology blog "The Heart": Shouldering the Risk Burden: Infection as the Reversible Cause of Arteriosclerosis Read this article in CIRCULATION:http://circ.ahajournals.org/content/107/11/e74.full.pdf Then read the outcome of the study mentioned here:…
- Cardiome Provides Update on Merck's Development Plans for... Vancouver, Canada, March 19th, 2012 -- Cardiome Pharma Corp. (NASDAQ: CRME / TSX: COM) today announced that Merck, known as MSD outside the United States and Canada, has communicated to Cardiome their decision to discontinue further development of the oral formulation of vernakalant. The decision was based on Merck’s assessment of the regulatory environment and projected development timeline. Vernakalant oral was being evaluated as maintenance therapy for the long term…
- Red Meat Consumption and Mortality Background Red meat consumption has been associated with an increased risk of chronic diseases. However, its relationship with mortality remains uncertain. Methods We prospectively observed 37 698 men from the Health Professionals Follow-up Study (1986-2008) and 83 644 women from the Nurses' Health Study (1980-2008) who were free of…
- Segmental Approach to Imaging of Congenital Heart Disease
- FDA Drug Safety Communication: Interactions between certa... [3-01-2012] The U.S. Food and Drug Administration (FDA) is issuing updated recommendations concerning drug-drug interactions between drugs for human immunodeficiency virus (HIV) or hepatitis C virus (HCV) known as protease inhibitors and certain cholesterol-lowering drugs known as statins. Protease inhibitors and statins taken together may raise the blood levels of statins and increase the risk for muscle injury (myopathy). The most serious form of myopathy, called…
- Association of Age and Sex With Myocardial Infarction Sym... Context Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. Objective To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after…
- Do you Know Your Numbers Please check above page on Face book for updates on High Blood Pressure and Cardiovascular Prevention updates.
- A Treatable CNP infection leads to development of Patholo... http://newmedia.ufm.edu/maniscalconanobacterium Our principal cardiology investigator, Benedict Maniscalco, MD, FACC in a lecture on the development of pathological calcification in CAD. Dr. Maniscalco was the lead investigator for my NanobacTX clinical trial some years ago....the study was published in a cardiology journal. Please feel free to email me if any questions: info@nanobiotech.us or visit…
HeartLinx News
- The acute haemodynamic effect of nebulised frusemide in s... Heart, Lung, and Circulation
- Depression and anxiety are associated with a diagnosis of... Journal of Human Hypertension
- Does nutrition education improve the risk factors of card... Journal of Diabetes
- Additive renoprotective effects of aliskiren on angiotens... Hypertension Research
- Comparative study on safety, efficacy, and midterm result... Catheterization and Cardiovascular Interventions
- Combination of Copeptin and Troponin Assays to Rapidly Ru... Academic Emergency Medicine
- Comparative effect of angiotensin II type I receptor bloc... Cardiovascular Diabetology
- Management of non-ST-segment elevation acute coronary syn... Critical Pathways in Cardiology
- A guidance pathway for the selection of novel anticoagula... Critical Pathways in Cardiology
- Electrophysiology Procedures in Adults with Congenital He... Congenital Heart Disease
Nature Reviews Cardiology
- Hypertension: Tackling challenges in the diagnosis and ma... Despite the availability of multiple pharmacotherapies and the known preventative effects of lifestyle modification, hypertension remains a highly prevalent disorder worldwide. Indeed, high blood pressure (BP) is estimated to result in approximately half of the global burden of all cardiovascular disease (WHO. Global health
- Vascular disease: Corticosteroid therapy improves outcome... Results from a ground-breaking study published in the Lancet show that the addition of prednisolone to primary immunoglobulin therapy reduces the incidence of coronary artery defects in patients with severe Kawasaki disease. “Many pediatricians have hesitated to use corticosteroids for Kawasaki disease,” explains first
- Hypertension: Cardiac effects of renal denervation Renal sympathetic denervation (RSD) improves cardiac function in patients with resistant hypertension. “Besides the known effect on blood pressure [BP],” claim the investigators, “our study showed for the first time that RSD significantly reduces left ventricular [LV] mass and improves diastolic function.”BP elevation and
- Coronary artery disease: Stents should not precede optima... A new meta-analysis of eight randomized, controlled trials (RCTs) has confirmed that percutaneous coronary intervention (PCI) should not be the first treatment option pursued in patients with stable coronary artery disease (CAD). Initial stent implantation was shown to provide no benefit over optimal medical therapy
- Pharmacotherapy: Elevating HDL-cholesterol levels with da... Statins effectively lower LDL-cholesterol levels, but residual cardiovascular risk remains, particularly in patients with low levels of HDL cholesterol. Inhibition of the cholesteryl ester transfer protein (CETP) with torcetrapib successfully elevated HDL-cholesterol levels, but unexpectedly increased cardiovascular morbidity and mortality. Dalcetrapib is a novel CETP
- Acute coronary syndromes: High uric acid levels predict m... “Elevated levels of uric acid predict an increased risk of 1-year mortality across the whole spectrum of patients with acute coronary syndrome (ACS),” suggests Gjin Ndrepepa, the lead investigator in a new study published in the American Journal of Cardiology.The team from the
- Hypertension: Impact of having 'Prehypertension' Approximately one-third of the Japanese population is estimated to have blood pressure (BP) within the range 120–139/80–89 mmHg, a condition known as prehypertension. However, as Dr. Hisatomi Arima explains, “there has been uncertainty surrounding the effects of the lower range of prehypertension (or 'normal BP'
- Antiplatelet therapy: Intracoronary abciximab during PCI ... Antiplatelet therapy with the glycoprotein IIb/IIIa inhibitor abciximab in patients with an acute ST-segment elevation myocardial infarction (STEMI) who are undergoing revascularization by a percutaneous coronary intervention (PCI) improves coronary microcirculation and reduces major adverse events in particular high-risk patients. The results of the AIDA
- Prevention: Cost-effectiveness of cardiovascular disease ... A team of researchers in collaboration with the WHO has identified a set of interventions for the prevention and management of cardiovascular disease (CVD) that are cost-effective in two developing regions—sub-Saharan Africa and South-East Asia.Noncommunicable diseases, such as CVD, represent a grave public health
- Acute coronary syndromes: Challenging accepted post-MI se... On the basis of high-quality observational data, Goyal et al. have found that serum potassium levels <3.5 mmol/l or ≥4.5 mmol/l are associated with increased in-hospital mortality in patients with acute myocardial infarction. We discuss whether target potassium levels in clinical practice and guidelines should be changed to 3.5–4.5 mmol/l.
The Lancet Cardiology
- [Articles] Apixaban compared with warfarin in patients wi... The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population.
- [Comment] Statins for all by the age of 50 years? In The Lancet, the Cholesterol Treatment Trialists' (CTT) Collaborators report a relative risk reduction on statins of about 20% (RR 0.79, 95% CI 0.77–0.81) for major vascular events per 1 mmol/L reduction in LDL cholesterol across different levels of cardiovascular risk. Men and women, old and young, and people with and without cardiovascular disease all benefit. These findings confirm the efficacy of statins for primary prevention, resolving concerns about possible serious adverse effects and potential sources of bias in randomised trials.
- [Comment] Mendelian randomisation, lipids, and cardiovasc... In The Lancet, Benjamin Voight and colleagues use mendelian randomisation analysis to investigate the relation between HDL cholesterol and coronary heart disease. High HDL cholesterol concentration is associated with reduced risk of coronary heart disease in observational studies, but whether the association is causal cannot be unequivocally ascertained from these studies alone, and whether raising of HDL cholesterol would be an effective means to reduce risk of coronary heart disease remains uncertain.
- [Articles] Plasma HDL cholesterol and risk of myocardial ... Some genetic mechanisms that raise plasma HDL cholesterol do not seem to lower risk of myocardial infarction. These data challenge the concept that raising of plasma HDL cholesterol will uniformly translate into reductions in risk of myocardial infarction.
- [Articles] The effects of lowering LDL cholesterol with s... In individuals with 5-year risk of major vascular events lower than 10%, each 1 mmol/L reduction in LDL cholesterol produced an absolute reduction in major vascular events of about 11 per 1000 over 5 years. This benefit greatly exceeds any known hazards of statin therapy. Under present guidelines, such individuals would not typically be regarded as suitable for LDL-lowering statin therapy. The present report suggests, therefore, that these guidelines might need to be reconsidered.
- [Comment] Verbal-autopsy-based projection of cancer death... Complete information about causes of deaths is valuable for planning and implementation of effective public health services. However, a civil registration system (CRS) of deaths is far from complete in many countries, including India. Only half the estimated 9·8 million deaths annually are captured by the CRS and fewer than 4% are medically certified in India, where more than three-quarters of deaths occur at home. The Sample Registration System (SRS) has become an alternative method to generate reliable data for births and deaths.
- [Articles] Cancer mortality in India: a nationally repres... Prevention of tobacco-related and cervical cancers and earlier detection of treatable cancers would reduce cancer deaths in India, particularly in the rural areas that are underserved by cancer services. The substantial variation in cancer rates in India suggests other risk factors or causative agents that remain to be discovered.
- [Comment] Global child survival: beyond numbers The remarkable progress made over the past decade in reducing the burden of child mortality is commendable. From an estimated annual child mortality rate of 10 million in 2000, now corrected to 9·6 million deaths, Li Liu and colleagues' study in The Lancet suggests that there are 2·0–2·4 million fewer deaths ever year, with major reductions in the number of deaths from diarrhoea, pneumonia, and measles. Differences in methodological approaches aside, the overall figures for child mortality are similar to those published last year by Lozano and colleagues.
- [Articles] Global, regional, and national causes of child... Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010–15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates.
- [Comment] The Millennium Villages project The poverty in which a large proportion of the world's population lives and the consequent unnecessary deaths of over 7 million children every year are scandals of our age. In 2000, global heads of state reached agreement on the Millennium Development Goals; how to reach, or even to approach, these goals has been the subject of much advice, debate, and effort since, with so far only partial success.
Journal of American College of Cardiology
- Inside This Issue
- Quadruple Valve Replacement: Visualization With 256-Slice...
- The Year in Cardiac Imaging
- Temporal Trends in and Factors Associated With Bleeding C... Objectives The purpose of this study was to examine temporal trends in post-percutaneous coronary intervention (PCI) bleeding among patients with elective PCI, unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Background The impact of bleeding avoidance strategies on post-PCI bleeding rates over time is unknown. Methods Using the CathPCI Registry, we examined temporal trends in post-PCI bleeding from 2005 to 2009 among patients with elective PCI (n = 599,524), UA/NSTEMI (n = 836,103), and STEMI (n = 267,632). We quantified the linear time trend in bleeding using 3 sequential logistic regression models: 1) clinical factors; 2) clinical + vascular access strategies (femoral vs. radial, use of closure devices); and 3) clinical, vascular strategies + antithrombotic treatments (anticoagulant ± glycoprotein IIb/IIIa inhibitor [GPI]). Changes in the odds ratio for time trend in bleeding were compared using bootstrapping and converted to risk ratio. Results An approximate 20% reduction in post-PCI bleeding was seen (elective PCI: 1.4% to 1.1%; UA/NSTEMI: 2.3% to 1.8; STEMI: 4.9% to 4.5%). Radial approach remained low (<3%), and closure device use increased marginally from 44% to 49%. Bivalirudin use increased (17% to 30%), whereas any heparin + GPI decreased (41% to 28%). There was a significant 6% to 8% per year reduction in annual bleeding risk in UA/NSTEMI and elective PCI, but not in STEMI. Antithrombotic strategies were associated with roughly half of the reduction in annual bleeding risk: change in risk ratio from 7.5% to 4% for elective PCI, and 5.7% to 2.8% for UA/NSTEMI (both p <0.001). Conclusions The nearly 20% reduction in post-PCI bleeding over time was largely due to temporal changes in antithrombotic strategies. Further reductions in bleeding complications may be possible as bleeding avoidance strategies evolve, especially in STEMI.
- Appropriateness of Coronary Revascularization for Patient... Objectives The purpose of this study was to determine appropriateness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery performed in New York for patients without acute coronary syndrome (ACS) or previous CABG surgery. Background The American College of Cardiology Foundation (ACCF) and 6 other societies recently published joint appropriateness criteria for coronary revascularization. Methods Data from patients who underwent CABG surgery and PCI without acute coronary syndrome or previous CABG surgery in New York in 2009 and 2010 were used to assess appropriateness and to examine the variation across hospitals in inappropriateness ratings. Results Of the 8,168 patients undergoing CABG surgery in New York without ACS/prior CABG who could be rated, 90.0% were appropriate for revascularization, 1.1% were inappropriate, and 8.6% were uncertain. Of the 33,970 PCI patients eligible for rating, 28% lacked sufficient information to be rated. Of the patients who could be rated, 36.1% were appropriate, 14.3% were inappropriate, and 49.6% were uncertain. A total of 91% of the patients undergoing PCI who were classified as inappropriate had 1- or 2-vessel disease without proximal left anterior descending artery disease and had no or minimal anti-ischemic medical therapy. Conclusions For patients without ACS/prior CABG, only 1% of patients undergoing CABG surgery who could be rated were found to be inappropriate for the procedure according to the ACCF appropriateness criteria, but 14% of the PCI patients who could be rated were found to be inappropriate, and 28% lacked enough noninvasive test information to be rated.
- The Need to Improve the Appropriate Use of Coronary Revas...
- Impact of Coronary Plaque Composition on Cardiac Troponin... Objectives The authors used multidetector computed tomography (MDCT) to study the relation between culprit plaque characteristics and cardiac troponin T (cTnT) elevation after percutaneous coronary intervention (PCI). Background Percutaneous coronary intervention is often complicated by post-procedural myocardial necrosis manifested by elevated cardiac biomarkers. Methods Stable angina patients (n = 107) with normal pre-PCI cTnT levels underwent 64-slice MDCT before PCI to evaluate plaque characteristics of culprit lesions. Patients were divided into 2 groups according to presence (group I, n = 36) or absence (group II, n = 71) of post-PCI cTnT elevation ≥3 times the upper limit of normal (0.010 ng/ml) at 24 h after PCI. Results Computed tomography attenuation values were significantly lower in group I than in group II (43.0 [26.5 to 75.7] HU vs. 94.0 [65.0 to 109.0] HU, p < 0.001). Remodeling index was significantly greater in group I than in group II (1.20 ± 0.18 vs. 1.04 ± 0.15, p < 0.001). Spotty calcification was observed significantly more frequently in group I than in group II (50% vs. 11%, p < 0.001). Multivariate analysis showed presence of positive remodeling (remodeling index >1.05; odds ratio: 4.54; 95% confidence interval: 1.36 to 15.9; p = 0.014) and spotty calcification (odds ratio: 4.27; 95% confidence interval: 1.30 to 14.8; p = 0.016) were statistically significant independent predictors for cTnT elevation. For prediction of cTnT elevation, the presence of all 3 variables (CT attenuation value <55 HU; remodeling index >1.05, and spotty calcification) showed a high positive predictive value of 94%, and their absence showed a high negative predictive value of 90%. Conclusions MDCT may be useful in detecting which lesions are at high risk for myocardial necrosis after PCI.
- Predicting Periprocedural Myocardial Infarction: Target-L...
- Sudden Cardiac Death in Patients With Human Immunodeficie... Objectives The aim of this study was to determine the incidence and clinical characteristics of sudden cardiac death (SCD) in patients with human immunodeficiency virus (HIV) infection. Background As the HIV-infected population ages, cardiovascular disease prevalence and mortality are increasing, but the incidence and features of SCD have not yet been described. Methods The records of 2,860 consecutive patients in a public HIV clinic in San Francisco between April 2000 and August 2009 were examined. Identification of deaths, causes of death, and clinical characteristics were obtained by search of the National Death Index and/or clinic records. SCDs were determined using published retrospective criteria: 1) the International Classification of Diseases-10th Revision, code for all cardiac causes of death; and (2) circumstances of death meeting World Health Organization criteria. Results Of 230 deaths over a median of 3.7 years of follow-up, 30 (13%) met SCD criteria, 131 (57%) were due to acquired immune deficiency syndrome (AIDS), 25 (11%) were due to other (natural) diseases, and 44 (19%) were due to overdoses, suicides, or unknown causes. SCDs accounted for 86% of all cardiac deaths (30 of 35). The mean SCD rate was 2.6 per 1,000 person-years (95% confidence interval: 1.8 to 3.8), 4.5-fold higher than expected. SCDs occurred in older patients than did AIDS deaths (mean 49.0 vs. 44.9 years, p = 0.02). Compared with AIDS and natural deaths combined, SCDs had a higher prevalence of prior myocardial infarction (17% vs. 1%, p < 0.0005), cardiomyopathy (23% vs. 3%, p < 0.0005), heart failure (30% vs. 9%, p = 0.004), and arrhythmias (20% vs. 3%, p = 0.003). Conclusions SCDs account for most cardiac and many non-AIDS natural deaths in HIV-infected patients. Further investigation is needed to ascertain underlying mechanisms, which may include inflammation, antiretroviral therapy interruption, and concomitant medications.
- Head-to-Head Comparison of Left Ventricular Function Asse... Objectives This study was designed to compare the accuracy of 64-row contrast computed tomography (CT), invasive cineventriculography (CVG), 2-dimensional echocardiography (2D Echo), and 3-dimensional echocardiography (3D Echo) for left ventricular (LV) function assessment with magnetic resonance imaging (MRI). Background Cardiac function is an important determinant of therapy and is a major predictor for long-term survival in patients with coronary artery disease. A number of methods are available for assessment of function, but there are limited data on the comparison between these multiple methods in the same patients. Methods A total of 36 patients prospectively underwent 64-row CT, CVG, 2D Echo, 3D Echo, and MRI (as the reference standard). Global and regional LV wall motion and ejection fraction (EF) were measured. In addition, assessment of interobserver agreement was performed. Results For the global EF, Bland-Altman analysis showed significantly higher agreement between CT and MRI (p < 0.005, 95% confidence interval: ±14.2%) than for CVG (±20.2%) and 3D Echo (±21.2%). Only CVG (59.5 ± 13.9%, p = 0.03) significantly overestimated EF in comparison with MRI (55.6 ± 16.0%). CT showed significantly better agreement for stroke volume than 2D Echo, 3D Echo, and CVG. In comparison with MRI, CVG—but not CT—significantly overestimated the end-diastolic volume (p < 0.001), whereas 2D Echo and 3D Echo significantly underestimated the EDV (p < 0.05). There was no significant difference in diagnostic accuracy (range: 76% to 88%) for regional LV function assessment between the 4 methods when compared with MRI. Interobserver agreement for EF showed high intraclass correlation for 64-row CT, MRI, 2D Echo, and 3D Echo (intraclass correlation coefficient >0.8), whereas agreement was lower for CVG (intraclass correlation coefficient = 0.58). Conclusions 64-row CT may be more accurate than CVG, 2D Echo, and 3D Echo in comparison with MRI as the reference standard for assessment of global LV function.
American Journal of Cardiology
- Eugene Braunwald, MD and the Early Years of Hypertrophic ... There is some uncertainty, and even controversy, as to when hypertrophic cardiomyopathy was first recognized. Dating back to 1868, there are autopsy-based case reports from France, Germany, and the United Kingdom composed of 1 or a few patients who appear to have died suddenly of a disease consistent in its features with hypertrophic cardiomyopathy. The 1959 and 1960 reports from London of Brock (clinical) and Teare (pathologic) are generally regarded as the first contemporary descriptions of hypertrophic cardiomyopathy. However, it is appropriate at this time to reflect on how and why this important disease was transformed from the subject of a few anecdotal case reports into a robust and treatable clinical entity ultimately regarded as a common genetic heart disease and the most frequent cause of sudden death in young individuals (including trained athletes).
- Influence of Diabetes Mellitus on Long-Term (Five-Year) O... Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and for diffuse and progressive atherosclerosis. We evaluated the outcomes of drug-eluting stent (DES) placement and coronary artery bypass grafting (CABG) in 891 diabetic patients (489 for DES implantation and 402 for CABG) and 2,151 nondiabetic patients (1,058 for DES implantation and 1,093 for CABG) with multivessel CAD treated from January 2003 through December 2005 and followed up for a median 5.6 years. Outcomes of interest included death; the composite outcome of death, myocardial infarction (MI), or stroke; and repeat revascularization. In diabetic patients, after adjusting for baseline covariates, 5-year risk of death (hazard ratio 1.01, 95% confidence interval 0.77 to 1.33, p = 0.96) and the composite of death, MI, or stroke (hazard ratio 1.03, 95% confidence interval 0.80 to 1.31, p = 0.91) were similar in patients undergoing DES or CABG. However, rate of repeat revascularization was significantly higher in the DES group (hazard ratio 3.69, 95% confidence interval 2.64 to 5.17, p <0.001). These trends were consistent in nondiabetic patients (hazard ratio 0.80, 95% confidence interval 0.55 to 1.16, p = 0.23 for death; hazard ratio 0.77, 95% confidence interval 0.56 to 1.05, p = 0.10 for composite of death, MI, or stroke; hazard ratio 2.77, 95% CI 1.95 to 3.91, p <0.001 for repeat revascularization). There was no significant interaction between diabetic status and treatment strategy on clinical outcomes (p for interaction = 0.36 for death; 0.20 for the composite of death, MI, or stroke; and 0.40 for repeat revascularization). In conclusion, there was no significant prognostic influence of diabetes on long-term treatment with DES or CABG in patients with multivessel CAD.
- Relation of Routine, Periodic Fasting to Risk of Diabetes... Previously we discovered that routine periodic fasting was associated with a lower prevalence of coronary artery disease (CAD). Other studies have shown that fasting increases longevity in animals. A hypothesis-generating analysis suggested that fasting may also associate with diabetes. This study prospectively tested whether routine periodic fasting is associated with diabetes mellitus (DM). Patients (n = 200) undergoing coronary angiography were surveyed for routine fasting behavior before their procedure. DM diagnosis was based on physician reports of current and historical clinical and medication data. Secondary end points included CAD (physician reported for ≥1 lesion of ≥70% stenosis), glucose, and body mass index (BMI). Meta-analyses were performed by evaluation of these patients and 448 patients from a previous study. DM was present in 10.3% of patients who fasted routinely and 22.0% of those who do not fast (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.17 to 0.99, p = 0.042). CAD was found in 63.2% of fasting and 75.0% of nonfasting patients (OR 0.42, CI 0.21 to 0.84, p = 0.014), and in nondiabetics this CAD association was similar (OR 0.38, CI 0.16 to 0.89, p = 0.025). Meta-analysis showed modest differences for fasters versus nonfasters in glucose concentrations (108 ± 36 vs 115 ± 46 mg/dl, p = 0.047) and BMI (27.9 ± 5.3 vs 29.0 ± 5.8 kg/m2, p = 0.044). In conclusion, prospective hypothesis testing showed that routine periodic fasting was associated with a lower prevalence of DM in patients undergoing coronary angiography. A reported fasting association with a lower CAD risk was also validated and fasting associations with lower glucose and BMI were found.
- Comparison of Late (3-Year) Registry Data Outcomes Using ... Clinical trial data have supported the safety and efficacy of drug-eluting stents (DES) in the treatment of patients with ST-segment elevation myocardial infarctions (STEMIs), but contemporary “real-world” registry data regarding the late safety profiles of DES are limited. This prospective registry-based study included 1,569 consecutive unselected patients with STEMIs who underwent emergency primary percutaneous coronary intervention from January 2001 to December 2009. Of the study cohort, 200 patients (12.7%) received DES, while 1,369 patients (87.3%) underwent bare-metal stent (BMS) placement. The primary end points of the study were all-cause mortality and target vessel revascularization at 1, 2, and 3 years. Survival status was assessed by municipal civil registries. Repeat revascularization procedures were prospectively collected in the hospital database. All-cause mortality was significantly lower in the DES group at 3 years (4.2% vs 13.5%, p = 0.007) compared to BMS-treated patients, but DES use was not an independent predictor of all-cause mortality (adjusted odds ratio 0.5, 95% confidence interval 0.2 to 1.2, p = 0.10). Target vessel revascularization was significantly lower in the DES group compared to the BMS group at 3 years (10.5% vs 21%, p = 0.001). DES use was an independent predictor of reduced target vessel revascularization (adjusted odds ratio 0.44, 95% confidence interval 0.25 to 0.77, p = 0.004). Late definite stent thrombosis occurring after 1 year occurred in 4 (2.5%) patients in the DES group compared to 6 (0.7%) in the BMS group (p = 0.05). DES use was an independent predictor of late stent thrombosis (adjusted odds ratio 8.6, 95% confidence interval 1.9 to 38, p = 0.004). In conclusion, this contemporary registry-based study of patients who underwent primary percutaneous coronary intervention for STEMI demonstrated improved revascularization rates without increased 3-year hazard of adverse clinical outcomes in DES-treated patients.
- Comparison of Frail Patients Versus Nonfrail Patients ≥... Frailty is a geriatric syndrome characterized by functional impairments and is associated with poor outcomes; however, the prevalence of frailty and its association with health status in patients treated with percutaneous coronary intervention (PCI) are unknown. To assess the prevalence of frailty and its association with health status in PCI-treated patients, we studied 629 patients ≥65 years old undergoing PCI from October 2005 through September 2008. Frailty was characterized using the Fried criteria: weight loss >10 lbs. in previous 1 year, exhaustion, low physical activity, poor gait speed, and poor grip strength (3 features = frail; 1 feature to 2 features = intermediate frailty; 0 feature = not frail). Health status was assessed using the Short-Form 36 and the Seattle Angina Questionnaire (SAQ). Multivariable linear regression models were used to estimate the independent association between frailty and health status. Complete data on 545 patients demonstrated that 19% (n = 117) were frail, 47% (n = 298) had intermediate frailty, and 21% (n = 130) were not frail. Frail patients had more co-morbidities and more frequent left main coronary artery or multivessel disease after adjusting for age and gender (p <0.05 across groups). Multivariable linear regression demonstrated poorer health status in frail patients compared to nonfrail patients as evidenced by lower Short-Form 36 scores, lower SAQ scores for physical limitation, and lower SAQ scores for quality of life (p <0.001 for each health status domain). In conclusion, 1/5 of older patients are frail at the time of PCI and have greater comorbid burden, angiographic disease severity, and poorer health status than nonfrail adults.
- Intravascular Ultrasound Findings That Are Predictive of ... The aim of this study was to investigate the relation between intravascular ultrasound (IVUS) findings and the no-reflow phenomenon and long-term outcome after percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions. No reflow was defined as Thrombolysis In Myocardial Infarction grade 0, 1, or 2 flow after PCI. Of 311 patients who underwent IVUS before and after stenting, no reflow was observed in 39 patients (13%). Degenerated SVG (62% vs 36%, p = 0.002), IVUS-detected intraluminal mass (82% vs 43%, p <0.001), culprit lesion multiple plaque ruptures (23% vs 6%, p <0.001), and tissue prolapse (51% vs 35%, p = 0.043) were observed more frequently in patients with no reflow. In multivariate logistic regression analysis, an intraluminal mass (odds ratio [OR] 4.84, 95% confidence interval [CI] 1.98 to 10.49, p = 0.001), culprit lesion multiple plaque ruptures (OR 3.46, 95% CI 1.46 to 8.41, p = 0.014), and degenerated SVGs (OR 3.17, 95% CI 1.17 to 6.56, p = 0.024) were the independent predictors of no reflow after PCI. At 5-year clinical follow-up, rates of death (14, 36%, vs 55, 20%, p = 0.036) and myocardial infarction (13, 33%, vs 52, 19%, p = 0.039) were significantly higher in the no-reflow group. However, rate of target vessel revascularization was not significantly different between the 2 groups (15, 38%, vs 90, 33%, p = 0.3). IVUS-detected intraluminal mass, multiple plaque ruptures, and degenerated SVGs were associated with no reflow in SVG lesions after PCI. In conclusion, no reflow was associated with poor long-term clinical outcomes after PCI for SVG lesions.
- Are the Results of a Regional ST-Elevation Myocardial Inf... Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-elevation myocardial infarction (STEMI) if it can be performed in a timely manner in high-volume centers. Regional STEMI networks improve timely access to PCI but are frequently criticized for being single center. To determine if results of regional STEMI systems could be replicated and achieve similar outcomes in 2 separate geographic regions, we examined the prospective databases of 2 large regional STEMI networks that use identical standardized protocols and integrated transfer systems. The Minneapolis Heart Institute (MHI) database included 2,266 patients with STEMI from 31 hospitals (498 at the PCI hospital, 1,033 transferred from 11 hospitals <60 miles away, and 735 transferred from 19 hospitals 60 to 210 miles away). The Iowa Heart Center (IHC) database included 1,206 patients with STEMI from 24 hospitals (710 at the PCI hospital, 266 transferred from 10 hospitals <60 miles away, and 230 transferred from 13 hospitals 60 to 120 miles away). Median total door-to-balloon times for the PCI hospital, zone 1, and zone 2 patients were 64, 95, and 123 minutes for the MHI and 59, 102, and 136 for the IHC (p <0.05 for each comparison between MHI and IHC). Overall in-hospital, 30-day, and 1-year mortalities was 4.8%, 5.4%, and 8.0% respectively (p = NS for each comparison between MHI and IHC). In conclusion, the use of identical protocols in 2 large regional STEMI systems in geographically separate locations produced nearly identical outcomes, adding to evidence that regional STEMI centers expand timely access to PCI.
- Recent Trends in Hospitalization for Acute Myocardial Inf... Rates of acute myocardial infarction (AMI) hospitalizations for elderly Medicare patients decreased during the previous decade. However, trends in population rates of AMI hospitalizations for all adults by subgroups have not been described. Using data from a large all-payer administrative database of hospitalizations, we calculated annual AMI hospitalization rates from 2001 through 2007. Trend analysis was performed across age, gender, and ethnicity categories using survey regression. Overall rate decreased from 314 to 222 AMI hospitalizations per 100,000 patients from 2001 through 2007, representing a 29.2% decrease. Significant decreases were observed in AMI hospitalization rate for each group by age categories (p <0.001) and by gender (p <0.001). When stratified by ethnicity and gender, age-adjusted AMI hospitalization rates in white men and women decreased by 30.8% and 31.4%, whereas black men and women had significantly slower rates of decrease of 13.6% and 12.6%, respectively. In conclusion, although the overall rate of AMI hospitalizations decreased from 2001 through 2007, the observed decrease was smaller for black patients compared to white patients across all age groups studied.
- Within-Hospital and 30-Day Outcomes in 107,994 Patients U... Comparative clinical outcomes after exposure to alternate low osmolar contrast media (LOCM) during invasive coronary angiography (ICA) and/or percutaneous coronary intervention (PCI) have been incompletely examined. From a retrospective multicenter observational study, we identified 107,994 adults without previous hemodialysis undergoing ICA and/or PCI with iohexol, iopamidol, or ioversol. We created a propensity score for contrast media type using age, gender, coverage status, route of hospitalization, illness severity, physician specialty, co-morbidities, and procedure type. Propensity matching was performed in a 1:1 fashion for iohexol (n = 10,204) and iopamidol (n = 10,204) and in a 1:1 fashion for iohexol (n = 19,482) and ioversol (n = 19,482). Groups were examined for differences in in-hospital mortality or subsequent hemodialysis, length of stay, and 30-day readmission for contrast-induced nephropathy (CIN). Compared to patients exposed to iohexol, no differences were observed for patients exposed to iopamidol or ioversol for in-hospital hemodialysis (0.5% vs 0.4%, p = 0.45; 0.3% vs 0.5%, p = 0.05), in-hospital mortality (0.7% vs 0.6%, p = 0.60; 0.5% vs 0.6%, p = 0.42), or composite hemodialysis or mortality (1.1% vs 1.0%, p = 0.58; 0.8% vs 1.0%, p = 0.06); for hospital length of stay (2.9 ± 2.7 vs 2.9 ± 2.7 days, p = 0.05; 2.8 ± 2.6 vs 2.9 ± 3.1 days, p = 0.35); or for 30-day readmission for CIN (0.1% vs 0.1%, p = 0.82; 0.1% vs 0.1%, p = 0.52). In conclusion, for patients undergoing ICA and/or PCI exposed to alternate LOCM, in-hospital death, need for hemodialysis, or readmission for CIN are uncommon, with no apparent clinical advantage among LOCM agents.
- Comparison of Two- and Three-Dimensional Quantitative Cor... Angiographic evaluation of intermediate left main coronary artery stenosis (LMS) is often limited. Three-dimensional (3D) quantitative coronary angiography has recently developed to overcome 2-dimensional (2D) quantitative coronary angiographic (QCA) limitations. In patients with angiographically intermediate LMS, we investigated whether 3D quantitative coronary angiography was superior to 2D quantitative coronary angiography in predicting the presence of a significant LMS, defined as a minimum luminal area <6 mm2 at intravascular ultrasound (IVUS). 2D and 3D quantitative coronary angiography were compared in their measurements of minimum luminal area, percent area stenosis, minimum luminal diameter, and percent diameter stenosis and in their prediction of an IVUS minimum luminal area <6 mm2. In total 58 target lesions were interrogated, 25 (43%) of which had an IVUS minimum luminal area <6 mm2. Correlation between 3D-QCA minimum luminal area and IVUS minimum luminal area was stronger than the correlation between 2D-QCA minimum luminal area (or minimum luminal diameter) and IVUS minimum luminal area (R = 0.67, p = 0.0001, and R = 0.40, p = 0.001, respectively, p = 0.04 for comparison). To predict IVUS minimum luminal area <6 mm2, the most accurate 2D-QCA measurement was minimum luminal diameter (area under curve 0.81, cutoff 2.2 mm, p = 0.0001), and the most accurate 3D-QCA measurement was minimum luminal area (area under curve 0.86, cutoff 5.6 mm2, p = 0.0001). 2D-QCA percent diameter stenosis did not significantly predict IVUS minimum luminal area <6 mm2 (area under curve 0.56, cutoff 38%, p = 0.45). In conclusion, the accuracy of quantitative coronary angiography in predicting LM IVUS minimum luminal area <6 mm2 is limited. When IVUS is not available or contraindicated, 3D quantitative coronary angiography may assist in the evaluation of intermediate LMS. Among 2D-QCA parameters, minimum luminal diameter is more accurate than percent diameter stenosis in predicting significant LMS.
Canadian Journal of Cardiology
- A strange coincidence happened in March while I was in Ottawa participating in ongoing discussions about a strategy for a pan-Canadian Vascular Network. As I was listening to presentations by a number of initiative leaders, including Dr Duncan Stewart, Vice President of Research at the Ottawa Heart Institute, I suddenly had a feeling of déjà vu.
- Role of Endothelin-1 and Endothelial Dysfunction in Prehy... Hypertension is one of the most common chronic diseases worldwide, and it accounts for a substantial amount of cardiovascular disease morbidity and mortality. Despite the high prevalence and intense efforts, understanding of the pathogenesis of essential hypertension is still limited. Among other mechanisms, hypertension has been associated with increased peripheral vascular resistance. Vascular tone is regulated by multiple mediators, among them endothelin-1.
- Lessons From Africa: The Importance of Measuring Plasma R... Although most North American physicians are aware that black patients have lower levels of plasma renin on average, seldom are the reasons given sufficient consideration. Weder et al. found that black study participants excreted a water load more slowly than white participants, and suggested that this may have a selective advantage for human beings surviving in hot arid climates. An important reason why blood pressure is not well controlled in African-Americans is the failure of physicians to recognize that patients of African origin are more likely to have specific causes of low-renin hypertension that require specific therapies. This probably accounts for the observation by Howard et al. that black patients in the stroke belt are more likely to be aware of and more likely to be treated for hypertension, more likely to be treated more intensively, but less likely to be controlled. This could explain why African-Americans have twice the risk of stroke, that is more likely to be due to hypertensive small vessel disease.
- Bridging the Gap: Innovative Knowledge Translation and th... Successful and innovative knowledge translation (KT) of guidelines into clinical practice requires a highly structured and systematic process. Canada has had annually updated evidence-based recommendations for hypertension management since 1999. At that time, it was recognized that producing a document outlining best practices in the form of a series of recommendations was not sufficient to improve blood pressure control. Innovative KT is needed to address challenges in guidelines implementation, to translate new evidence-based recommendations into meaningful changes in primary care.
- A Framework for Discussion on How to Improve Prevention, ... Abstract: Increased blood pressure is a leading risk for premature death and disability. The causes of increased blood pressure are intuitive and well known. However, the fundamental basis and means for improving blood pressure control are highly integrated into our complex societal structure both inside and outside our health system and hence require a comprehensive discussion of the pathway forward. A group of Canadian experts was appointed by Hypertension Canada with funding from Public Health Agency of Canada and the Heart and Stroke Foundation of Canada, Canadian Institute for Health Research (HSFC-CIHR) Chair in Hypertension Prevention and Control to draft a discussion Framework for prevention and control of hypertension. The report includes an environmental scan of past and current activities, proposals for key indicators, and targets to be achieved by 2020, and what changes are likely to be required in Canada to achieve the proposed targets. The key targets are to reduce the prevalence of hypertension to 13% of adults and improve control to 78% of those with hypertension. Broad changes in government policy, research, and health services delivery are required for these changes to occur. The Hypertension Framework process is designed to have 3 phases. The first includes the experts' report which is summarized in this report. The second phase is to gather input and priorities for action from individuals and organizations for revision of the Framework. It is hoped the Framework will stimulate discussion and input for its full intended lifespan 2011-2020. The third phase is to work with individuals and organizations on the priorities set in phase 2. Résumé: L'élévation de la pression artérielle est le principal risque lié à la mort prématurée et à l'incapacité. Les causes de l'élévation de la pression artérielle sont intuitives et bien connues. Cependant, la base et les moyens fondamentaux pour améliorer la maîtrise de la pression artérielle sont fortement intégrés à la structure complexe de notre société tant à l'intérieur qu'à l'extérieur de notre système de santé et, en conséquence, nécessiteront une discussion sérieuse sur la marche à suivre. Un groupe d'experts canadiens a été désigné par Hypertension Canada qui bénéficie des fonds de l'Agence de la santé publique du Canada et de la chaire de la Fondation des maladies du cœur du Canada et des Instituts de recherche en santé du Canada (FMCC-IRSC) en prévention et contrôle de l'hypertension artérielle pour élaborer un cadre de discussion sur la prévention et la maîtrise de l'hypertension. Le rapport inclut une étude sur l'environnement des activités passées et courantes, les propositions comme principaux indicateurs et les objectifs à atteindre pour 2020, et les changements qui sont susceptibles d'être nécessaires au Canada pour atteindre les objectifs proposés. Les objectifs principaux de l'hypertension sont d'en réduire la prévalence à 13 % des adultes et d'en améliorer la maîtrise à 78 % chez ceux qui en sont atteints. Des changements d'envergure dans la politique gouvernementale, la recherche et l'offre des services de santé sont nécessaires pour que des changements surviennent. Le processus-cadre sur l'hypertension comporte 3 étapes. La première étape inclut le rapport des experts qui est résumé dans le présent rapport. La deuxième est de recueillir les commentaires et de connaître les priorités d'action des individus et des organisations dans la révision du cadre. Il est à souhaiter que le cadre stimulera la discussion et les commentaires tout au long de sa durée de 2011 à 2020. La troisième étape est de travailler avec les individus et les organisations sur l'ensemble des priorités de l'étape 2.
- The 2012 Canadian Hypertension Education Program Recommen... Abstract: We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg. Résumé: Nous avons mis à jour les recommandations factuelles en ce qui a trait au diagnostic, à l'évaluation, à la prévention et au traitement de l'hypertension chez les adultes pour 2012. Les nouvelles recommandations sont : 1) l'utilisation de la mesure de la pression artérielle à domicile pour confirmer un diagnostic de « syndrome de la blouse blanche »; 2) les antagonistes du récepteur minéralocorticoïde peuvent être utilisés chez des patients ayant de l'hypertension et une insuffisance cardiaque systolique; 3) un antécédent de fibrillation auriculaire chez les patients ayant de l'hypertension ne devrait pas être un facteur de décision pour prescrire un inhibiteur du récepteur de l'angiotensine dans le traitement de l'hypertension; 4) la pression artérielle cible des patients non diabétiques ayant une maladie rénale chronique est maintenant de < 140/90 mm Hg au lieu de < 130/90 mm Hg. Nous avons aussi revu les données récentes sur la pression artérielle cible des patients ayant de l'hypertension et un diabète, et nous continuons de recommander une pression artérielle cible de moins de 130/80 mm Hg.
- Molecular Mechanisms of Hypertension—Reactive Oxygen Sp... Abstract: Many factors have been implicated in the pathophysiology of hypertension such as upregulation of the renin-angiotensin-aldosterone system, activation of the sympathetic nervous system, perturbed G protein-coupled receptor signalling, inflammation, and altered T-cell function. Common to these processes is increased bioavailability of reactive oxygen species (ROS) (termed oxidative stress) due to excess ROS generation, decreased nitric oxide (NO) levels, and reduced antioxidant capacity in the cardiovascular, renal, and nervous systems. Although oxidative stress may not be the sole etiology of hypertension, it amplifies blood pressure elevation in the presence of other prohypertensive factors. In the cardiovascular system ROS play a physiological role in controlling endothelial function, vascular tone, and cardiac function, and a pathophysiological role in inflammation, hypertrophy, proliferation, apoptosis, migration, fibrosis, angiogenesis, and rarefaction, all of which are important processes contributing to endothelial dysfunction and cardiovascular remodelling in hypertension. A major source for cardiovascular ROS is a family of nonphagocytic nicotinamide adenine dinucleotide phosphate (NADPH) oxidases (Nox1, Nox2, Nox4, and Nox5). Other sources include mitochondrial enzymes, xanthine oxidase, and uncoupled NO synthase (NOS). Although convincing data from animal studies support a causative role for oxidative stress in the pathogenesis of hypertension, there is still no solid evidence that oxidative stress causes hypertension in humans. However, biomarkers of excess ROS are increased in patients with hypertension and oxidative damage is important in the molecular mechanisms associated with cardiovascular and renal injury in hypertension. Although clinical trials failed to show beneficial antihypertensive effects of antioxidants, strategies that combat oxidative stress by targeting Noxs in an isoform-specific manner may have therapeutic potential. Résumé: Plusieurs facteurs tels la régulation à la hausse du système rénine-angiotensine-aldostérone, l'activation du système nerveux sympathique, la signalisation perturbée des récepteurs couplés aux protéines G, l'inflammation et le fonctionnement altéré de la cellule-T ont été mis en cause dans la physiopathologie de l'hypertension. Associée à ces procédés, la biodisponibilité des espèces réactives de l'oxygène (ERO), que l'on appelle le stress oxydatif, a augmenté en raison de l'excès de génération des ERO, des concentrations réduites d'oxyde nitrique (NO) et de la réduction de la capacité oxydative des systèmes cardiovasculaire et nerveux, et des reins. Même si le stress oxydatif n'est peut-être pas la seule étiologie de l'hypertension, il accentue l'augmentation de la pression artérielle en présence d'autres facteurs prohypertenseurs. Dans le système cardiovasculaire, les ERO jouent un rôle physiologique dans la maîtrise du fonctionnement endothélial, du tonus vasculaire et du fonctionnement cardiaque, et un rôle physiopathologique dans l'inflammation, l'hypertrophie, la prolifération, l'apoptose, la migration, la fibrose, l'angiogénèse et la raréfaction,tous d'importants procédés contribuant au dysfonctionnement endothélial et au remodelage cardiovasculaire dans l'hypertension. Une source importante d'ERO cardiovasculaires est une famille de nicotinamide adénine diphosphate (NADPH: nicotinamide adenine dinucleotique phosphate) oxydases (NOx1, NOx2, NOx4 et NOx5) non phagocytaires. D'autres sources incluent les enzymes mitochondriales, la xanthine oxydase et l' NO synthase (NOS) non couplé. Même si des données convaincantes provenant d'études animales établissent un lien de causalité au stress oxydatif dans la pathogénèse de l'hypertension, il n'y a encore aucune preuve solide démontrant que le stress oxydatif cause l'hypertension chez les humains. Cependant, les biomarqueurs de l'excès d'ERO augmentent chez les patients ayant de l'hypertension, et les lésions oxydatives sont importantes dans les mécanismes moléculaires associés aux lésions cardiovasculaires et rénales dans l'hypertension. Même si les essais cliniques ne sont pas parvenus à démontrer les effets antihypertenseurs bénéfiques des antioxydants, les stratégies qui combattent le stress oxydatif en ciblant les NOx de manière spécifique aux isoformes peuvent avoir un potentiel thérapeutique.
- Genetics and Hypertension: Is It Time to Change My Practice? Abstract: Recent advances in genotyping technology and in particular a number of large-scale genome-wide association studies have helped to unravel the genetic basis of hypertension. Although our knowledge is still far from being complete it is important to ask how genetic findings could be translated to clinical practice. In a first step we summarize the strategies to dissect the genetics of hypertension from candidate gene studies to genome-wide association studies and recent sequencing experiments. The greatest hope in this context is the development of new drugs that are based on newly discovered pathophysiological principles. We describe examples where significant therapeutic effects are achieved with agents targeting pathways that contribute only small amounts to the genetic variability of a phenotype. There are good reasons to believe that new drugs will be developed based on genetic data in hypertension. We also highlight the potential for pharmacogenetics and risk stratification. The former is not currently supported by a larger body of evidence, but well designed studies are under way. The latter needs to follow the same principles for evaluation of other novel biomarkers of cardiovascular risk and is unlikely to influence clinical practice in the next few years. Résumé: Les récentes avancées de la technologie de génotypage et, en particulier, de nombreuses études d'association pangénomiques à grande échelle ont aidé à éclaircir les bases génétiques de l'hypertension. Même si nos connaissances sont encore loin d'être complètes, il est important de s'interroger sur la manière dont les découvertes génétiques pourraient être traduites dans la pratique clinique. Dans un premier temps, nous résumons les stratégies pour disséquer la génétique de l'hypertension des études de gènes candidats aux études d'association pangénomiques et aux récentes expériences de séquençage. Le plus grand espoir dans ce contexte est la mise au point de nouveaux médicaments qui sont basés sur des principes physiopathologiques récemment découverts. Nous décrivons des exemples où des résultats thérapeutiques importants sont atteints à l'aide d'agents ciblant les voies qui contribuent que très peu à la variabilité génétique d'un phénotype. Il y a de bonnes raisons de croire que de nouveaux médicaments basés sur les données génétiques de l'hypertension seront mis au point. Nous mettons en relief le potentiel de la pharmacogénétique et de la stratification de risque. La première n'est actuellement pas soutenue par un grand nombre de preuves, mais des études bien conçues sont en cours. La seconde a besoin de suivre les mêmes principes dans l'évaluation d'autres nouveaux biomarqueurs de risque cardiovasculaire et n'est pas susceptible d'influencer la pratique clinique au cours des prochaines années.
- The Kidney and Hypertension: Lessons From Mouse Models Abstract: The pathogenesis of hypertension is multi-factorial, involving many of the systems contributing to blood pressure homeostasis including the vasculature, kidneys, central, and sympathetic nervous systems, along with various hormonal regulators. However, over the years, many studies have indicated a predominant importance of the kidney in blood pressure homeostasis and hypertension. This work has established the notion that the kidney is a key determinant of the chronic level of intra-arterial pressure playing a major role in the pathogenesis of hypertension. Therefore, this review will focus on recent work using genetically modified mouse models addressing the role of the kidney in hypertension. In particular, human genetic studies of Mendelian disorders with major impact on blood pressure homeostasis have provided powerful evidence for a role of the kidney in hypertension. Of the approximately 20 genes identified as causal in these disorders, virtually all have an effect on the control of solute transport in the kidney. As such, we have especially focused on generation of mouse models addressing the nature of these specific molecular defects in nephron function that produce an alteration in blood pressure. Résumé: La pathogenèse de l'hypertension est multifactorielle et comporte plusieurs systèmes et organes contribuant à l'homéostasie de la pression artérielle dont la vasculature, les reins, les systèmes nerveux central et sympathique, de même que les divers régulateurs hormonaux. Cependant, au cours des années, plusieurs études ont démontré l'importance capitale des reins dans l'homéostasie de la pression artérielle et l'hypertension. Cet ouvrage a établi la notion selon laquelle le rein est un facteur déterminant de la chronicité de la pression intraartérielle jouant un rôle majeur dans la pathogenèse de l'hypertension. Par conséquent, cette revue se concentre sur les travaux récents qui utilisent des modèles de souris génétiquement modifiées portant sur le rôle des reins dans l'hypertension. En particulier, les études de génétique humaine sur les troubles mendéliens ayant des conséquences majeures sur l'homéostasie de la pression artérielle ont fourni une preuve très importante sur le rôle des reins dans l'hypertension. Dans les quelque 20 gènes identifiés comme étant la cause de ces troubles, presque tous ont un effet sur la maîtrise du transport rénal de solutés. À ce titre, nous nous sommes penchés plus spécifiquement sur la génération de modèles de souris portant sur la nature de ces anomalies moléculaires spécifiques au fonctionnement du néphron qui entraînent une altération de la pression artérielle.
- The Sympathetic Nervous System and New Nonpharmacologic A... Abstract: The sympathetic nervous system is activated in a variety of cardiovascular and metabolic diseases. This is particularly the case for essential hypertension, in which various indices of adrenergic activity, such as plasma norepinephrine, norepinephrine spillover, and sympathetic nerve firing rate, are all well above the reference range of values, thereby documenting sympathetic overdrive. Evidence is available that sympathetic neural factors participate in disease progression, as well as in the development of cardiac and renal organ damage. These findings represent the rationale for therapeutic interventions that counteract the adrenergic overdrive in the hypertensive state. This paper, after reviewing the key findings of the neuroadrenergic abnormalities occurring in hypertension, examines the rationale and the technical details, as well as the results achieved so far, with the use of a new technique that allows the elimination of afferent and efferent innervation of the kidney in resistant hypertension, ie, the ablation of renal nerves. Strengths and potential limitations of the renal denervation approach are briefly addressed. Résumé: Le système nerveux sympathique est activé dans diverses maladies cardiovasculaires et métaboliques. C'est particulièrement le cas de l'hypertension essentielle, dans laquelle des indices divers d'activité adrénergique, comme la norépinéphrine plasmatique, l'excès de norépinéphrine et la cautérisation du nerf sympathique sont nettement supérieurs à l'intervalle de référence des valeurs, documentant ainsi l'hyperactivité sympathique. Il est prouvé que les facteurs neurosympathiques participent à l'évolution de la maladie, ainsi qu'au développement d'atteintes rénales ou cardiaques. Ces découvertes justifient les interventions thérapeutiques qui contrebalancent l'hyperactivité adrénergique de l'état hypertensif. Cet article, après examen des constatations sur les anomalies neuroadrénergiques se produisant dans l'hypertension, étudie la justification et les détails techniques, ainsi que les résultats atteints jusqu'à maintenant, par l'utilisation d'une nouvelle technique qui permet l'élimination des innervations afférentes et efférentes du rein dans l'hypertension résistante, c.-à-d. la dénervation rénale. Les forces et les limites de cette approche sont prises brièvement en considération.
Catheterization and Cardiovascular Interventions
- A stitch in time saves none
- Long-term outcome of transcatheter polytetrafluoroethylen... We report the long-term outcome of a child with Kawasaki disease (KD), who had a giant aneurysm with stenotic lesions in the right coronary artery, resulting in the transcatheter implantation of a polytetrafluoroethylene (PTFE)-covered stent at the age of eight. Quantitative coronary angiography (QCA) analysis later showed the increase of the diameter stenosis at both stent edges for the first ten months after implantation; however, the stenosis did not develop thereafter. Coronary perfusion was still well maintained at follow-up coronary angiography 5.5 years after implantation (diameter stenosis was 36.5% at proximal and 37.4% at distal edge, respectively). Although further follow-up is necessary, the long-term outcome of a PTFE-covered stent implantation for a KD patient is satisfactory in this instance. Implantation of a covered stent in a giant aneurysm is considered a promising treatment option. © 2012 Wiley Periodicals, Inc.
- Major adverse limb events and wound healing following inf... Background:Percutaneous transluminal angioplasty (PTA) with stent deployment of infrapopliteal arteries is an accepted but unproven therapy for patients with critical limb ischemia (CLI). We evaluated the safety and effectiveness of the Xpert• self-expanding nitinol stent (Abbott Vascular, Redwood City, CA) in Rutherford Class 4-6 subjects with infrapopliteal lesions of 4-15 cm in length.Methods and Results:120 patients (140 limbs, 212 implanted devices) underwent primary infrapopliteal nitinol stent deployment as part of this multicenter registry. The primary endpoint was 12-month amputation-free survival (AFS); secondary endpoints included limb salvage, target lesion revascularization (TLR), 6- month angiographic patency and 6- and 12-month outcomes of wound healing and pain relief. Despite a 6-month binary stent restenosis rate of 68.5%, the 12-month AFS rate was 78.3%. Stratified according to baseline Rutherford classes 4, 5 and 6, the 12-month AFS rates were 100%, 77.3% and 55.2%, respectively, and freedom from major amputation rates were 100%, 90.9% and 70.1%, respectively. The 12 month freedom from major amputation rate and clinically driven TLR were 89.6% and 70.1%, respectively. The 6- and 12-month complete wound-healing rates were 49.0% and 54.4%, respectively. Rutherford Class 4 patients had significant pain relief through 12-months (P<0.05).Conclusions:Primary infrapopliteal nitinol stenting to treat CLI is safe and effective in improving 6-and 12-month clinical outcomes.Clinical Trial Registration:URL: http://clinicaltrials.gov. Unique Identifier: NCT00515346 © 2012 Wiley-Liss, Inc.
- 9-month Results of the REFORM study (a prospective, singl... Objectives:To evaluate the 9-month safety and effectiveness outcomes of the Formula™ Balloon-Expandable Renal Stent (Cook Medical, Bloomington, IN) for the treatment of atherosclerotic renal artery stenosis following suboptimal angioplasty.Background:Atherosclerotic renal artery stenosis can cause hypertension and ischemic nephropathy. When clinically indicated, an interventional approach with renal angioplasty and stent implantation is the preferred method for revascularization of atherosclerotic renal artery stenoses.Methods:The REFORM study is a prospective, multicenter, single-arm study of stent implantation following suboptimal PTRA using the Formula stent. One hundred patients with atherosclerotic ostial renal artery lesions ≤ 18 mm in length with a > 50% residual stenosis following PTA were enrolled. The primary endpoint was 9-month primary patency.Results:The 9-month primary patency rate was 91.7%. The 9-month major adverse event rate was 2.2%. Mean systolic blood pressure was significantly decreased at follow-up (from 150 ± 21 mmHg at baseline to 141 ± 21 mmHg at 9 months; p = 0.003). Mean serum creatinine level and mean estimated glomerular filtration rate (eGFR) were not significantly different at 9 months. A clinically meaningful improvement in renal function (i.e., ≥ 25% increase in eGFR or ≥ 0.5 mg/dl decrease in serum creatinine) was observed in 9% of patients at 1 month and 12% of patients at 9 months. A clinically meaningful decline in renal function (i.e., ≥ 25% decrease in eGFR or ≥ 0.5 mg/dl increase in serum creatinine) was observed in only 3% of patients at 1 month and 7% of patients at 9 months.Conclusions:The Formula stent was safe and effective in treating atherosclerotic renal artery stenosis following suboptimal angioplasty. © 2012 Wiley Periodicals, Inc.
- Switching antiplatelet regimens: alternatives to clopidog... Dual antiplatelet therapy with aspirin plus a P2Y12 receptor inhibitor is the cornerstone of treatment for patients with acute coronary syndrome (ACS) and in those undergoing percutaneous coronary intervention (PCI). Clopidogrel is the most widely used P2Y12 receptor inhibitor. Despite the clinical benefits associated with adjunctive clopidogrel therapy, a considerable number of patients continue to experience recurrent cardiovascular events. Importantly, the interindividual response to clopidogrel is variable and is affected by multiple factors, including genetic polymorphisms and drugs that interfere with the conversion of clopidogrel to its active metabolite. The individual variability to clopidogrel-induced antiplatelet effects has significant clinical implications that can result in an increased risk of atherothrombotic recurrences, including stent thrombosis. The introduction of novel P2Y12 receptor inhibitors, such as prasugrel or ticagrelor, characterized by more potent and consistent platelet inhibitory effects, represent an opportunity for clinicians to consider these alternative therapies to overcome the limitations of clopidogrel. Understanding the strategies and implications of switching antiplatelet treatment regimens is, therefore, key in the clinical setting. The present article provides an overview of the literature on switching antiplatelet treatment strategies and practical considerations for the interventional cardiologist. © 2012 Wiley Periodicals, Inc.
- Safety of bivalirudin in percutaneous coronary interventi... Objectives:To evaluate the safety of bivalirudin (BIV) use during percutaneous coronary intervention (PCI) following thrombolytic therapy in patients with ST-segment elevation myocardial infarction (STEMI).Background:BIV has emerged as a safer anticoagulant than unfractionated heparin (UFH) during primary PCI; however, its use in patients who receive thrombolytic therapy has not been established.Methods:A consecutive series of 104 patients who presented with STEMI, treated with full-dose thrombolytics, and who subsequently received PCI within 6 hours was identified and analyzed. BIV use was compared to UFH for in-hospital bleeding and ischemic events. The primary end points were the rate of major bleeding and the rate of net adverse clinical events as defined in the HORIZONS-AMI trial. The study cohort consisted of 104 patients, of whom 47 (45%) received BIV and 57 (55%) received UFH.Results:Patients on BIV were more frequently pre-loaded with clopidogrel, while intra-procedural glycoprotein IIb/IIIa inhibitors were used only in UFH patients. In-hospital death, ischemic events, and Thrombolysis In Myocardial Infarction major bleeding occurred more frequently in patients treated with UFH. The net adverse clinical events rate was lower in the intra-procedural BIV group (3 [6.4%] vs. 12 [21.1%] UFH, p=0.034).Conclusion:The use of BIV in patients presenting with STEMI who were pretreated with thrombolytic therapy and who subsequently underwent PCI is safe and is associated with less ischemic and bleeding events when compared to UFH, and should be considered as the first line anticoagulant for these patients during PCI. © 2012 Wiley Periodicals, Inc.
- Device closure of paravalvular defects following transcat... Paravalvular aortic insufficiency is observed in the majority of patients undergoing transcatheter aortic valve replacement. While paravalvular AI is most commonly modest following TAVR, moderate or severe AI was seen in 10.5% and 6.8% of the PARTNER inoperable and high risk cohorts at 1 year and has been reportedly associated with dyspnea and diminished survival. We report 2 cases of transcather heart valve associated paravalvular defects closed using catheter delivered devices. Both patients derived hemodynamic and symptomatic improvement from device closure. Additional research is warranted to define the adverse consequences of THV associated AI, indications for treatment, and risks associated with device closure of these defects. © 2012 Wiley Periodicals, Inc.
- Assessment of safety, accuracy and human CD34+ cell reten... ObjectivesAssess accuracy of Helix injections via fluoroscopic-mapping and evaluate delivery safety.BackgroundPercutaneous intramyocardial-delivery of agents must be safe and accurate; retention is also important. A delivery system (Helical Infusion/Morph Guide-Catheter, Biocardia Inc) has been developed to improve maneuverability and stability of catheter-needle-myocardium intersection.MethodsAccuracy and safety: 12 swine underwent LV and coronary angiography via 8F sheath. Targeted delivery was assigned into LAD, LCX, or RCA. System was advanced into LV and 6 targeted intramyocardial dye injections (5mm apart) delivered using fluoroscopy. After euthanization, hearts underwent gross and histologic evaluation.Retention was assessed by iron-oxide and fluorochrome labeled CD34+ cells. Cells were injected into 6 swine using same techniques. Delivery system was advanced into LV, and injections delivered using fluoroscopy. Euthanization was performed at 2 hours and hearts formalin fixed. MRI was performed on 6 treated hearts and 4 untreated controls. Blinded analysis performed by 2 radiologists. Two treated hearts underwent immunohistologic analysis.ResultsAccuracy and safety evaluation: 71/72 injections (98.6%) were within pre-specified zone; 7/72 (9.7%) less than 5mm apart. No adverse events occurred. MRI-presence of iron-oxide labeled CD34+ cells were correctly identified in 95% (19/20) of imaged injections. Anti-CD34+ antibody staining and fluorescence microscopy confirmed CD34+ cells in myocardium. Histology confirmed cell viability at fixation.ConclusionsHelix system was accurate and safe. Retention of CD34+ cells was confirmed by MRI and immunohistology. Further preclinical studies are needed to characterize retention over time and quantify efficiency. Studies are needed to confirm accuracy, safety, and retention in humans. © 2012 Wiley Periodicals, Inc.
- Acute and medium-term outcomes of endovascular therapy of... BACKGROUND:Common femoral endarterectomy is regarded as the standard revascularization strategy for the treatment of common femoral artery (CFA) disease. The availability of a variety of endovascular tools has resulted in an increased number of patients with CFA disease being treated using an endovascular strategy. We sought to evaluate clinical outcomes in a contemporary series of patients who were treated for CFA disease using an endovascular-first approach.METHODS:All patients with obstructive CFA disease who were treated using endovascular therapy were retrospectively identified from a peripheral interventional database. Baseline patient characteristics, anatomic details, procedural data, and clinical outcomes were assessed. Kaplan-Meier (KM) curves for mortality, amputation-free survival, and primary and secondary patency were generated.RESULTS:Between 2006 and 2011, a total 30 patients underwent 31 CFA procedures. The primary etiologies of CFA obstruction were atherosclerosis (58%), access-site related complication (32%), and thromboembolism (10%). Patients presented with severe claudication (60%), critical limb ischemia (13%) or acute limb ischemia (27%). The procedure was technically successful in 90% of cases with major complications in two (7%) patients. There was no procedure-related mortality. The KM estimate of survival and amputation-free survival at one-year was 96% (±4%) and 96% (±4%), respectively. In those patients who had a successful revascularization, the overall one year estimate for primary and secondary patency was 88% (±6) and 92% (±5%), respectively. There was a non-significant trend toward lower patency in patients treated for atherosclerotic disease compared to those with access site-related complications and thromboembolic disease at 2 year follow-up (76% vs 100%, p=0.08).CONCLUSIONS:Endovascular therapy for treatment of obstructive disease of the CFA is associated with a high rate of acute technical success. Primary patency rates in the cohort treated for access site-related complications and thromboembolic disease is excellent and supports an endovascular-first approach for this patient subset. Based on lower patency rates, surgical endarterectomy for the treatment of atherosclerotic disease in the CFA remains the gold standard in patients with normal surgical risk. © 2012 Wiley Periodicals, Inc.
- Left ventricular guidewire pacing for transcatheter aorti... Previous reports prove the safety and efficacy of cardiac pacing employing a guidewire in the left ventricle as unipolar pacing electrode. We describe the use of left ventricular guidewire pacing as an alternative to conventional transvenous temporary right ventricular pacing in the context of transcatheter aortic valve implantation. © 2012 Wiley Periodicals, Inc.
Heart Rhythm
- Effect of electrocardiographic lead placement on localiza... Background: The origin of outflow tract ventricular tachycardia (OTVT) can be predicted from a surface electrocardiogram: indexes of R-wave amplitudes in leads V1 and V2 are used to differentiate a right origin from a left origin, while the axis of lead I differentiates an anterior origin from a posterior origin. Incorrect electrode placement is clinically common and may alter predictability of OTVTs. Objective: To explore the influence of vertical deviation in leads V1 and V2 and arm lead position on the QRS morphology of OTVTs. Methods: Vertical deviation of leads V1 and V2 was studied in 18 patients with OTVTs. Ventricular premature depolarization beats were recorded in the standard position, superior position, and inferior position. The effect of arm lead position was studied in a separate cohort of 16 patients: ventricular premature depolarizations were recorded with limb leads positioned over the shoulders and over the chest. The origin of tachycardia was determined by using activation mapping and confirmed by successful ablation. Results: Superior displacement of leads V1 and V2 reduced the R-wave amplitude and led to a decreased R/S ratio (0.11 ± 0.09 vs 0.17 ± 0.1; P <.01), while inferior displacement of leads V1 and V2 resulted in an increased R-wave amplitude and led to an increased R/S ratio (0.46 ± 0.35 vs 0.17 ± 0.1; P <.01). Anterior displacement of the arm leads from shoulders to chest resulted in the reduction in the R-wave amplitude in lead I (0.25 ± 0.30 mV vs 0.04 ± 0.43 mV; P <.05). Conclusions: Small changes in electrocardiographic electrode placement markedly alter the QRS morphology of OTVTs and thus alter the predictability of OTVT origin. These deviations are well within the range of clinical application and have the potential to misdirect ablation procedures.
- Predictors of long-term success after catheter ablation o... Background: Electrophysiologic characteristics, mapping strategies, and acute success rates of radiofrequency catheter ablation of atriofascicular accessory pathways are well described. However, data on long-term prognosis and predictors for freedom from arrhythmias are lacking. Objective: To report our 20-year single-center experience on ablation of atriofascicular fibers. Method: Between 1992 and 2010, 34 patients with atriofascicular accessory pathways underwent catheter ablation at our institution because of symptomatic antidromic atrioventricular reentrant tachycardias. Radiofrequency procedures were retrospectively analyzed, and patients were followed for recurrences of tachyarrhythmias. Electrocardiograms (before and after ablation and at follow-up) were analyzed for each patient. Results: Successful catheter ablation of the atriofascicular fiber was achieved in 23 (68%) patients. Mechanical block during mapping occurred in 3 (9%) patients, and in 2 of them ablation was performed at the site of mechanical block. Mere modification of conduction properties of the pathway without complete block was achieved in 5 patients (15%). Fast pathway ablation was performed in 2 (6%) of the patients ablated in the early 1990s. During follow-up of 9.3 ± 5.5 years, 24 patients (71%) remained free of tachyarrhythmias, 7 reported significant improvement, and 3 (9%) had no change in symptoms after ablation. Long-term success was identical between patients from the first (1992–1999) and second (2000–2010) decade (12 of 17 [71%] vs 12 of 17 [71%]). It was 87% in those with complete block of the atriofascicular fiber while all patients with mechanical block during mapping reported recurrences. Fast pathway ablation was complicated by complete atrioventricular block in 1 patient, who required pacemaker implantation 18 years after ablation owing to loss of conduction properties of the atriofascicular fiber over the years. On analyzing patients with preexcitation before ablation (n = 16; 47%), we found that the PR interval after ablation was significantly longer only in those without recurrence (162 ± 21 ms vs 134 ± 21 ms; P = .042). None of the other analyzed electrocardiographic parameters, including PR, QRS duration, and preexcitation, had prognostic impact. Conclusion: Acute success of complete ablation of atriofascicular pathways is associated with excellent long-term success (87%). Mere modification of conduction properties of atriofascicular fibers or ablation at the sites of mechanical block are less promising end points of ablation with high recurrence rates. Technical innovations during decades may not further improve long-term outcome in these patients.
- Contact force–controlled zero-fluoroscopy catheter abla... Background: Conventional catheter ablation of cardiac arrhythmias is associated with radiation risks for patients and laboratory personnel. However, nonfluoroscopic catheter guidance may increase the risk for inadvertent cardiac injury. A novel radiofrequency ablation catheter capable of real-time tissue-tip contact force measurements may compensate for nonfluoroscopic safety issues. Objective: To investigate the feasibility of contact force–controlled zero-fluoroscopy catheter ablation. Methods: In 30 patients (including 12 pediatric patients), zero-fluoroscopy catheter ablation of right-sided (right atrium, n = 20; right ventricle, n = 2) and left atrial (n = 8) arrhythmias was attempted. Inclusion criteria were symptomatic suspected atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal right atrial and ventricular arrhythmias, and lone atrial fibrillation. A novel irrigated-tip catheter with an integrated contact force sensor was used for nonfluoroscopic 3-dimensional electroanatomical mapping and radiofrequency ablation. Transseptal access was gained under transesophageal guidance for ablation of left-sided arrhythmias. Results: Procedural success without fluoroscopy was achieved in 29 of the 30 patients (97%). In 1 patient, endocardial nonfluoroscopic ablation failed because of an epicardial accessory pathway within a coronary sinus aneurysm. Mean total contact force and amplitude of force undulations were kept below 50 g during mapping and below 40 g during ablation to prevent contact force peaks (>100 g). Apart from a transient second-degree type I atrioventricular block, no complications occurred. The mean procedure time was 2.8 ± 0.9 hours. There were no arrhythmia recurrences during a mean follow-up of 6.2 ± 4.2 months. Conclusion: Contact force–controlled zero-fluoroscopy catheter ablation is generally feasible in right-sided and left atrial cardiac arrhythmias.
- Radiation exposure: A silent complication of catheter abl... An underappreciated “silent complication” of catheter ablation procedures is radiation exposure. X-ray exposure results in acute complications related to dose- and time-dependent exposure as well as a cumulative, lifetime risk to not only the patient but also the operator and electrophysiology staff. These risks include acute and subacute dermatologic injury, musculoskeletal injury, cataracts, malignancy, and genetic defects. These risks are heightened for lengthy and multiple ablation procedures (eg, atrial fibrillation) and for vulnerable patients such as pediatric, obese, and pregnant patients.
- Unpredictable battery depletion of St Jude Atlas II and A... Background: Predictable progression to battery depletion is necessary for device management in patients with pacemakers or implantable cardioverter-defibrillators, particularly in patients who either are pacemaker dependent or have required implantable cardioverter-defibrillator therapies. Objective: To determine the incidence and characteristics of unexpected battery depletion in patients implanted with a cardiac resynchronization therapy – defibrillator (CRT-D) device. Methods: All patients with a St Jude Atlas+ HF or Atlas II HF CRT-D device implanted between 2004 and 2007 at the Massachusetts General Hospital and the Nashville VA Medical Center (Vanderbilt University) were studied. All patients with early generator depletion (transition of generator voltage above specified elective replacement indicator [ERI] to end of life [EOL] in less than 90 days) were evaluated further. Results: Eight cases (mean age 69.6 ± 9 years) with abrupt battery depletion were identified among 191 patients (4.2%) implanted with a St Jude Atlas CRT-D device. The longevity of 8 premature depletion devices was 46.4 ± 10 months (median 45 months). The battery voltage in these 8 devices decreased from a mean of 2.48 ± 0.03 V (above ERI) to 2.3 ± 0.08 V (below ERI) over 33.3 ± 23 days (range 1–59 days; median 38.5 days). One device reached EOL status within 1 day of having battery voltage above ERI and another device within 12 days. Conclusion: The incidence of abrupt battery depletion was 4.2% in patients implanted with a St Jude Atlas CRT-D device. No common mechanism has been identified for this failure. Close monitoring of battery voltage and timely generator replacement are required in patients with these devices.
- Expecting the unpredictable The implantable cardioverter-defibrillator (ICD) is the cornerstone for the prevention of sudden cardiac death in high-risk patients. This has been proven time and again in numerous randomized trials and observational studies conducted over the last 20 years. However, its efficacy depends heavily on the predictability of device longevity and integrity. Impaired longevity confers risks to the patient associated with more frequent reoperations (infection, lead damage, etc). In addition, cost-effectiveness calculations are perturbed by significant differences between projected and observed device longevities. Impaired integrity might put the patient at risk for malignant arrhythmias that are not detected, not treated, or neither detected nor treated or at a risk of sudden deterioration of heart failure or syncope due to pacing failure.
- Percutaneous extraction of stented device leads Background: There are limited published data regarding the percutaneous extraction of device leads jailed by a venous stent. Objective: In this study we assessed the feasibility and safety of percutaneous extraction of stented device leads. Methods: We reviewed our experience percutaneously extracting 7 chronically implanted device leads jailed to the wall of the left innominate and/or subclavian veins by a previously placed stent. Results: All leads were successfully extracted by using a percutaneous approach. Both pacing leads and defibrillator leads were extracted. The oldest pacing lead extracted was 14 years old. The oldest defibrillator lead extracted was 6 years old. Three of the leads were extracted with simple manual traction alone. The 4 remaining leads required a more complex, femoral extraction approach for successful removal. Conclusion: In our experience extracting 7 stented device leads, complete percutaneous removal was feasible 100% of the time using a combination of simple manual traction and a femoral approach. No major complications were associated with the extraction procedures.
- Incidence and predictors of short- and long-term complica... Background: Today quantitative information about the type of complications and their incidence during long-term pacemaker (PM) follow-up is scarce. Objective: To assess the incidence and determinants of short- and long-term complications after first pacemaker implantation for bradycardia. Methods: A prospective multicenter cohort study (the FOLLOWPACE study) was conducted among 1517 patients receiving a PM between January 2003 and November 2007. The independent association of patient and implantation-procedure characteristics with the incidence of PM complications was analyzed using multivariable Cox regression analysis. Results: A total of 1517 patients in 23 Dutch PM centers were followed for a mean of 5.8 years (SD 1.1), resulting in 8797 patient-years. Within 2 months, 188 (12.4%) patients developed PM complications. Male gender, age at implantation, body mass index, a history of cerebrovascular accident, congestive heart failure, use of anticoagulant drugs, and passive atrial lead fixation were independent predictors for complications within 2 months, yielding a C-index of 0.62 (95% confidence interval 0.57–0.66). Annual hospital implanting volume did not additionally contribute to the prediction of short-term complications. Thereafter, 140 (9.2%) patients experienced complications, mostly lead-related complications (n = 84). Independent predictors for long-term complications were age, body mass index, hypertension, and a dual-chamber device, yielding a C-index of 0.62 (95% confidence interval 0.57–0.67). The occurrence of a short-term PM complication was not predictive of future PM complications. Conclusions: Complication incidence in modern pacing therapy is still substantial. Most complications occur early after PM implantation. Although various patient- and procedure-related characteristics are independent predictors for early and late complications, their ability to identify the patient at high risk is rather poor. This relatively high incidence of PM complications and their poor prediction underscores the usefulness of current guidelines for regular follow-up of patients with PM.
- Potential mechanisms underlying the effect of gender on r... Background: Recent studies demonstrate that women may respond more favorably to cardiac resynchronization therapy (CRT) than do men. The mechanisms remain unclear. Objectives: To describe the effects of gender on response to CRT and to explore potential mechanisms behind these differences. Methods: Data for 846 patients from the SMART-AV trial were used to evaluate the mechanisms behind the effects of gender on CRT response. Atrioventricular optimization (AVO) was performed via SmartDelay or echocardiography. Baseline and 6-month left ventricular end systolic volume index (LVESVi) were fitted to a linear regression model with gender predicting change in LVESVi and adjusted for baseline covariates significantly differing by gender. The interaction variable for AVO and gender was also assessed for its effect on change in LVESVi. Results: Baseline variables, including age, body mass index, left ventricular ejection fraction, QRS width, and severity of heart failure symptoms, were comparable between men and women. Women had a higher incidence of left bundle branch block conduction and nonischemic cardiomyopathy and exhibited greater reductions in LVESVi even after adjustment for these differences (13.4 mL/m2 vs 8.5 mL/m2; P = .002). In addition, women had greater percentages of biventricular pacing and appeared to derive greater reductions in left ventricular volume with AVO than did men. Conclusions: Women demonstrated greater reductions in LVESVi with CRT than did men. These observations are not explained by differences in baseline characteristics. Greater degrees of biventricular pacing and enhanced response to AVO in women may partly explain the reason for the gender effect on CRT response.
- Riata implantable cardioverter-defibrillator lead failure... Background: The Riata family of implantable cardioverter-defibrillator leads (St Jude Medical, Sylmar, CA) appears prone to a unique failure mechanism whereby the conductor cables wear through the silicone insulation from inside-out and are seen outside the lead body (externalized conductors). Objective: To assess the extent of Riata lead damage associated with inside-out insulation defects and their clinical consequences. Methods: In September 2011, we searched the U.S. Food and Drug Administration's Manufacturers and User Defined Experience medical device database for reports describing Riata lead failures that had been analyzed by the manufacturer. Results: The Manufacturers and User Defined Experience search identified 105 leads that had inside-out insulation defects. Eight-French single-coil Riata leads accounted for a higher-than-expected proportion (25.7%) of the leads with this defect. A total of 226 insulation defects were found in the 105 leads (2.2 defects per lead), including 143 inside-out defects (1.4 defects per lead). The most common location of insulation defects was distal to the proximal coil (n = 108). Twenty-eight leads (26.7%) had inside-out insulation defects underneath the shocking coils. Of 43 leads whose cables were assessed for the integrity of the ethylene-tetrafluoroethylene cable coating, 22 (51.2%) were found to be abraded, exposing the conductor surfaces. On X-ray radiography or fluoroscopy, 7 leads were found to have externalized cables; 2 of these leads had no electrical abnormalities, while 4 exhibited noise or increased impedance. Inappropriate shocks were experienced by 31 of the 105 patients (29.5%). Conclusion: Riata leads that have inside-out insulation defects often have multiple defects, including additional inside-out abrasions along the body of the lead and beneath the shocking coils. Eight-French single-coil Riata models may be more prone to externalized cables than are dual-coil and 7-F designs. Externalized cables are but one manifestation of interior insulation damage. Our findings question the durability of the ethylene-tetrafluoroethylene cable coating on exposed cables.
International Journal of Cardiology
- Editorial Board
- The use of coercive trial acronyms should be discouraged Physicians, especially cardiologists, like to use or invent acronyms . All the current medical journals, especially cardiological journals, continue to be filled with acronyms. New acronyms are being invented every day, especially for cardiological trials. The use of acronyms is sometimes necessary to simplify and facilitate modern communication in our highly technical world, especially to avoid repetition of long, unwieldy, breath-catching and space-occupying trial names in a scientific publication . A trial acronym is particularly advantageous to the participating investigators of the trial who, by merely mentioning the acronym, can be instantly referred to the appropriate staff to answer any questions when they call a trial center to register a potential patient .
- Circulating biomarkers with preventive, diagnostic and pr... Abstract: The search for molecules that may contribute to better identify patients at risk for cardiovascular diseases (CVD) represents today an active field in clinical research. Few biomarkers have already been identified as reliable and useful tools in medical decision making, such as cardiac troponin (cTn) and NT-proBNP. At the same time, evidence regarding the possible role of other molecules is piling up. Every new putative biomarker has demonstrated effectiveness in at least one clinical application: cardiovascular risk assessment, diagnosis or outcome prediction. On the other hand, combination of preventive, diagnostic and prognostic implications for the same molecule is expected to improve enormously the usefulness of a biomarker in medicine. We performed a search of the literature looking for circulating molecules found to exert discriminating abilities in all three mentioned clinical applications. The purpose of the present review is to bring to the attention of medical and research communities those biomarkers for which a relevant amount of evidence has been accumulated regarding their potential application in all clinical steps of the cardiovascular continuum.Furthermore, since simultaneous testing of different plasmatic molecules has been proposed as a suitable tool to improve medical decision making, we also discuss feasible associations of biomarkers that promise to be the most effective for cardiovascular risk assessment in the general population and for outcome prediction in patients affected by acute coronary syndrome (ACS) and by heart failure (HF).
- Non-red blood cell transfusion as a risk factor for morta... Abstract: Background: Bleeding following percutaneous coronary intervention (PCI) is common and may lead to transfusion and death. Although previous work has examined the effect of red blood cell (RBC) transfusion in patients with coronary disease, no study had investigated whether transfusion of non-RBC components was associated with mortality following PCI.Methods: All subjects transfused in the 10days following PCI were identified using the British Columbia Cardiac and Central Transfusion Registries. Patients undergoing cardiac surgery following PCI were excluded as transfusion was assumed to be due to surgical related bleeding. Transfusion products were categorised as RBC and non-RBC comprising platelets, plasma and cryoprecipitate. Blood product use was compared according to thirty day mortality using multivariate regression and propensity adjustment for confounding variables.Results: From a total of 32,580 patients who underwent PCI, 952 patients received at least 1 blood product within 10days of PCI. Non-RBC transfusion occurred more commonly in the cohort of transfused patients dying within 30days (p<0.001). After adjustment for baseline risk, transfusion of plasma/cryoprecipitate (HR 5.17; 95% C.I. 2.87–9.32, p<0.001) and platelets (HR 2.13; 95% C.I. 1.10–4.13, p=0.03) was associated with increased 30day mortality. In a propensity risk adjusted model, transfusion of plasma/cryoprecipitate and RBC transfusion volume remained as significant predictors of 30-day mortality (p<0.001).Conclusions: Transfusion following PCI appears to be associated with an increased risk of death within 30days. We now report that transfusion with plasma rich non-RBC products may confer an additional mortality risk to patients undergoing PCI.
- Tanshinone IIA prevents doxorubicin-induced cardiomyocyte... Abstract: Background: Doxorubicin, one of the original anthracyclines, remains among the most effective anticancer drugs ever developed. Clinical use of doxorubicin is, however, greatly limited by its serious adverse cardiac effects that may ultimately lead to cardiomyopathy and heart failure. Tanshinone IIA is the main effective component of Salvia miltiorrhiza known as ‘Danshen’ in traditional Chinese medicine for treating cardiovascular disorders. The objective of this study was set to evaluate the protective effect of tanshinone IIA on doxorubicin-induced cardiomyocyte apoptosis, and to explore its intracellular mechanism(s).Methods: Primary cultured neonatal rat cardiomyocytes were treated with the vehicle, doxorubicin (1μM), tanshinone IIA (0.1, 0.3, 1 and 3μM), or tanshinone IIA plus doxorubicin.Results: We found that tanshinone IIA (1 and 3μM) inhibited doxorubicin-induced reactive oxygen species generation, reduced the quantity of cleaved caspase-3 and cytosol cytochrome c, and increased BcL-xL expression, resulting in protecting cardiomyocytes from doxorubicin-induced apoptosis. In addition, Akt phosphorylation was enhanced by tanshinone IIA treatment in cardiomyocytes. The wortmannin (100nM), LY294002 (10nM), and siRNA transfection for Akt significantly reduced tanshinone IIA-induced protective effect.Conclusions: These findings suggest that tanshinone IIA protects cardiomyocytes from doxorubicin-induced apoptosis in part through Akt-signaling pathways, which may potentially protect the heart from the severe toxicity of doxorubicin.
- Duration of preceding hypertension is associated with pro... Abstract: Background: A substantial proportion of patients suffer prolonged length of intensive care unit stay (PLOS) or prolonged mechanical ventilation (PMV) following coronary artery bypass grafting (CABG). Identifying factors associated with PLOS and PMV would aid in patient risk stratification. We sought to identify the factors associated with PLOS and PMV following CABG.Methods: Participants were patients undergoing first-time elective CABG. All were observed until discharge and clinical data were collected on a standardized proforma. PLOS and PMV were defined a priori as >2days and >12h respectively, based on centre norms.Results: Of the 439 patients in the study, 105 (23.9%) had PLOS and 111 (25.2%) had PMV. Independent predictors of PMV were age, diabetes, previous myocardial infarction (MI), New York Heart Association (NYHA) class and statin use. The only independent predictor of PLOS was the duration of preceding hypertension.Conclusion: The factors associated with PMV and PLOS in our study are easily attainable, routine clinical details and may be built into bed management algorithms. Confirmation of the association of preceding hypertension and subsequent investigation of the possible mechanism mediating this association, is suggested.
- Duty-cycled unipolar/bipolar versus conventional radiofre... Abstract: Background: Duty-cycled (DC) radiofrequency ablation (RFA) for atrial fibrillation (AF) has been introduced, however, data on large patient series and comparison to conventional RFA are scarce.Methods: Between 2006 and 2008DC RFA was performed in 209 consecutive patients (143 (68%) paroxysmal and 66 (32%) persistent AF). As controls served 211 patients, 155 (73%) with paroxysmal and 56 (27%) with persistent AF (p=0.3). In DC RFA, the pulmonary veins (PV) were isolated followed by ablation at the septum and left atrium, if AF persisted. Conventional PV isolation was followed by anatomical lines at the roof and mitral isthmus.Results: Freedom of paroxysmal AF was demonstrated after 1.08DC RFA procedures per patient in 82% and after 1.19 conventional procedures in 87% after 8.5±6.5months (ns). In persistent AF, success rates were 79% after 1.35DC RFA procedures and 80% after 1.34 conventional procedures after 11.5±8.5months (ns). The subgroup analysis of 119 patients with follow-up ≥12months (17.5 [14.1–23.6] months) showed similar results. Left atrial flutter occurred in 3% and 8% after paroxysmal AF ablation (p<0.05) and in 12% and 23% after persistent AF ablation (p=0.1). Multivariate predictors for success in both groups were age, left atrial size, presence of persistent vs. paroxysmal AF and previous pacemaker implantation, but not the ablation technique used. Non-fatal complications were seen in 2.8% with no differences between the groups.Conclusion: Outcome in DC RFA is similar to conventional RFA with a final success rate exceeding 80% in both paroxysmal and persistent AF in the absence of fatal complications.
- The N-terminal pro-B-type natriuretic peptide as a predic... Abstract: Background: The purpose of this study was to evaluate the value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a predictor of disease progression in patients with pericardial effusions (PE).Method: We retrospectively studied consecutive patients that had moderate or large PEs. Patients with pericardial events, such as reaccumulation of PE, persistent drainage through a catheter longer than one week, or newly developed constrictive pericarditis were defined as the progression group (Group A), and patients without these findings were defined as the group with no progression (Group B). The NT-proBNP assay was performed when PE was detected.Results: Compared to Group B (27 patients), Group A (15 patients) exhibited lower systolic and diastolic blood pressures (106±13 vs. 118±19mmHg, p=0.028; 69±9 vs. 75±11mmHg, p=0.047), higher NT-proBNP levels (1063±756 vs. 578±1090ng/L, p=0.002), larger inferior vena cava (21±6 vs. 17±5mm, p=0.039) and higher estimated right ventricular systolic pressure (37±5 vs. 32±6mmHg, p=0.024). NT-proBNP was the only independent predictor of disease progression (p=0.034) by multivariate regression analysis. The receiver-operating characteristic curve analysis showed that NT-proBNP values ≥548ng/L demonstrated a sensitivity of 80% and a specificity of 78% for identifying disease progression (p=0.001).Conclusions: The NT-proBNP value may predict disease progression in patients with PE. However, additional prospective studies with more patients are needed.
- Combined effects of up- and downstream therapies on atria... Abstract: Background: Recent reports suggest angiotensin receptor blockers (ARBs) and some antiarrhythmic agents affect atrial remodeling in atrial fibrillation (AF). We evaluated the effect of combination therapy with olmesartan (Olm) and bepridil (Bep) in a canine model of AF.Methods and results: An atrial stimulation device was implanted in 10 dogs undergoing 6-week pacing at 400bpm. They were divided into Olm (2mg/kg/day) (n=5) and Olm+Bep (Olm, 2mg/kg/day; Bep, 10mg/kg/day) groups (n=5). Atrial effective refractory period (AERP), conduction velocity (CV), and AF inducibility were evaluated weekly, and hemodynamics, atrial histology, and mRNA expression and protein expression of ion-channel and gap junction-related molecules at 6weeks. Data were compared between groups and with non-pacing control and pacing-control groups from our previous report.The pacing-control group exhibited shortened AERP, decreased CV, increased AF inducibility and tissue fibrosis, and down-regulated L-type Ca2+ channel (LCC), SCN5A, Kv4.3 and connexin43 (Cx43). By comparison, the Olm group exhibited suppression of the decrease in CV and of the increase in AF inducibility, but no change in AERP shortening. The Olm+Bep group exhibited suppression of AERP shortening as well as the greatest decrease in AF inducibility. Histologically, tissue fibrosis was suppressed in Olm and Olm+Bep groups. Down-regulation of Cx43 was partly suppressed in the Olm group while that of LCC, SCN5A, and Cx43 was suppressed in the Olm+Bep group.Conclusion: Olm and Bep in combination suppressed AF inducibility more strongly than Olm alone, and may be more useful in the suppression of AF.
- Defining high-risk patients with ST-segment elevation acu... Abstract: Background: Identification of high-risk patients with ST-segment elevation acute myocardial infarction (STEMI) is of the utmost importance for adequate patient stratification and evaluation of additive treatments. However, there is no consensus on the optimal definition of high-risk patients.Methods: We therefore compared 5 scoring systems in the assessment of the risk of 30-day mortality in 3214 patients with STEMI treated with primary percutaneous coronary intervention (PCI).Results: Clinical scores showed a large variability in risk stratifying patients. Identification of high-risk patients ranged from 15% (PAMI score≥9) to 66% (McNamara definition). McNamara, Antoniucci and Brodie definitions had the best sensitivity (0.87–0.88 and 95% confidence intervals (CI) ranging from 0.82–0.93) while PAMI≥9 had the best specificity (0.87 with 95% CI of 0.86–0.88), while its sensitivity was quite low (0.42). In a sample size simulation of a trial aimed at demonstrating a 33% difference in 30-day mortality between two hypothetical treatments, the number of STEMI patients needed to be screened varied from 4712 for the Brodie definition to 9038 for the PAMI≥9 score.Conclusions: There is a large variability in risk stratification, sensitivity, specificity and predictive values among different scoring systems. These considerations should be taken into account when designing randomised trials.
American Heart Journal
- Triple antithrombotic therapy after coronary stenting in ... Dual antiplatelet therapy has become the cornerstone of the treatment for patients undergoing coronary stenting and of those with acute coronary syndromes with or without stent implantation. Although there is consensus about the indication for dual antiplatelet therapy, there is little evidence about the optimal duration of therapy. In patients surviving non–ST-segment elevation acute coronary syndromes, 1 year of treatment is advised. Cardiologists prefer longer dual antiplatelet therapy rather than single antiplatelet medication (aspirin alone) in patients with drug-eluting stents when compared with carriers of bare metal stents. Consequently, many patients in the cardiology practice in 2012 are on dual antiplatelet therapy, mainly aspirin and clopidogrel. The only important side effect of dual antiplatelet therapy is increased bleeding in comparison with aspirin alone. This has been established in the large trials with clopidogrel in acute coronary syndromes and therafter as well as in atrial fibrillation. Especially in the latter, dual antiplatelet therapy has shown to be as hazardous as oral anticoagulation. Special attention of the risks of dual antiplatelet therapy has been given to patients awaiting coronary artery bypass surgery. Clopidogrel on top of aspirin has been associated with significantly increased blood loss during coronary surgery when compared with aspirin alone. However, this excess bleeding was not significantly associated with an increased risk of reoperation or mortality. Yet, it is generally advised to discontinue clopidogrel 5 days ahead of coronary surgery. Little is known, however, about the optimal strategy in patients on dual antiplatelet therapy undergoing other forms of surgery such as abdominal surgery, orthopedic procedures, neurosurgical operations, or procedures in other vital organs where bleeding can result in organ loss.
- Rationale and design of a Global Rheumatic Heart Disease ... Background: Rheumatic heart disease (RHD) is the principal cause of valvular heart disease–related mortality and morbidity in low- and middle-income countries. The disease predominantly affects children and young adults. It is estimated that RHD may potentially be responsible for 1.4 million deaths annually worldwide and 7.5% of all strokes occurring in developing countries. Despite the staggering global burden, there are no contemporary data documenting the presentation, clinical course, complications, and treatment practices among patients with RHD.Methods: The REMEDY study is a prospective, international, multicenter, hospital-based registry planned in 2 phases: the vanguard phase involving centers in Africa and India will enrol 3,000 participants with RHD over a 1-year period. We will document clinical and echocardiographic characteristics of patients at presentation. Over a 2-year follow-up, we will document disease progression and treatment practices with particular reference to adherence to secondary prophylaxis and oral anticoagulation regimens. With 3,000 patients, we will be able to reliably determine the incidence of all-cause mortality, worsening heart failure requiring hospitalization, systemic embolism (including stroke), and major bleeding individually among all participants. We will identify barriers to care in a subgroup of 500 patients.Conclusion: The REMEDY study will provide comprehensive, contemporary data on patients with RHD and will help in the development of strategies to prevent and manage RHD and its complications.
- Target temperature management after out-of-hospital cardi... Background: Experimental animal studies and previous randomized trials suggest an improvement in mortality and neurologic function with induced hypothermia after cardiac arrest. International guidelines advocate the use of a target temperature management of 32°C to 34°C for 12 to 24 hours after resuscitation from out-of-hospital cardiac arrest. A systematic review indicates that the evidence for recommending this intervention is inconclusive, and the GRADE level of evidence is low. Previous trials were small, with high risk of bias, evaluated select populations, and did not treat hyperthermia in the control groups. The optimal target temperature management strategy is not known.Methods: The TTM trial is an investigator-initiated, international, randomized, parallel-group, and assessor-blinded clinical trial designed to enroll at least 850 adult, unconscious patients resuscitated after out-of-hospital cardiac arrest of a presumed cardiac cause. The patients will be randomized to a target temperature management of either 33°C or 36°C after return of spontaneous circulation. In both groups, the intervention will last 36 hours. The primary outcome is all-cause mortality at maximal follow-up. The main secondary outcomes are the composite outcome of all-cause mortality and poor neurologic function (cerebral performance categories 3 and 4) at hospital discharge and at 180 days, cognitive status and quality of life at 180 days, assessment of safety and harm.Discussion: The TTM trial will investigate potential benefit and harm of 2 target temperature strategies, both avoiding hyperthermia in a large proportion of the out-of-hospital cardiac arrest population.
- Design and rationale for the PREVAIL study: Effect of e-H... Intensive exercise may be an important part of rehabilitation in patients with congenital heart disease (CHD). However, performing regular physical exercise is challenging for many adolescent patients. Consequently, effective exercise encouragements may be needed. Little is known on the effect of e-Health encouragements on physical fitness, physical activity, and health-related quality of life in adolescents.This trial is a nationwide interactive e-Health rehabilitation study lasting 1 year, centered on interactive use of mobile phone and Internet technology. We hypothesize that e-Health encouragements and interactive monitoring of intensive exercise for 1 year can improve physical fitness, physical activity, and health-related quality of life.Two hundred sixteen adolescents (age, 13-16 years) with surgically corrected complex CHD but without significant hemodynamic residual defects and no restrictions to participate in physical activity are in the process of being enrolled by invitation after informed consent.Physical fitness is measured as the maximal oxygen uptake (Vo2) at baseline and after 12 months by an assessor blinded to the randomization group. After baseline testing, the patients are 1:1 randomized to an intervention group or a control group.Individually fully automated tailored e-Health encouragements—SMS, Internet, and mobile applications—aimed at increasing physical activity are delivered to the participants in the intervention group once a week. The Bandura's Social Cognitive Theory inspires the behavioral theoretical background. The e-Health intervention and the Godfrey cycle ergometer protocol have been feasibility tested and seem applicable to adolescents with CHD. The trial is expected to contribute with new knowledge regarding how physical activity in adolescents with CHD can be increased and, possibly, comorbidity be reduced.
- DUrable polymer-based sTent CHallenge of Promus ElemEnt v... Background: Drug-eluting stents (DES) are increasingly used for the treatment of coronary artery disease. An optimized DES performance is desirable to successfully treat various challenging coronary lesions in a broad population of patients. In response to this demand, third-generation DES with an improved deliverability were developed. Promus Element (Boston Scientific, Natick, MA) and Resolute Integrity (Medtronic Vascular, Santa Rosa, CA) are 2 novel third-generation DES for which limited clinical data are available. Accordingly, we designed the current multicenter study to investigate in an all-comers population whether the clinical outcome is similar after stenting with Promus Element versus Resolute Integrity.Methods: DUTCH PEERS is a multicenter, prospective, single-blinded, randomized trial in a Dutch all-comers population. Patients with all clinical syndromes who require percutaneous coronary interventions with DES implantation are eligible. In these patients, the type of DES implanted will be randomized in a 1:1 ratio between Resolute Integrity versus Promus Element. The trial is powered based on a noninferiority hypothesis. For each stent arm, 894 patients will be enrolled, resulting in a total study population of 1,788 patients. The primary end point is the incidence of target vessel failure at 1-year follow-up.Summary: DUTCH PEERS is the first randomized multicenter trial with a head-to-head comparison of Promus Element and Resolute Integrity to investigate the safety and efficacy of these third-generation DES.
- Reinfarction after percutaneous coronary intervention or ... Background: The OAT study randomized 2,201 patients with a totally occluded infarct-related artery on days 3 to 28 (>24 hours) after myocardial infarction (MI) to percutaneous coronary intervention (PCI) or medical treatment (MED). There was no difference in the primary end point of death, reinfarction, or heart failure at 2.9 or 6-year mean follow-up. However, in patients randomized to PCI, there was a trend toward a higher rate of reinfarction.Methods: We analyzed the characteristics and types of reinfarction according to the universal definition. Independent predictors of reinfarction were determined using Cox proportional hazard models with follow-up up to 9 years.Results: There were 169 reinfarctions: 9.4% PCI vs 8.0% MED, hazard ratio 1.31, 95% CI 0.97-1.77, P = .08. Spontaneous reinfarction (type 1) occurred with similar frequency in the groups: 4.9% PCI vs 6.7% MED, hazard ratio 0.78, 95% CI 0.53-1.15, P = .21. Rates of type 2 (secondary) and 3 (sudden death) MI were similar in both groups. There was an increase in type 4a reinfarctions (related to protocol or other PCI) (0.8% PCI vs 0.1% MED, P = .01) and type 4b reinfarctions (stent thrombosis) (2.7% PCI vs 0.6% MED, P < .001).Multivariate predictors of reinfarction were history of PCI before study entry (P = .001), diabetes (P = .005), and absence of new Q waves with the index infarction (P = .01).Conclusions: There was a trend for reinfarctions to be more frequent with PCI. Opening an occluded infarct-related artery in stable patients with late post-MI may expose them to a risk of subsequent reinfarction related to reocclusion and stent thrombosis.
- Differences in symptom presentation and hospital mortalit... Background: Chest pain/discomfort (CP) is the hallmark symptom of acute myocardial infarction (MI), but some patients with MI present without CP. We hypothesized that MI type (ST-segment elevation MI [STEMI] or non-STEMI [NSTEMI]) may be associated with the presence or absence of CP.Methods: We investigated the association between CP at presentation and MI type, hospital care, and mortality among 1,143,513 patients with MI in the National Registry of Myocardial Infarction (NRMI) from 1994 to 2006.Results: Overall, 43.6% of patients with NSTEMI and 27.1% of patients with STEMI presented without CP. For both MI type, patients without CP were older, were more frequently female, had more diabetes or history of heart failure, were more likely to delay hospital arrival, and were less likely to receive evidence-based medical therapies and invasive cardiac procedures. Multivariable analysis indicated that NSTEMI (vs STEMI) was the strongest predictor of atypical symptoms (adjusted odds ratio [95% CI], 1.93 [1.91-1.95]). Within the 4 CP/MI type categories, hospital mortality was highest for no CP/STEMI (27.8%), followed by no CP/NSTEMI (15.3%) and CP/STEMI (9.6%), and was lowest for CP/NSTEMI (5.4%). The adjusted odds ratio of mortality was 1.38 (1.35-1.41) for no CP (vs CP) in the STEMI group and 1.31 (1.28-1.34) in the NSTEMI group.Conclusions: Hospitalized patients with NSTEMI were nearly 2-fold more likely to present without CP than patients with STEMI. Patients with MI without CP were less quickly diagnosed and treated and had higher adjusted odds of hospital mortality, regardless of whether they had ST-segment elevation.
- Heart rate recovery in pulmonary arterial hypertension: R... Background: Delayed postexercise heart rate recovery (HRR) has been associated with disability and poor prognosis in chronic cardiopulmonary diseases. The usefulness of HRR to predict exercise impairment and mortality in patients with pulmonary arterial hypertension (PAH), however, remains largely unexplored.Methods: Seventy-two patients with PAH of varied etiology (New York Heart Association classes I-IV) and 21 age- and gender-matched controls underwent a maximal incremental cardiopulmonary exercise test (CPET), with heart rate being recorded up to the fifth minute of recovery.Results: Heart rate recovery was consistently lower in the patients compared with the controls (P 18 (n = 32) had better New York Heart Association scores, resting hemodynamics and 6-minute walking distance. In fact, HRR1min >18 was associated with a range of maximal and submaximal CPET variables indicative of less severe exercise impairment (P 18 beats) is associated with less impaired responses to incremental exercise in patients with PAH. Conversely, a delayed HRR1min response has negative prognostic implications, a finding likely to be clinically useful when more sophisticated (and costlier) analyses provided by a full CPET are not available.
- Current practice for determining pulmonary capillary wedg... Background: Accurate measurement of left ventricular filling pressure is important to distinguish between category 1 pulmonary arterial hypertension (PAH) and category 2 pulmonary hypertension (PH) from left heart diseases (PH-HFpEF). We hypothesized that the common practice of relying on the digitized mean pulmonary capillary wedge pressure (PCWP-digital) results in erroneous recordings, whereas end-expiratory PCWP measurements (PCWP–end Exp) provide a reliable surrogate measurement for end-expiratory left ventricular end-diastolic pressure (LVEDP–end Exp–end Exp).Methods: We prospectively performed left and right cardiac catheterization on 61 patients referred for evaluation of PH and compared the LVEDP–end Exp to end-expiration to the (a) PCWP–end Exp and (b) PCWP-digital.Results: The PCWP–end Exp was a more reliable reflection of LVEDP–end Exp (mean 13.2 mm Hg vs 12.4 mm Hg; P, nonsignificant) than PCWP-digital (mean 8.0 mm Hg vs 12.4 mm Hg, P < .05). Bland-Altman analysis of PCWP-digital and LVEDP–end Exp revealed a mean bias of −4.4 mm Hg with 95% limits of agreement of −11.3 to 2.5 mm Hg. Bland-Altman analysis of PCWP–end Exp and LVEDP–end Exp revealed a mean bias of 0.9 mm Hg with 95% limits of agreement of −5.2 to 6.9 mm Hg. If PCWP-digital were used to define LVEDP–end Exp, 14 (27%) of 52 patients would have been misclassified as having PAH rather than PH-HFpEF. Patients with obesity and hypoxia were particularly more likely to be misclassified as PAH instead of PH-HFpEF if PCWP-digital was used to define LVEDP–end Exp (odds ratio 8.1, 95% CI 1.644-40.04, P = .01).Conclusions: The common practice of using PCWP-digital instead of PCWP–end Exp results in a significant underestimation of LVEDP–end Exp. In our study, this translated to nearly 30% of patients being misclassified as having PAH rather than PH from HFpEF.
- Use of a highly sensitive assay for cardiac troponin T an... Background: Biomarkers have been proposed to augment or replace endomyocardial biopsy (EMB) to diagnose acute transplant rejection (AR). A new, highly sensitive assay for troponin T detects levels of cardiac troponin T (cTnT) 10- to 100-fold lower than standard assays but has not been investigated in transplant patients. N-terminal pro-brain natriuretic peptide (NT-proBNP) has not been evaluated in pediatric transplant patients. The purpose of this pilot study was to evaluate the association of cTnT and NT-proBNP with AR in pediatric cardiac transplant patients.Methods: Plasma was obtained at the time of EMB from pediatric patients ≥1 year old. N-terminal pro-brain natriuretic peptide was measured in fresh plasma at the time of biopsy, and cTnT was measured from frozen, stored samples using the highly sensitive assay for troponin T. Biomarker data were correlated with EMB results. Cellular AR was defined as an International Society for Heart and Lung Transplantation biopsy score of grade ≥2R.Results: Fifty-three blood samples were obtained from 42 patients (mean age 11 years). Seven episodes of AR occurred in 5 patients. Biopsies with vs without AR were associated with higher cTnT (median [interquartile range {IQR}] 66 [45-139] vs 7 [2-13] pg/mL, P = .001) and NT-proBNP (median [IQR] 11,169 [280-23,317] vs 334 [160-650] pg/mL, P < .01). After successful treatment of AR in 5 patients, cTnT fell markedly (median [IQR] 53.5 [44.8-66.5] to 10.7 [1.5-16.4], P = .05).Conclusion: In this pilot study, we found marked elevation of cTnT and NT-proBNP among children with AR. Moreover, reduction in cTnT levels after treatment paralleled improvement in EMB results. If these findings are confirmed in larger prospective studies, monitoring with these biomarkers may obviate surveillance EMB.
American Journal of Cardiovascular Drugs
- Role of Antihypertensive Drugs in Arterial ‘De-Stiffeni... Arterial stiffness is an independent predictor of cardiovascular (CV) morbidity and mortality in patients with hypertension, as well as a potential therapeutic target. There is increasing awareness that the pulsatile hemodynamics (central blood pressure [CBP], pulse pressure [PP], wave reflections [augmentation index or AIx] and pulse wave velocity [PWV]) may provide better insight into the pathophysiology of CV disorders and target organ damage related to hypertension. Different antihypertensive drugs produce diverse effects on arterial stiffness variables, despite similar effects on peripheral (brachial) blood pressure. Identifying the pharmacologic interventions that can improve arterial stiffness (‘de-stiffening’ treatment) is a promising field of research.
- Therapeutic Potential of Terminalia Arjuna in Cardiovascu... The bark of the tree Terminalia arjuna (Roxb.) is widely used in Indian medicine (Ayurveda) for various cardiovascular ailments. The bark has been reported to contain several bioactive compounds. Many experimental studies have reported its antioxidant, anti-ischemic, antihypertensive, and antihypertrophic effects, which have relevance to its therapeutic potential in cardiovascular diseases in humans. Several clinical studies have reported its efficacy mostly in patients with ischemic heart disease, hypertension, and heart failure. However, a major shortcoming in all these experimental and clinical studies is the absence of phytochemical standardization of the extracts. In addition, many clinical studies are poor in terms of design and methods used for generating safety data. This review discusses how to address all these issues for a scientific validation of this medicinal plant.
- Epidemiology and Management of Hypertension in the Hispan... Hispanics are the fastest growing ethnic minority in the USA. Among Hispanics, lack of hypertension awareness and lack of effective blood pressure (BP) control are problematic, as are higher incidence rates of hypertension-related co-morbidities compared with non-Hispanic populations. Moreover, there are currently no hypertension treatment guidelines that address the unique characteristics of this ethnic group. This article discusses ethnic differences in hypertension and cardiovascular risk factors and reviews the literature on the efficacy of antihypertensive agents in Hispanic patients, with a focus on the role of renin-angiotensin-aldosterone system (RAAS) inhibition in the management of hypertension in these patients. Hypertension in Hispanic patients can be challenging to manage, in part because this population has a higher prevalence of obesity, diabetes, and metabolic syndrome compared with non-Hispanic whites. The presence of these co-morbidities suggests that RAAS-inhibitor-based therapies may be particularly beneficial in this population. However, few studies have evaluated the efficacy of antihypertensive treatments in Hispanic patients. Two outcomes studies in hypertensive patients have shown the benefits of treating Hispanic patients with antihypertensive therapy and included RAAS inhibitors as part of the treatment regimen. In addition, BP-lowering trials have shown the antihypertensive efficacy of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and direct renin inhibitors, although data on the latter are more limited. Additional studies are needed to more thoroughly evaluate the effects of RAAS inhibitors (and other drug classes) on outcomes and BP lowering in the Hispanic hypertensive population.
- Heart Rate-Lowering Efficacy and Respiratory Safety of Iv... Background: There is substantial evidence that heart rate (HR) is a powerful predictor of mortality in both normal individuals and in patients with cardiovascular disease. The use of β-adrenoceptor antagonists (β-blockers) has confirmed the importance of lowering elevated HR in a patient's prognosis. However, these agents can have undesirable adverse effects (AEs) and due to the risk of bronchoconstriction are contraindicated in patients with obstructive airway disease. A selective bradycardic agent, without such undesirable effects, could be of therapeutic interest. Ivabradine, a new If inhibitor that acts specifically on the sino-atrial node, is a pure HR-lowering agent. Objective: The objective of this study was to assess HR-lowering efficacy and respiratory safety of ivabradine in patients with asthma and chronic obstructive pulmonary disease (COPD). Methods: This was a randomized, single-center, double-blind, placebo-controlled, crossover trial. Enrolment began in May 2009, and the last patient completed the study in January 2011. The study was conducted in an ambulatory setting. A total of 40 patients completed the study (20 asthmatic patients and 20 COPD patients). Inclusion criteria were: documented diagnosis of asthma or COPD according to international guidelines, age 18–75 years, and mean HR on Holter ECG recording of ≥60 beats/min. Exclusion criteria included disease exacerbation in a previous month or inability to understand instructions on the study procedures. All patients received ivabradine 7.5 mg twice daily for 5 days and placebo twice daily for 5 days in a crossover manner, in one of the two arms of the study, with at least 2 days of washout between treatments. The main outcome measures included the difference in HR between ivabradine and placebo treatment and change in HR in comparison with baseline. Other evaluated outcomes were differences in the peak expiratory flow rate (PEFR), the daily symptom score, rescue medication consumption, and AEs. Results: Ivabradine produced significantly lower mean HR than placebo in both groups of patients: asthma 67.4 ± 8.38 versus 82.85 ± 11.19 beats/min (p 0.05). Both treatments were well tolerated. The incidence of AEs was low and generally similar in both periods of treatment, except for visual symptoms during treatment with ivabradine, which was reported by 5% of the patients. Conclusion: Our study demonstrated that selective HR reduction with ivabradine is effective in patients with asthma and COPD, with no alteration in respiratory function or symptoms over the duration of the study. Ivabradine offers an interesting alternative, as an HR-lowering agent, in patients with respiratory disease and contraindications to β-blockers. Clinical Trial Registration: Registered at www.clinicaltrials.gov (NCT01365286).
- Comparison of the Efficacy and Safety of Fixed-Dose Amlod... Background: Fixed-dose combination drugs may enhance blood pressure (BP) goal attainment through complementary effects and reduced side effects, which leads to better compliance. Objective: This study aimed to evaluate the efficacy and safety profiles of once-daily combination amlodipine/losartan versus losartan. Methods: This was an 8-week, double-blind, multicenter, randomized phase III study conducted in outpatient hospital clinics. Korean patients with essential hypertension inadequately controlled on losartan 100 mg were administered amlodipine/losartan 5 mg/100 mg combination versus losartan 100 mg. The main outcome measures were changes in sitting diastolic blood pressure (DBP) and sitting systolic blood pressure (SBP) and BP response rate from baseline values, which were assessed after 4 and 8 weeks of treatment. Safety and tolerability were also assessed. Results: At week 8, both groups achieved significant reductions from baseline in DBP (11.7 ± 7.0 and 3.2 ± 7.9 mmHg), which was significantly greater in the amlodipine/losartan 5 mg/100 mg combination (n = 70) group (p < 0.0001). Additionally, the amlodipine/losartan 5 mg/100 mg combination group achieved significantly greater reductions in SBP at week 8 and in SBP and DBP at week 4 compared with the losartan 100 mg (n = 72) group (all p < 0.0001). Response rates were significantly higher in the amlodipine/losartan 5 mg/100 mg group versus the losartan 100 mg group (81.4% vs 63.9% at week 4, p < 0.0192; 90.0% vs 66.7% at week 8, p < 0.001). Both treatments were generally well tolerated. Conclusion: Switching to a fixed-dose combination therapy of amlodipine/losartan 5 mg/100 mg was associated with significantly greater reductions in BP and superior achievement of BP goals compared with a maintenance dose of losartan 100 mg in Korean patients with essential hypertension inadequately controlled on losartan 100 mg. Clinical Trial Registration: Registered at Clinicaltrials.gov as NCT00940680.
- Consistency of Extended-Release Niacin/Laropiprant Effect... Background: According to prior analyses, extended-release niacin/laropiprant (ERN/LRPT) consistently reduces low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG) and increases high-density lipoprotein cholesterol (HDL-C) levels across a wide range of dyslipidemic patient subgroups. Objectives: This analysis examined ERN/LRPT's consistency across four phase III, randomized, double-blind trials in improving other lipid/lipoprotein parameters associated with cardiovascular risk, across several key dyslipidemic patient subgroups. Methods: In three of the studies, the randomized population included patients with primary hypercholesterolemia or mixed hyperlipidemia; in the remaining study, the population included patients with type 2 diabetes mellitus. The lipid-altering consistency of ERN/LRPT's efficacy was evaluated versus the pre-defined comparator (placebo or active control) among key subgroups of sex, race (White, non-White), region (US, ex-US), baseline age (<65 years, ≥65 years), use of statin therapy (yes, no), coronary heart disease (yes, no), risk status (low, multiple, high), and type of hyperlipidemia (primary hypercholesterolemia, mixed dyslipidemia), as well as across baseline LDL-C, HDL-C, and TG levels. The consistency of the treatment effects on lipoprotein(a).[Lp(a)], apolipoprotein B (ApoB), non-HDL-C, ApoA1, and ApoB/ApoA1 ratio was evaluated by examining treatment difference estimates of the percentage change from baseline with 95% confidence intervals. Results: Treatment with ERN/LRPT produced significantly greater improvements in Lp(a), ApoB, non-HDL-C, ApoA1, and ApoB/ApoA1 ratio compared with placebo/active comparator in each study. These effects were generally consistent across key subgroups within each study. Conclusion: ERN/LRPT produced lipid-altering efficacy on the parameters evaluated in four controlled studies; these effects were generally consistent across all examined subgroups. ERN/LRPT represents an effective and reliable therapeutic option for the treatment of dyslipidemia in a wide range of patient types. Clinical Trial Registration: Registered as Clinicaltrials.gov NCT00269204, NCT00269217, NCT00479388, and NCT00485758.
- Prasugrel: A Guide to Its Use in Patients with Acute Coro... Oral prasugrel (Effient®; Efient®) provides rapid, potent inhibition of platelet aggregation. It is indicated (in combination with aspirin) for the prevention of atherothrombotic events in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). In the pivotal clinical trial in this patient population, prasugrel-based therapy was associated with a significantly lower incidence of ischemic events than clopidogrel-based therapy. However, the efficacy of prasugrel was offset by a higher risk of bleeding than clopidogrel, with patients aged ≥75 years, those weighing <60 kg and those with a history of stroke or transient ischemic attack at the greatest risk. Prasugrel appears to have an overall favorable risk : benefit ratio in ACS patients undergoing PCI who do not have these three easily identifiable clinical characteristics. Limited pharmacoeconomic analyses suggest that prasugrel-based therapy is an economically attractive treatment strategy relative to clopidogrel-based therapy from a US healthcare payer perspective.
The British Journal of Diabetes & Vascular Disease
- Diabetes: A tale of two cultures
- Diabetes mellitus in anaesthesia Anaesthesiologists frequently encounter patients with diseases of the endocrine system, in particular diabetes mellitus. The major risk factors for people with diabetes undergoing surgery are the associated end-organ diseases: cardiovascular autonomic neuropathy, joint collagen tissue, and immune deficiency. Due to the fact that endocrine diseases can be associated with significant peri-operative morbidity and mortality, it is critical that anaesthesiologists understand these disorders and when indicated request the appropriate investigations.
- Hypertriglyceridaemia in type 2 diabetes: prevalence, ris... Cardiovascular disease (CVD) associated with type 2 diabetes will impose an increasing burden on primary care over the next few decades. Several mutually reinforcing factors account for the increased CVD risk among patients with diabetes, including hypertriglyceridaemia, the importance of which has been generally underestimated. A consensus from the literature suggests that fasting triglyceride levels of 1.7 mmol/L or above may be a cause for cardiovascular concern and warrant further investigation. Apart from CVD, hypertriglyceridaemia can increase the risk of pancreatitis. Clinicians in primary care should become active in identifying and managing secondary causes of hypertriglyceridaemia and encourage patients with diabetes to implement lifestyle changes. Statins are the mainstay of treatment for diabetic dyslipidaemia that remains inadequately controlled. However, the National Institute for Health and Clinical Excellence (NICE) suggests prescribing a fibrate if triglyceride levels remain >4.5 mmol/L after addressing secondary causes. Clinicians could consider adding a fibrate if triglyceride levels remain between 2.3 and 4.5 mmol/L despite statin monotherapy for patients at high CVD risk. NICE advocates a trial of highly concentrated, licensed omega-3 fish oils if lifestyle measures and fibrate fail to adequately reduce hypertriglyceridaemia.
- Left atrial myxoma with aortobifemoral thromboembolism, r... A 56-year-old man presented with aortobifemoral thromboembolism, ischaemic paraplegia, rhabdomyolysis and acute renal tubular necrosis while awaiting nephrectomy for a right renal tumour. An echocardiogram to investigate the source of embolism revealed a 7 x 3 cm mass attached to the left atrial septal wall which prolapsed through the mitral valve. The patient successfully underwent bilateral femoral embolectomy and staged operations for the excision of the left atrial mass, reported on histopathology as myxoma, and open partial nephrectomy of a high grade papillary type renal cell carcinoma. We discuss the dilemmas of diagnosis and the staging of various surgical interventions in a patient of known malignancy who presents with aortobifemoral thromboembolism with multiorgan complications and also harbours a cardiac mass which could be another thrombus, an unrelated primary benign or malignant tumour or a metastasis from the primary renal tumour.
- Prevalence and predictors of metabolic syndrome among hea... The prevalence of metabolic syndrome was determined as a cross-sectional study among 600 healthy Saudi adults (52% males and 58% aged 35–50 years) attending National Guard clinics using the definition proposed by National Cholesterol Education Program Adult Treatment Panel III. The prevalence of metabolic syndrome was 21%. Only one third of the participants had normal weight (body mass index = 18.5–24.9). Central obesity based on waist circumferences was noted in 21% of males and 22% of females. Low high-density lipoprotein-C showed the highest prevalence (29%) followed by high triglyceride (24%). About 14% of participants had impaired fasting blood glucose (≥ 110 mg/dl). Only 6% had high blood pressure (≥ 130/85 mmHg). More than three quarters (77.3%) of the respondents had > 1 component of metabolic syndrome. In conclusion, metabolic syndrome needs to be addressed as an important health problem in the Gulf region.
- Effect of a high monounsaturated fatty acid diet alone or... The aims of this study were to investigate the effect of a high monounsaturated fatty acid (MUFA) diet alone or with combined vitamin E and C, or lycopene intake on oxidative stress in type 2 diabetes in Saudi Arabia. Forty-eight type 2 diabetic patients consumed a high MUFA diet for 16 weeks. After four weeks of high MUFA diet alone, supplements of vitamins E (400 mg) and C (1,000 mg) were taken for four weeks, followed by a four-week washout period. In the final four weeks, subjects consumed a high MUFA diet with tomato paste (equivalent to 12 mg lycopene). Plasma samples were tested for vitamin E and C, lycopene, malondialdehyde (MDA), total antioxidant status, fasting plasma glucose and glycated haemoglobin A1c (HbA1c). A high-MUFA diet with vitamins E and C or lycopene caused significant elevation of plasma vitamins E, C and lycopene compared to a high-MUFA diet alone. Plasma MDA was reduced with vitamins, but not lycopene supplementation. The total antioxidant status increased significantly following a high-MUFA diet and with vitamin and lycopene supplementations. Fasting glucose was not affected whereas HbA1c decreased significantly after vitamin supplementation compared to baseline. A high-MUFA diet supplemented with vitamin E and C, or lycopene improves antioxidant status in type 2 diabetes.
- Erlotinib appears to produce prolonged remission of insul... Patients with metabolic syndrome are at higher risk for type 2 diabetes and for chronic kidney disease. Metformin is the oral medication of choice for the treatment of type 2 diabetes in the absence of chronic kidney disease. There is a need for another oral glucose lowering agent for use in metabolic syndrome with type 2 diabetes and chronic kidney disease. We submit the first report of erlotinib, a once-daily oral medication for the treatment of non-small-cell lung cancer associated with specific genetic mutations, appearing to eliminate the need for insulin in insulin-requiring type 2 diabetes associated with metabolic syndrome and chronic kidney disease. The mechanism by which erlotinib, a tyrosine kinase inhibitor of the epidermal growth factor receptor may improve glycaemic control is unknown. Potential possibilities are explored.
- CSII from patient to politics; a national and local persp... Continuous subcutaneous infusion of insulin (CSII), or insulin pump therapy, is increasingly recognised as an important treatment option for type 1 diabetes. In the UK, however, patient usage remains low, owing in part to the politics surrounding funding. In this article, current CSII use in Scotland is discussed and the evidence base and cost effectiveness of the therapy, with respect to biochemical parameters and quality of life reviewed. The guidance on CSII use from national organisations (Scottish Intercollegiate Guideline Network and the National Institute for Health and Clinical Excellence) is also presented. There is strong support for CSII among patients, and personal patient stories are included to highlight the potential impact of CSII on everyday life. Finally, we discuss our local strategy for recruiting and commencing pump therapy and the local and national challenges faced. As CSII use increases, it is important that all doctors, nurses and allied health professionals have an awareness of what it is and how it works. Patients need ongoing support to best manage their health and health professionals should ensure that the most appropriate and cost-effective therapies are being offered.
- Re: The Policy Puzzle: the diabetes maze in Europe1
- A rare cause of a leg ulcer in a patient with diabetes
Pacing and Clinical Electrophysiology
- An ICD Lead Advisory: A Plea for More Diligence and More ...
- Atrial Undersensing and Cycle Prolongation Related to Aut...
- Cardiac Resynchronization and Atrial Fibrillation: What's...
- Flecainide Suppresses Defibrillator-Induced Storming in C... Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited condition associated with ventricular tachycardia (VT) triggered by exercise or sympathetic stress. Incessant VT may develop due to defibrillator-induced storming—a condition where implantable cardioverter-defibrillator discharges result in a hyperadrenergic state, provoking further VT and defibrillator discharge. We describe the case of a 14-year-old boy with CPVT caused by a calsequestrin-2 mutation, who presented with defibrillator-induced storming refractory to β-blockers, calcium-channel blockers, amiodarone, and dronedarone. Flecainide and β-blocker use suppressed incessant VT and defibrillator-induced storming. (PACE 2012;XX:e1–e4)
- 3:2 Antegrade Atrioventricular Block with AV Nodal Reentr...
- Chronic Performance of a Subcutaneous Hemodynamic Sensor Background:A subcutaneous photoplethysmography (PPG) sensor uses light to detect changes in vascular volume from a location outside the bloodstream. Incorporation into a chronically implanted device, such as a pacemaker or an implantable cardioverter defibrillator, may facilitate therapy optimization and disease monitoring by providing continuous assessment of hemodynamic function and arterial oxygen saturation. However, performance of a chronically placed subcutaneous sensor has not been established.Methods:Six dogs were implanted with 2–4 PPG sensors subcutaneously in the neck or posterior thorax. Half of the sensors were directed toward deep tissue and half toward overlying cutaneous tissue. Each sensor contained a red and an infrared light emitting diode, a photodetector, and supporting electronics, which were encapsulated in epoxy and attached to a transcutaneous connector. Data were collected at implant and every 3 ± 1 days for 4–9 months starting 3 weeks postimplant. At explant, the fibrous encapsulation was histologically analyzed.Results:A minimally to moderately neovascularized encapsulation formed over all sensors, consisting of fibrous and granulation tissue. Higher cardiac pulse amplitudes and direct current (DC) components were recorded in sensors oriented toward deep tissue, but no significant difference between orientations was found in respiratory wave amplitude. Cardiac pulse amplitude, respiratory wave amplitude, and DC component amplitude, as recorded by the sensor, did not significantly change over time.Conclusions:Despite fibrous encapsulation of PPG sensors, cardiac pulses and respiratory waves could easily be measured throughout the study and remained constant over time. These results suggest suitability of subcutaneous PPG technology for chronic applications. (PACE 2012;XX:1–8)
- Extraordinarily Favorable Left Ventricular Reverse Remode... Background:Some chronic heart failure (CHF) patients show remarkable improvement in left ventricular (LV) remodeling after cardiac resynchronization therapy (CRT), for unclear reasons. This study aimed at identifying predictors of an extraordinarily favorable response to CRT.Methods:We studied 136 CRT patients (104 men, median 66 years, QRS 162 ms, left ventricular ejection fraction 24 ± 7%, 70% coronary disease, all left bundle branch block [LBBB]). We measured LV end diastolic diameter (LVEDD) before and after long-term (9.4 ± 6.3 months) CRT. At baseline, LV pre-ejection interval (LVPEI), interventricular mechanical delay (IVMD), LV dyssynchrony (standard deviation of electromechanical delays [SDEMD] in eight LV segments), exercise capacity (pVO2), and ventilatory efficiency (VE/VCO2) were assessed. Patients with a LVEDD reduction beyond the 80th percentile (high responders [HR]) were compared to low responders (LR).Results:In the HR group (n = 22), LVEDD was reduced from 71 to 52 mm (LR 64–61 mm, P < 0.001). HR had predominantly nonischemic heart disease (HR: 72%, LR: 44%, P = 0.019), tended to have a wider QRS (HR: 178 ms, LR: 162 ms, P = 0.066), had a longer LVPEI (HR: 179 ms, LR: 155 ms, P = 0.004), wider IVMD (HR: 60 ms, LR 48 ms, P = 0.05), larger LVEDD (P = 0.002), higher SDEMD (HR: 69 ms, LR: 46 ms, P = 0.044), but higher pVO2 (HR: 17.5 mL/min/kg, LR: 13.5 mL/kg/min, P = 0.025) and lower VE/VCO2 (HR: 31, LR: 35, P = 0.043), all compared to LR patients.Conclusion:Extraordinarily favorable reverse LV remodeling through CRT in CHF and LBBB appears to require a particularly dilated LV due to nonischemic heart disease with pronounced electromechanical alteration, but with a fairly preserved functional capacity before CRT. (PACE 2012;XX:1–7)
- LETTER TO THE EDITOR
- LETTER TO THE EDITOR
- Subcutaneous Implantable Cardioverter Defibrillator in a ... Sudden cardiac arrest in young healthy adults has concerned the medical and social communities due to its fatal effect.Implantable cardioverter defibrillator (ICD) has been demonstrated to be an effective measure for prevention of sudden death in patients at risk of ventricular arrhythmia. Subcutaneous ICD has been developed to overcome some problems associated with transvenous leads in the conventional ICD.In this case report, we describe the use of completely subcutaneous ICD for a young patient with pectus excavatum following presentation with out-of-hospital VF arrest with no complication in device or lead positioning. (PACE 2011;XX:e1–e2)
Expert Review of Cardiovascular Therapy
- Lipoprotein oxidation biomarkers for cardiovascular risk:... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 399-402.
- Should statins be included in standard care following isc... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 403-405.
- News in brief Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 407-409.
- Bivalirudin for primary percutaneous coronary interventio... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 411-422.
- Thromboembolic prophylaxis in orthopedic surgery using da... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 423-427.
- No country for old stents? Improving long-term patient ou... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 429-432.
- Aspirin in stroke prevention in nonvalvular atrial fibril... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 433-439.
- New technologies aimed at percutaneous intervention in th... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 441-455.
- Current imaging modalities for atherosclerosis Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 457-471.
- Novel drugs for oral anticoagulation pharmacotherapy Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 473-488.
Future Cardiology
- Cinacalcet: will it play a role in reducing cardiovascula... Future Cardiology , Ahead of Print, Pages 1-14.
- The REG-1 anticoagulation system: a novel actively contro... Future Cardiology , Ahead of Print, Pages 1-12.
- Congenital heart disease Future Cardiology , March 2012, Vol. 8, No. 2, Pages 143-147.
- Novel imaging techniques for the diagnosis and treatment ... Future Cardiology , March 2012, Vol. 8, No. 2, Pages 149-152.
- Bulletin Board Future Cardiology , March 2012, Vol. 8, No. 2, Pages 153-155.
- Personalized Medicine in the Genomics Era: highlights fro... Future Cardiology , March 2012, Vol. 8, No. 2, Pages 157-160.
- Potential for stem cell use in congenital heart disease Future Cardiology , March 2012, Vol. 8, No. 2, Pages 161-169.
- Changing epidemiology and mortality in adult congenital h... Future Cardiology , March 2012, Vol. 8, No. 2, Pages 171-177.
- Neurological injury and anesthetic neurotoxicity followin... Future Cardiology , March 2012, Vol. 8, No. 2, Pages 179-188.
- Fetal cardiac screening and variation in prenatal detecti... Future Cardiology , March 2012, Vol. 8, No. 2, Pages 189-202.
Interventional Cardiology
- Biodegradable polymer and permanent polymer drug-eluting ... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 147-150.
- Carotid stenting versus carotid endarterectomy: how relev... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 151-153.
- Wall shear stress and evolution of coronary atheroscleros... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 155-157.
- News & Views in Interventional Cardiology Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 159-161.
- Conference Scene: 38th Annual VEITHsymposium™ Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 163-164.
- Conference Scene: ACC/STS Transcatheter Heart Valve Pract... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 165-167.
- Accelerating endothelialization of coronary stents by cap... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 169-181.
- Endovascular aspiration thrombectomy in acute ischemic st... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 183-191.
- Percutaneous pulmonary valve implantation: the Munich exp... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 193-201.
- What do we know about the natural history of severe sympt... Interventional Cardiology , April 2012, Vol. 4, No. 2, Pages 203-210.
Journal of Cardiovascular Electrophysiology
- A novel missense mutation causing a G487R substitution in... Introduction: Mutations of human ether-à-go-go-related gene (hERG), which encodes a cardiac K+ channel responsible for the acceleration of the repolarizing phase of an action potential and the prevention of premature action potential regeneration, often cause severe arrhythmic disorders. We found a novel missense mutation of hERG that results in a G487R substitution in the S2-S3 loop of the channel subunit [hERG(G487R)] from a family and determined whether this mutant gene could induce an abnormality in channel function. Methods and Results: We made whole-cell voltage-clamp recordings from HEK-293T cells transfected with wild-type hERG [hERG(WT)], hERG(G487R), or both. We measured hERG channel-mediated current as the “tail” of a depolarization-elicited current. The current density of the tail current and its voltage- and time-dependences were not different among all the cell groups. The time-courses of deactivation, inactivation, and recovery from inactivation and their voltage-dependences were not different among all the cell groups. Furthermore, we performed immunocytochemical analysis using an anti-hERG subunit antibody. The ratio of the immunoreactivity of the plasma membrane to that of the cytoplasm was not different between cells transfected with hERG(WT), hERG(G487R), or both. Conclusion: hERG(G487R) can produce functional channels with normal gating kinetics and cell-surface expression efficiency with or without the aid of hERG(WT). Therefore, neither the heterozygous nor homozygous inheritance of hERG(G487R) is thought to cause severe cardiac disorders. hERG(G487R) would be a candidate for a rare variant or polymorphism of hERG with an amino acid substitution in the unusual region of the channel subunit.
- Clinical Significance of Induced Atrial Tachycardia after... Introduction: The utility of inducibility test of atrial tachycardia (AT) in patients with longstanding persistent atrial fibrillation (AF) (LPAF) is unclear. This study aimed to evaluate the significance of induced AT and the impact of their ablation on the clinical outcome.Methods: In 194 patients with LPAF (> 1 year) who underwent catheter ablation (pulmonary vein isolation with substrate ablation), an inducibility test was performed after AF termination.Results: AT was induced in 108 (56%) patients (induced AT group); neither AT nor AF was inducible in 37 (19%, non-induction group). During 39 ± 21 months, AT recurred in 30 patients (28%), AF in 19 (17%), and no arrhythmia in 56 (52%) among induced AT group, while there was a recurrence of AT in 9 (24%), AF in 6 (16%), and no arrhythmia in 22 (60%) among non-induction group (p = NS). Ten patients with repeated ablation in induced AT group revealed eight different and two similar recurrent ATs compared to the induced ATs at first session. The mean cycle length of induced AT that terminated by ablation (271 ± 64ms) was longer than that without (249 ± 58 ms, p < 0.05). In induced AT group, AT recurrence rate in patients who achieved AT termination by ablation was lower than those without termination (5% vs 36%, p < 0.05).Conclusions: ATs that are inducible after LPAF termination do not necessarily become clinical AT. However, patients who achieved non-inducibility of AT by ablating slower cycle length of AT had better outcomes.
- Mitral Isthmus Ablation Using Steerable Sheath and High A... Background: Mitral isthmus ablation is challenging. The use of steerable sheath and high ablation power may improve success rate.Methods: This single-center, prospective study enrolled 200 patients who underwent ablation for atrial fibrillation, including mitral isthmus ablation. Mitral isthmus ablation was performed using an irrigated ablation catheter via a steerable sheath (Endocardium: max power: 40/50W limited to annular end, max temp: 48˚C; Coronary Sinus (CS): max power: 25/30W, max temp: 48˚C). Endpoint was bidirectional mitral isthmus block.Results: Mitral isthmus block was acutely achieved in 182/200 patients (91%). 69% of patients required CS ablation. Mean total ablation time was 13±6 min. There was one case of acute circumflex artery occlusion. Mean LA diameter was significantly bigger in patients with unsuccessful mitral isthmus ablation (49±4 mm vs 43±6 mm, p = 0.0007). In redo procedures, the incidence of re-conduction at the mitral isthmus, roof and cavotricuspid isthmus was 44%, 37% and 29%, respectively. Overall incidence of perimitral flutter was 9%. Prior CFAE ablation was a predictor for microreentrant atrial tachycardia while gaps in linear lesions predicted macroreentrant flutters. After a mean follow-up of 20±9 months, 73% of patients remained free from AF or AT.Conclusion: We reported on a series of mitral isthmus ablation using steerable sheath and high ablation power (50W). Larger LA diameter was a predictor of failure to achieve mitral isthmus block. The mitral isthmus had a moderately high incidence of re-conduction but was only associated with a relatively low incidence of perimitral flutter.
- A Prospective, Randomized Comparison of Modified Pulmonar... Introduction: Pulmonary vein isolation (PVI) is the primary ablation therapy in patients with atrial fibrillation (AF). We hypothesized that high dominant frequency sites (AF nests during sinus rhythm, SR) adjacent to the PV ostia are associated with the atrial substrate that maintains AF, and PVI incorporating the high frequency AF nests may have a higher efficacy.Methods and Results: In a prospective and randomized comparison, 126 symptomatic paroxysmal AF patients that underwent PVI were enrolled. We compared the efficacy of a modified PVI (ablation line: 1.0–1.5 cm from the PV ostium with encircling the AF nests 〔spectral analysis with DF> 70Hz during SR, Group II〕) versus the anatomy-guided conventional PVI (Group I). In Group II, the DF value along the PV ostium was lower than 70 Hz after the PVI. The primary endpoint was the freedom from symptomatic atrial arrhythmias after a single procedure. We also followed the autonomic function by a time-domain analysis of the heart rate variability. In both groups, AF nests were observed and electric isolation was successfully obtained in all patients. With a mean duration of 16±6.1 months of follow-up, Group II had a higher single procedure efficacy without drugs (78.7% vs. 66.1%, log-rank test: P = 0.02), and fewer repeat procedures (6.6% vs. 23%, P = 0.04), as compared to Group I.Conclusion: Pulmonary vein isolation incorporating the high frequency AF nests adjacent to the PV ostia had a better single procedure efficacy.
- Prevalence and Predictors of Cable Extrusion and Loss of ... Introduction: Recently, a medical advisory was issued regarding the Riata and Riata ST silicone endocardial defibrillator leads (St. Jude Medical, Sylmar, CA, USA) addressing the issue of conductor cables extruding in an “inside-out” fashion from the main body of the lead. However, little data exist to guide our management of patients with these leads.Methods and Results: A retrospective analysis was performed of 84 patients with a Riata lead who underwent cine-fluoroscopy and electrical evaluation as part of a screening program to assess for cable extrusion. All leads screened were dual-coil except for one single-coil lead. Of 84 patients, 23 patients (27.4%) had fluoroscopic evidence of cable extrusion. Multivariate analysis showed that the duration of time since lead implant and the presence of multiple right ventricular leads were significantly associated with cable extrusion. All 23 patients had normal electrical parameters on routine device interrogation. Fifteen of these 23 patients (65%) with extruded cables had high voltage shocks within 12 months of lead screening; only one patient demonstrated post-shock electrical abnormalities.Conclusions: The prevalence of cable extrusion in dual-coil Riata leads is significantly higher than previously reported at 27.4%. The duration of time since implantation and the presence of multiple right ventricular leads are associated with cable extrusion. High-energy shocks did not reveal electrical abnormalities in most patients with cable extrusion.
- Long-term Outcome after Catheter Ablation for Left Poster... Background: Catheter ablation of left posterior fascicular (LPF) ventricular tachycardia (VT) is commonly performed during tachycardia. The current study reports on the long-term outcome of patients undergoing ablation of LPF VT targeting the earliest retrograde activation within the posterior Purkinje fiber network during sinus rhythm (SR).Methods: This study retrospectively analyzed 24 consecutive patients (8 female; mean age 26 ± 11 years) referred for catheter ablation of electrocardiographically documented LPF VT. Programmed stimulation was performed to induce tachycardia, while mapping and ablation was aided by use of a 3-D electroanatomical mapping system. Catheter ablation targeted the earliest potential suggestive of retrograde activation within the posterior Purkinje fiber network (retro-PP) recorded along the posterior midseptal left ventricle during SR if LPF VT was noninducible.Results: Overall, 21/24 (87.5%) patients underwent successful catheter ablation in SR targeting the earliest retro-PP, while 3/24 (12.5%) patients were successfully ablated during tachycardia. In none of the patients, ablation resulted in LPF block. No procedure-related complications occurred. After a median follow-up period of 8.9 (4.8–10.9) years, 22/24 (92%) patients were free from recurrent VT.Conclusion: In patients presenting with LPF VT, ablation of the earliest retro-PP along the posterior midseptal LV during SR results in excellent longterm outcome during a median follow-up period of almost 9 years.
- Reverse electrical remodeling by cardiac resynchronizatio... Background: Cardiac resynchronization Therapy (CRT) improves left ventricular ejection fraction (LVEF) in patients with congestive heart failure, LV systolic dysfunction and a wide QRS complex. Previous reports suggest that CRT may also induce electrical remodeling but the impact on clinical outcome remains unknown.Objective: We sought to determine 1) if chronic CRT induces a relevant shortening of the intrinsic QRS (iQRS), 2) whether changes in the native conduction system correlate with clinical or echocardiographic response to CRT, and 3) to identify predictors of iQRS width shortening.Methods: We prospectively included 85 consecutive patients with left bundle branch block who received a CRT device in 3 French centers. NYHA class, iQRS duration, LVEF and left ventricular volumes were assessed before and one year after CRT implantation. Clinical and echocardiographic CRT responders were defined respectively as NYHA class improvement >1 class without heart failure hospitalization and an increase of LVEF by ≥10% and/or a decrease in LVESV by ≥15%. Electrocardiographic responders were defined as a decrease in iQRS duration by ≥20msec.Results: Baseline and 1-year follow-up mean iQRS durations were respectively 168.0 ± 19.7 ms and 149.6 ± 31.6 ms (p<0.0001). Electrocardiographic response, observed in 43/85 patients (51%), was associated with a greater rate of clinical (p = 0.035) and echocardiographic (p = 0.023) response. Younger age, male gender and longer baseline QRS width were independent predictors of electrocardiographic response.Conclusion: CRT decreases iQRS duration. A reduction of at least 20 ms in iQRS duration is associated with better clinical and echocardiographic response.
- Implantation Feasibility, Procedure-Related Adverse Event... Introduction: Aim of this substudy was to assess implantation feasibility and long-term safety of triple-site resynchronization therapy (CRT) in a series of consecutive patients included in a randomized trial.Methods and results: One hundred consecutive patients enrolled into Triple-Site Versus Standard Cardiac Resynchronization Therapy Randomized Trial were analyzed. Eligibility criteria included NYHA class III-IV, sinus rhythm, QRS≥120msec, left ventricular ejection fraction ≤35%, and significant mechanical dyssynchrony. Patients were randomized in a 1:1 ratio to conventional or triple-site CRT with defibrillator-cardioverter. After 12 months of resynchronization 30% of patients with conventional resynchronization and 12.5% with triple-site CRT were in NYHA functional class III or IV (P<0.05). Implantation of triple-site systems was significantly longer (median 125 vs.96min; P<0.001), with higher fluoroscopic exposure, especially in patients with very enlarged left ventricle or pulmonary hypertension. Implantation success-rate was similar in the triple-site and conventional group (94 vs.98%; P = NS); however, additional techniques had to be used in a greater proportion of the triple-site patients (33.3 vs.16%; P<0.05). Long-term lead performance tests revealed significantly higher pacing threshold and lower impedance in the triple-site group. The 1-year incidence of serious, CRT-related adverse events was similar in triple-site and conventional group (20.8 vs.30%; P = NS).Conclusions: Triple-site CRT is associated with more pronounced functional improvement than standard resynchronization. This form of pacing is equally safe and feasible as the conventional CRT. However, triple-site procedure is more time-consuming, associated with higher radiation exposure and the need to use additional techniques. Triple-site resynchronization is associated with less favorable electrical lead characteristics.
- Idiopathic Ventricular Fibrillation Originating from the ... We report a case of a 59-year-old man with idiopathic ventricular fibrillation storm. Ventricular fibrillation was pause-dependent and triggered by an early-coupled right ventricular premature complex. The characteristic premature beat was mapped and successfully ablated from Purkinje fibers of the moderator band.
- Interventional Electrophysiology at the Crossroads: Cardi...
Heart BMJ
- Plasma asymmetric dimethylarginine in patients with acute... The implications of abnormal endothelial function in the pathophysiology and prognosis in patients with chronic heart failure (CHF) has been extensively discussed.1–3 Endothelial dysfunction may affect the cardiovascular system in different ways, such as impairment of peripheral perfusion, an adverse effect of vascular remodelling, reduced compliance of the failing left ventricle and consequently impaired left ventricular dysfunction.4 Endothelial dysfunction has been attributed to reduced production of endothelial nitric oxide (NO) production, and thus affects vasoreactivity and smooth muscle cell growth, platelet reactivity and leucocyte adhesion to the endothelium. Reduced production and bioavailability of NO can be caused by several mechanisms, one being increased production and/or accumulation of the amino acid asymmetric dimethylarginine (ADMA). ADMA is an endogenous competitive inhibitor of nitric oxide synthase (NOS),5 and is synthesised by methylation of proteins containing l-arginine, which is the substrate of NOS....
- Identifying the patient who FADES away prior to appropria... Despite important progress, sudden cardiac death (SCD) continues to represent an important clinical challenge for contemporary cardiology. Randomised controlled trials performed in high risk patients, such as patients with ischaemic heart disease and left ventricular dysfunction, showed that an approach based on antiarrhythmic drugs is not only useless, but sometimes even potentially harmful.1 Conversely, implantable cardioverter defibrillators (ICDs) have gained a specific role not only in patients with a previous ventricular tachyarrhythmia or cardiac arrest (secondary preventions of SCD) but also in the broader population of high-risk patients with ischaemic heart disease and left ventricular dysfunction, in whom use of ICDs for primary prevention of SCD may reduce overall mortality by 23%–54%.1 The high upfront cost of ICDs, particularly when implementing cardiac resynchronisation therapy (CRT-D), has prompted both the search to improve patient targeting and the development of appropriate economic evaluations on the cost-effectiveness of...
- Pathogenesis and diagnosis of myocarditis Acute myocarditis is an inflammatory disease of the heart muscle that may progress to dilated cardiomyopathy and chronic heart failure. A number of factors including the sex hormone testosterone, components of innate immunity, and profibrotic cytokines have been identified in animal models as important pathogenic mechanisms that increase inflammation and susceptibility to chronic dilated cardiomyopathy. The clinical presentation of acute myocarditis is non-specific and mimics more common causes of heart failure and arrhythmias. Suspected myocarditis is currently confirmed using advanced non-invasive imaging and histopathologic examination of heart tissue. However, the diverse presentations of myocarditis and the lack of widely available, safe, and accurate non-invasive diagnostic tests remain major obstacles to early diagnosis and population based research. Recent advances in the understanding of disease pathogenesis described in this review should lead to more accurate diagnostic algorithms and non-invasive tests.
- Early repolarisation: controversies and clinical implicat... Early repolarisation was previously considered a benign variant but in recent years has emerged as a marker of risk for sudden death. In part, this appears to reflect a change in the definition. ECG territory, degree of J-point elevation and ST-segment morphology are associated with different degrees of risk for subsequent ventricular arrhythmia. At present the dataset is insufficient to allow risk stratification in asymptomatic individuals and further epidemiological and mechanistic research is required.
- Newly diagnosed glucose intolerance and prognosis after a... Background Recent studies have demonstrated that newly diagnosed glucose intolerance is common among patients with acute myocardial infarction (AMI). The purpose of this study was to assess the long-term clinical cardiovascular outcomes in participants with AMI with abnormal fasting glucose compared with normal fasting glucose and an abnormal oral glucose tolerance test (OGTT) compared with a normal OGTT. Methods A prospective study was performed in 275 consecutive patients with AMI, 85 of whom had pre-diagnosed diabetes mellitus (DM). Those without DM were divided into two groups based on the 75 g OGTT at the time of discharge. Abnormal glucose tolerance (AGT) was defined as 2 h glucose ≥140 mg/dl; 78 patients had normal glucose tolerance (NGT) and 112 had AGT. The same patients were also reclassified into the normal fasting glucose group (NFG; n=168) or the impaired fasting glucose group (IFG; n=22). The association between the glucometabolic status and long-term major adverse cardiovascular event rates was evaluated. Results Kaplan–Meier survival curves showed that the AGT group had a worse prognosis than the NGT group and an equivalent prognosis to the DM group (p<0.0005). Cox proportional hazard model analysis showed that the HR of AGT to NGT for major adverse cardiovascular event rates was 2.65 (95% CI 1.37 to 5.15, p=0.004) while the HR of DM to NGT was 3.27 (1.68 to 6.38, p=0.0005). However, Cox HR of IFG to NFG for major adverse cardiovascular event rates was 1.83 (0.86 to 3.87), which was not significant. Conclusion In patients with AMI, an abnormal OGTT is a better risk factor for future adverse cardiovascular events than impaired fasting blood glucose.
- Adenosine plasma level and A2A adenosine receptor express... Objectives The purpose of this study was to investigate the hypothesis that responses to the ATP test and head-up tilt test (HUT) may be correlated with different purinergic profiles. Design and setting The ATP and HUT identify distinct subsets of patients with neurally mediated syncope (NMS). Adenosine and its A2A receptors (A2AR) may be implicated in the pathophysiology of NMS in patients with positive HUT. Nothing is known about the purinergic profile of patients with positive ATP. Patients and measures This prospective study includes a consecutive series of patients with suspected NMS. All patients underwent both HUT and ATP. Before testing, samples were collected for measurement of baseline adenosine plasma level (APL) and expression. Results A total of 46 patients (25 men and 21 women) with a mean age of 57±18 years were enrolled. The HUT test was positive in 27 patients and the ATP test in 20. Both tests were positive in 9 and negative in 8. High APL was associated with high probability of positive HUT while low APL was associated with high probability of positive ATP. Expression of A2AR was lower in patients with positive ATP than in those with positive HUT. Conclusion These findings indicate that patients with NMS present different purinergic profiles and that responses to HUT and ATP are correlated with these profiles.
- Plasma asymmetric dimethylarginine and mortality in patie... Objectives To investigate the prognostic value of circulating levels of asymmetric dimethylarginine (ADMA) in patients with acute decompensation of (New York Heart Association (NYHA) class III/IV) chronic heart failure and reduced left ventricular ejection fraction. Design Single-centre prospective observational study. Setting Tertiary referral centre. Patients A total of 651 consecutive and eligible hospitalised patients were studied. Patients were divided into four groups according to the quartiles of circulating levels of ADMA upon presentation. Main outcome measures Incidence of in-hospital (or 7-day in the case of prolonged hospitalisation), 31-day and 1-year cardiac mortality were the pre-specified study end points. Results Cumulative rates of in-hospital, 31-day and 1-year cardiac mortality were 10.6%, 18.7% and 36.4%, respectively. There was a gradual increased risk of in-hospital (pfor trend=0.011), 31-day (pfor trend=0.044) and 1-year (pfor trend<0.001) mortality with increasing ADMA quartiles. After adjustment for possible confounders, patients at the highest ADMA quartile were at significantly higher risk for in-hospital (p=0.042), 31-day (p=0.032) and 1-year (p<0.001) mortality than those in the lowest quartile. Conclusions According to the present results, an elevated circulating level of ADMA is a strong independent predictor of short-term and long-term mortality in patients with acute decompensation of NYHA class III/IV chronic heart failure and reduced left ventricular ejection fraction. ADMA levels upon presentation may confer enhanced risk stratification in this setting.
- ASPIRE-2-PREVENT: a survey of lifestyle, risk factor mana... Objective To determine in patients with coronary heart disease (CHD) and people at high risk of developing cardiovascular disease (CVD) whether the Joint British Societies' guidelines on CVD prevention (JBS2) are followed in everyday clinical practice. Design A cross-sectional survey was undertaken of medical records and patient interviews and examinations at least 6 months after the recruiting event or diagnosis using standardised instruments and a central laboratory for measurement of lipids and glucose. Settings The ASPIRE-2-PREVENT survey was undertaken in 19 randomly selected hospitals and 19 randomly selected general practices in 12 geographical regions in England, Northern Ireland, Wales and Scotland. Patients In hospitals, 1474 consecutive patients with CHD were identified and 676 (25.6% women) were interviewed. In general practice, 943 people at high CVD risk were identified and 446 (46.5% women) were interviewed. Results The prevalence of risk factors in patients with CHD and high-risk individuals was, respectively: smoking 14.1%, 13.3%; obesity 38%, 50.2%; not reaching physical activity target 83.3%, 85.4%; blood pressure ≥130/80 mm Hg (patients with CHD and self-reported diabetes) or ≥140/85 mm Hg (high-risk individuals) 46.9%, 51.3%; total cholesterol ≥4 mmol/l 52.6%, 78.7%; and diabetes 17.8%, 43.8%. Conclusions The potential among patients with CHD and individuals at high risk of developing CVD in the UK to achieve the JBS2 lifestyle and risk factor targets is considerable. CVD prevention needs a comprehensive multidisciplinary approach, addressing all aspects of lifestyle and risk factor management. The challenge is to engage and motivate cardiologists, physicians and other health professionals to routinely practice high quality preventive cardiology in a healthcare system which must invest in prevention.
- Clinical prediction model for death prior to appropriate ... Objectives To construct a risk score out of baseline variables to estimate the risk of death without prior implantable cardioverter defibrillator (ICD) in primary prevention ICD patients with ischaemic heart disease. Design Retrospective cohort study. Setting Tertiary care facility in The Netherlands. Patients All patients with ischaemic heart disease who received an ICD for primary prevention of sudden cardiac death at the Leiden University Medical Center, Leiden, The Netherlands in the period 1996–2009. Main outcome measure All-cause mortality without prior appropriate ICD therapy (anti-tachycardia pacing or shock). Results 900 patients (87% men, mean age 64±10 years) were included in the analysis. During a median follow-up of 669 days (IQR 363–1322 days), 150 patients (17%) died and 191 (21%) patients received appropriate device therapy. 114 (13%) patients died without prior appropriate therapy. Stratification of the risk for death without prior appropriate therapy resulted in risk categorisation of patients as low, intermediate or high risk. NYHA ≥III, advanced age, diabetes mellitus, left ventricular ejection fraction ≤25% and a history of smoking were significant independent predictors of death without appropriate ICD therapy. 5-year cumulative incidence for death without prior appropriate therapy ranged from 10% (95% CI 6% to 16%) in low-risk patients to 41% (95% CI 33% to 51%) in high-risk patients. Conclusions The risk of death without prior appropriate ICD therapy can be predicted in primary prevention ICD patients with ischaemic heart disease, which facilitates patient-tailored risk estimation.
- Heart transplantation: organisational aspects and current... Impact and limitations of heart transplantation: organisational aspects In spite of recent advances in the treatment of patients with end stage heart failure, heart transplantation (HTx) still remains the best option for patients under 70 years of age suffering from this condition. It provides not only a dramatic change in expected survival, unequalled by any other intervention, but also a substantial improvement in the quality of life of patients.1–3 w1 According to the Global Observatory on Donation and Transplantation, approximately 100 000 solid organ transplants are performed every year in the world, 5000 of which are HTx.3 w2 Data derived from the voluntary Registry of the International Society for Heart and Lung Transplantation (ISHLT) show that median survival after HTx is 10 years, and >90% of recipients live without significant activity limitations.2 w1 Similar results are shown in the exhaustive Spanish National...
European Heart Journal
- The best of the European Heart Journal: look back with pride
- CardioPulse Articles * Top EHJ Associate Editor Reviewers...
- Off-pump vs. on-pump CABG: are we any closer to a resolut...
- 'Mortality and cardiovascular risk associated with differ...
- Optimizing reperfusion therapy in acute ST-elevation myoc...
- Toward a therapeutic window for antiplatelet therapy in t...
- Non-alcoholic fatty liver disease: a new and important ca... Non-alcoholic fatty liver disease (NAFLD) affects up to a third of the population worldwide and may confer increased cardiometabolic risk with consequent adverse cardiovascular outcomes independent of traditional cardiovascular risk factors and the metabolic syndrome. It is characterized almost universally by insulin resistance and is strongly associated with type 2 diabetes and obesity. Non-alcoholic fatty liver disease is a marker of pathological ectopic fat accumulation combined with a low-grade chronic inflammatory state. This results in several deleterious pathophysiological processes including abnormal glucose, fatty acid and lipoprotein metabolism, increased oxidative stress, deranged adipokine profile, hypercoaguability, endothelial dysfunction, and accelerated progression of atherosclerosis. This ultimately leads to a dysfunctional cardiometabolic phenotype with cardiovascular mortality representing the main mode of premature death in NAFLD. This review is aimed at introducing NAFLD to the clinical cardiologist by discussing in-depth the evidence to date linking NAFLD with cardiovascular disease, reviewing the likely mechanisms underlying this association, as well as summarizing from a cardiologist's perspective, current and potential future treatment options for this increasingly prevalent disease.
- Aortopulmonary window
- Improvement of cardiovascular risk prediction using coron... Deaths from diseases of the heart are decreasing. Cardiovascular diseases (CVD) will be the main cause of morbidity and mortality in 2015 according to a WHO report. The main problem is related to the long-time delay between the start of the development of atherosclerosis in young adults and the manifestation many decades later. Despite a recent decline in a CVD mortality rate in men and women, the main problem is related to the acute manifestation as the acute coronary syndrome, which leads 30–50% of subjects to sudden and fatal outcomes. In addition, about 20% of first and recurrent acute myocardial infarctions are silent. The lifetime risk of coronary artery disease after 40 years is 49% for men and 32% for women. That means, we are confronted with a major health care problem. This is even more obvious, when the rate of coronary heart disease deaths out of the hospital are taken into account which amount to 70% in 2007. These data are confirmed for Europe despite a strong decline of hospital deaths. Another problem is related to the fact that the number of sudden cardiac death amounts to >300 000 in the general US population. It is about 10 times higher than in those patients who are defined as prone to sudden death due to low ejection fraction, ventricular arrhythmias, and acute myocardial infarction. For cardiologists, this general topic becomes even more obvious, because even well-known cardiologists experienced early (≤65 years) sudden cardiac deaths such as RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline again what has been emphasized 15 years ago by the MONICA study that two-thirds of patients die outside the hospital and that we have to concentrate on primary and secondary prevention, also in memory of these colleagues. This review will demonstrate the potential value of coronary artery calcification screening which can be used as a sign of subclinical coronary arteriosclerosis for improved risk prediction, the first step to prevention. Subclinical atherosclerosis represents the vessel memory of risk factor exposure.
- Biodegradable polymer drug-eluting stents reduce the risk... Aims The efficacy of durable polymer drug-eluting stents (DES) is delivered at the expense of delayed healing of the stented vessel. Biodegradable polymer DES aim to avoid this shortcoming and may potentially improve long-term clinical outcomes, with benefit expected to accrue over time. We sought to compare long-term outcomes in patients treated with biodegradable polymer DES vs. durable polymer sirolimus-eluting stents (SES). Methods and results We pooled individual patient data from three large-scale multicentre randomized clinical trials (ISAR-TEST 3, ISAR-TEST 4, and LEADERS) comparing biodegradable polymer DES with durable polymer SES and assessed clinical outcomes during follow-up through 4 years. The efficacy endpoint of interest was target lesion revascularization and the safety endpoint of interest was definite stent thrombosis. Out of 4062 patients included in the present analysis, 2358 were randomly assigned to treatment with biodegradable polymer DES (sirolimus-eluting, n= 1501; biolimus-eluting, n= 857) and 1704 patients to durable polymer SES. No heterogeneity across the trials was observed in analyses of the primary and secondary endpoints. At 4 years, the risk of target lesion revascularization was significantly lower among patients treated with biodegradable polymer DES vs. durable polymer SES (hazard ratio 0.82, 95% CI 0.68–0.98, P= 0.029). In addition, the risk of stent thrombosis was significantly reduced with biodegradable polymer DES vs. durable polymer SES (hazard ratio 0.56, 95% CI 0.35–0.90, P= 0.015), driven by a lower risk of very late stent thrombosis (hazard ratio 0.22, 95% CI 0.08–0.61, P= 0.004). In keeping with this, in landmark analysis between 1 and 4 years, the incidence of myocardial infarction was lower for patients treated with biodegradable polymer DES vs. durable polymer SES (hazard ratio 0.59, 95% CI 0.73–0.95, P= 0.031). Conclusion Biodegradable polymer DES improve safety and efficacy compared with durable polymer SES during long-term follow-up to 4 years.
European Journal of Heart Failure
- Adherence of heart failure patients to exercise: barriers... The practical management of heart failure remains a challenge. Not only are heart failure patients expected to adhere to a complicated pharmacological regimen, they are also asked to follow salt and fluid restriction, and to cope with various procedures and devices. Furthermore, physical training, whose benefits have been demonstrated, is highly recommended by the recent guidelines issued by the European Society of Cardiology, but it is still severely underutilized in this particular patient population. This position paper addresses the problem of non-adherence, currently recognized as a main obstacle to a wide implementation of physical training. Since the management of chronic heart failure and, even more, of training programmes is a multidisciplinary effort, the current manuscript intends to reach cardiologists, nurses, physiotherapists, as well as psychologists working in the field.
- Leads for cardiac resynchronization therapy: where and ho...
- Can we treat fluid overload with fluid? Role of peritonea...
- Management and outcomes following an acute coronary event... Aim The outcome of patients with chronic heart failure (CHF) following an ischaemic event is poorly understood. We evaluated the management and outcomes of CHF patients presenting with an acute coronary syndrome (ACS) and explored changes in outcomes over time. Method and results A total of 5556 patients enrolled in the Australia–New Zealand population of the Global Registry of Acute Coronary Events (GRACE) between 1999 and 2007 were included. Patients with CHF (n = 609) were compared with those without CHF (n = 4947). Patients with CHF were on average 10 years older, were more likely to be female, had more co-morbidities and cardiac risk factors, and were more likely to have a prior history of angina, myocardial infarction, and revascularization by coronary artery bypass graft (CABG) when compared with those without CHF. CHF was associated with a substantial increase in in-hospital renal failure [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.15–2.71], readmission post-discharge (OR 1.47, 95% CI 1.17–1.90), and 6-month mortality (OR 2.25, 95% CI 1.55–3.27). Over the 9 year study period, in-hospital and 6 month mortality in those with CHF declined by absolute rates of 7.5% and 14%, respectively. This was temporally associated with an increase in prescription of thienopyridines, beta-blockers, statins, and angiotensin II receptor blockers, increased rates of coronary angiography, and 31.8% absolute increase in referral rates for cardiac rehabilitation. Conclusions Acute coronary syndrome patients with pre-existing CHF are a very high risk group and carry a disproportionate mortality burden. Encouragingly, there was a marked temporal improvement in outcomes over a 9 year period with an increase in evidence-based treatments and secondary preventative measures.
- Gender and survival in patients with heart failure: inter... Aim The aim of this study was to investigate the relationship between gender and survival of patients with heart failure, using data from both randomized trials and observational studies, and the relative contribution of age, left ventricular systolic function, aetiology, and diabetes to differences in prognosis between men and women. Methods and results Data from 31 studies (41 949 patients; 28 052 men, 13 897 women) from the Meta-Analysis Global Group In Chronic Heart Failure (MAGGIC) individual patient meta-analysis were used. We performed survival analysis to assess the association of gender with mortality, adjusting for predictors of mortality, including age, reduced or preserved ejection fraction (EF), and ischaemic or non-ischaemic aetiology. Women were older [70.5 ( standard deviation 12.1) vs. 65.6 (standard deviation 11.6) years], more likely to have a history of hypertension (49.9% vs. 40.0%), and less likely to have a history of ischaemic heart disease (46.3% vs. 58.7%) and reduced EF (62.6% vs. 81.6%) compared with men. During 3 years follow-up, 3521 (25%) women and 7232 (26%) men died. After adjustment, male gender was an independent predictor of mortality, and the better prognosis associated with female gender was more marked in patients with heart failure of non-ischaemic, compared with ischaemic, aetiology (P-value for interaction = 0.03) and in patients without, compared with those with, diabetes (P-value for interaction <0.0001). Conclusion This large, individual patient data meta-analysis has demonstrated that survival is better for women with heart failure compared with men, irrespective of EF. This survival benefit is slightly more marked in non-ischaemic heart failure but is attenuated by concomitant diabetes.
- Screening to prevent heart failure (STOP-HF): expanding t... Aims We evaluated the extent to which left ventricular diastolic dysfunction (LVDD) contributes to the high false-positive rates observed when natriuretic peptides (NPs) are used to screen for left ventricular systolic dysfunction (LVSD), and the use of NPs in combination with electrocardiogram (ECG) to screen for pre-clinical ventricular dysfunction (PCVD). Methods and results Eight hundred and fourteen patients over 40 years of age and with at least one cardiovascular risk factor were recruited. Screening strategies for LVSD included brain natriuretic peptide (BNP) alone at cut-offs of 20, 50, and 100 pg/mL, and BNP and abnormal ECG combined. Systolic and diastolic function was assessed by Doppler echocardiography. A left ventricular ejection fraction (LVEF) of <50% was present in 33 (4.1%) of subjects, while 11 (1.4%) had LVEF <40%. At a cut-off of 20, 50, and 100 pg/mL, sensitivity for BNP alone when screening for LVSD was 88, 70, and 45%, and specificity 46, 77, and 90%, respectively. Of those labelled ‘false positive’ in the 20, 50, and 100 pg/mL cut-off groups, 26, 46, and 65%, respectively, were found to have significant LVDD (left atrial volume index >34 mL/m2). Optimal sensitivity (80%) and specificity (72%) for PCVD was obtained when BNP at a cut-off of 50 pg/mL or an abnormal ECG were defined as a positive screen so that only this group would be sent for Doppler echocardiography. Conclusions A significant number of patients at risk for LVSD and labelled false positive with screening were found to have LVDD. Identifying this at-risk cohort may improve outcomes, but the clinical and economic benefit of this screening strategy requires formal assessment.
- Relationship between plasma concentrations of N-terminal ... Aim The aim of this study was to explore the relationships between plasma concentrations of N-terminal pro brain natriuretic peptide (NT-proBNP) and characteristics and prognosis of patients with heart failure and preserved (HFPEF) left ventricular ejection fraction (LVEF). No substantial trial has shown that treatment alters prognosis in patients with HFPEF due, in part, to much lower than anticipated event rates. The lack of a simple, objective test to identify patients with HFPEF at increased risk of cardiovascular events would be valuable. Methods and results The Perindopril in Elderly People with Chronic Heart Failure Trial (PEP-CHF) was a randomized, controlled trial comparing perindopril and placebo in patients with symptoms and signs of heart failure who had an LVEF >40% and evidence of LV diastolic dysfunction. The primary endpoint was all-cause mortality or heart failure-related hospitalization. NT-proBNP was measured in 375 patients. Quartile thresholds were 176, 409, and 1035 pg/mL. Patients in the highest quartile of NT-proBNP were older, had lower body mass, more often had atrial fibrillation, had greater atrial and ventricular dimensions and a lower LVEF, and were more likely to receive loop diuretic therapy. Compared with the first quartile of NT-proBNP, the hazard ratios for the primary endpoint in the second {1.38 [95% confidence interval (CI) 0.64–2.99]}, third [2.84 (95% CI 1.42–5.72)], and fourth [4.47 (95% CI 2.30–8.72)] quartiles were increased. In a multivariable model, NT-proBNP, but not echocardiographic measures, was associated with outcome. Conclusions NT-proBNP is a powerful prognostic marker in patients with HFPEF.
- A randomized double-blind crossover trial of triventricul... Aims A significant proportion of patients implanted with biventricular (BiV) devices fail to respond. Clinical response may be improved by additional ventricular stimulation sites. This single-centre, double-blinded randomized crossover trial aimed to determine whether long-term multisite ventricular pacing is superior to conventional BiV pacing in heart failure patients. Methods and results A total of 43 patients referred for cardiac resynchronization therapy (CRT) underwent transvenous implantation of a triventricular (TriV) device. Pacing leads were positioned in the right ventricular (RV) apex and a lateral coronary sinus (CS) branch, with a third ventricular lead implanted in a further lateral CS branch in 23 patients (group A) and on the high RV septum in 20 patients (group B). Devices were programmed in a randomized order to four pre-determined pacing configurations: conventional BiV, TriV, and dual-site and single-site left bentricular (LV) or RV pacing for 3-month periods with clinical and echo assessment at the end of each period. The primary endpoint was the comparison of 6 min walk distance (6MW) after 3 months of BiV vs. TriV pacing; secondary endpoints were Minnesota Living With Heart Failure (MLWHF) scores, and LV dimensions and function. The 12-month follow-up period was completed by 37 patients. Compared with BiV pacing, TriV pacing resulted in significant improvements in 6MW (451 ± 112 m vs. 425 ± 119 m, P = 0.008), MLWHF (32 ± 19 vs. 38 ± 24, P = 0.036), LV end-systolic volume (158 ± 79mL vs. 168 ± 76 mL, P < 0.05), and ejection fraction (30 ± 8% vs. 27 ± 8%, P < 0.05). Conclusions TriV pacing was associated with significant improvements in clinical and echocardiographic parameters compared with BiV pacing.
- A randomized study of haemodynamic effects and left ventr... Aims The effect on left ventricular (LV) systolic function and LV dyssynchrony by alternative right ventricular (RV) lead position in cardiac resynchronization therapy (CRT) is unclear. In the present study, RV apical (RV-A) was compared with RV high posterior septal (RV-HS) lead position in CRT. Methods and results In 85 consecutive CRT patients (mean age 66 ±11 years) the RV lead placement was randomized to RV-A (n = 43) or RV-HS (n = 42). The LV lead was targeted to the latest activated LV segment (concordant LV lead), identified by two-dimensional speckle tracking radial strain (ST-RS) echocardiography. Concordant LV leads were obtained in 72%, similar in RV-A and RV-HS (79% vs. 64%; P = 0.13). Six months after CRT, no difference was found in LV reverse remodelling (reduction of LV end-systolic volume ≥15%) according to RV-A and RV-HS leads [26 (65%) vs. 25 (64%); P = 0.93]. Superior LV reverse remodelling was observed in concordant LV leads compared with discordant LV leads [41 (73%) vs. 10 (43%); P = 0.01]. At 6-month follow-up, LV reverse dyssynchrony (reduction of anteroseptal to posterior delay ≥50%) using ST-RS imaging was similar in RV-A and RV-HS [25 (63%) vs. 24 (62%); P = 0.93]. More LV reverse dyssynchrony was found in concordant LV leads vs. discordant LV leads [39 (70%) vs. 10 (43%); P = 0.03]. A concordant LV lead was an independent predictor of LV reverse remodelling (odds ratio, 3.65; P = 0.01) and LV reverse dyssynchrony (odds ratio, 4.22; P = 0.02) 6 months after CRT. Conclusion RV-A and RV-HS in CRT demonstrated similar LV reverse remodelling and LV reverse dyssynchrony at 6-month follow-up. Concordant LV leads provided superior LV reverse remodelling and LV reverse dyssynchrony. Trial registration: NCT01035489
- Left ventricular discoordination index measured by speckl... Aims This study aimed to evaluate the predictive value of a baseline speckle tracking strain rate imaging-derived discoordination index for response to cardiac resynchronization therapy (CRT). Methods and results Ninety-seven patients with QRS ≥120 ms and left ventricular (LV) ejection fraction ≤35% were prospectively followed after CRT in the Mayo CRT Registry. The LV discoordination index (stretch/shortening or thinning/thickening during ejection) was calculated from three types of deformation, radial, circumferential, and longitudinal, using two-dimensional speckle tracking strain rate imaging. The benefit of CRT was evaluated by reverse remodelling (i.e. reduction of LV end-systolic volume ≥15% at 6-month follow-up) and survival. The optimal cut-off value of the baseline discoordination index in discriminating responders from non-responders was determined by receiver operating characteristic curve analysis. Significant differences in baseline indices between responders and non-responders were noted for radial and circumferential discoordination indices. A mid-ventricular radial discoordination index (RDI-M) >38% best predicted responders, especially in patients with ischaemic cardiomyopathy (area under the curve 0.86 for all patients, sensitivity 80%, and specificity 91%). Death occurred in 28 patients over a median follow-up of 3.2 years. When adjusted for confounding variables, lack of significant discoordination (RDI-M <38%) before CRT was associated with a particularly high mortality (hazard ratio 7.05, 95% confidence interval 2.45–26.0). Conclusion LV discoordination assessed by speckle tracking RDI-M imaging was able to predict reverse remodelling at 6 months and survival of patients who received CRT.
Europace
- Atrial fibrillation: is there evidence to support an earl...
- Transseptal catheterization: a matter of technology, trai...
- Cardioversion for atrial fibrillation in the real world: ...
- Is the left bundle branch really blocked when suggested b...
- Appropriate implantable cardioverter defibrillator therap...
- Extracellular matrix alterations in the atria: insights i... Atrial fibrillation is the most common arrhythmia in clinical practice and is associated with increased cardiovascular morbidity and mortality. Atrial fibrosis, a detrimental process that causes imbalance in extracellular matrix deposition and degradation, has been implicated as a substrate for atrial fibrillation, but the precise mechanisms of structural remodelling and the relationship between atrial fibrosis and atrial fibrillation are not completely understood. A large number of experimental and clinical studies have shed light on the mechanisms of atrial fibrosis at the molecular and cellular level, including interactions between matrix metalloproteinases and their endogenous tissue inhibitors, and profibrotic signals through specific molecules and mediators such as angiotensin II, transforming growth factor-β1, connective tissue growth factor, and platelet-derived growth factor. This review focuses on the mechanisms of atrial fibrosis and highlights the relationship between atrial fibrosis and atrial fibrillation.
- Safe magnetic resonance image scanning of the pacemaker p... Magnetic resonance imaging (MRI) is the imaging modality of choice in many clinical situations, and its use is likely to grow due to expanding indications and an ageing population. Many patients with implantable devices are denied MRI except in cases of urgent need, and when scans must be performed they are complicated by the need for burdensome and costly personnel and monitoring requirements that have the net effect of restricting access to scans. Several small studies, enrolling a total of 344 patients, suggest that some patients with conventional systems may undergo MR examinations without clinically overt adverse events. However, a number of potential interactions exist between implantable cardiac devices and the static and gradient magnetic fields and modulated radio frequency (RF) fields generated during MR scans; nearly all studies have reported pacing capture threshold changes, troponin elevations, ectopy, unpredictable reed switch behaviour, and other ‘subclinical’ issues with pacemakers and implantable cardioverter-defibrillators (ICDs) in patients who have undergone MRI. Attention has turned to devices that are specifically designed to be safe in the MRI environment. A clinical study of one such device documented its ability to be exposed to MRI in a 1.5 T scanner without adverse impact on patient outcomes or pacemaker system function. Such new technologies may enable scanning of pacemaker and ICD patients with reduced concerns regarding the short- and long-term effects of MRI. As importantly, these devices may increase the number of centres that are able to safely perform MRI and, thus, expand access to scans for patients with these devices.
- Association between left atrial size and atrial fibrillat... Aims Left atrial (LA) enlargement is associated with atrial fibrillation (AF). However, it is controversial whether dilated atrium can predict post-ablation AF recurrence. We undertook a systematic review and meta-analysis to analyse the association between LA diameter and AF recurrence after single circumferential pulmonary vein isolation (CPVI) and explore the potential mechanism. Methods and results Electronic databases and bibliographies of retrieved studies were searched. The anteroposterior diameters of LA were available in all included studies, which were measured at end-systole by M-mode transthoracic echocardiography. Subgroup analysis was conducted based on the duration of follow-up. Weighted mean difference (WMD) and 95% confidence interval (CI) were calculated using random-effect or fixed-effect model, depending on statistical heterogeneity. Twenty-two studies with a total of 3750 individuals met the inclusion criteria. The summary WMD of LA diameter between patients with and without recurrence was 1.87 mm (95% CI 1.26–2.48, P< 0.001). Meta-regression analysis of the 22 studies indicated that study design, duration of follow-up, and measurement of asymptomatic recurrences were significant sources of heterogeneity. Sensitivity analysis suggested that the difference in LA diameter between patients with and without recurrences persisted regardless of the duration of follow-up. Conclusion Dilated LA significantly increases the risk of AF recurrence after single CPVI. This is especially applicable to the patients with long-term follow-up.
- Prior antiarrhythmic drug use and the outcome of atrial f... Aims Atrial fibrillation (AF) ablation is generally performed after patients fail antiarrhythmic drug (AAD) therapy. Some patients have drug contraindications or choose to avoid a lifetime of drug therapy. Little is known about the impact of previous drug therapy on ablation outcomes. We evaluated AAD use before AF ablation and its impact on ablation outcomes. Methods and results We evaluated freedom from AF after ablation and patients' clinical characteristics by number of AADs failed in 1125 patients undergoing 1504 ablations. We also evaluated reasons why some patients did not receive prior drug therapy. Cox multivariate analysis examined factors predicting ablation failure. Patients failing more drugs before ablation were older (P = 0.001), had a longer duration of AF (P = 0.0001), were more likely female (P = 0.037), had more repeat ablations (P = 0.045), and less paroxysmal AF (P = 0.003). For patients with either paroxysmal or persistent AF, the number of drugs failed predicted AF recurrence (P = 0.0001). Other factors predicting AF recurrence following final ablation included age (P = 0.004), left atrial size (P = 0.002), female gender (P = 0.0001), and persistent AF (P = 0.0001). The reason for not receiving prior drug therapy was medical in 21.5% and patient choice in 78.5%. Number of drugs failed did not influence ablation outcome for patients with long-standing persistent AF (P = 0.352). Conclusions For paroxysmal and persistent AF patients undergoing ablation, those failing fewer AADs have different clinical characteristics than those who fail more drugs. Our study also suggests that the more drugs failed pre-ablation, the lower the freedom from AF post-procedure, possibly due to AF progression during drug trials.
- Acute electrical isolation is a necessary but insufficien... Aims Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional ‘visual gap’ (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results Twenty-eight patients undergoing ablation for paroxysmal (n= 20) or persistent atrial fibrillation (n= 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75% (n= 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter (n= 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these ‘isolated’ PVs exhibit dormant conduction—predominantly via the un-ablated ‘ViGs’ in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.
Arteriosclerosis, Thrombosis, and Vascular Biology
- Development of a Magnetic Resonance Imaging Protocol for ... Objective— Acute ischemic events are often caused by the disruption of lipid-rich plaques, which are frequently not angiographically visible. Vascular cell adhesion molecule-1 and apoptotic cell-targeted peptides studied during our previous work were conjugated to ultrasmall superparamagnetic iron oxide (USPIO) (USPIO-R832 for vascular cell adhesion molecule-1 targeting; USPIO-R826 for apoptosis targeting) and assessed by magnetic resonance imaging. Methods and Results— Apolipoprotein E knockout mice were injected with 0.1 mmol Fe/kg body weight and were imaged on a 4.7-T Bruker magnetic resonance imaging until 24 hours after contrast agent administration. Aortic samples were then harvested and examined by histochemistry, and the magnetic resonance images and histological micrographs were analyzed with ImageJ software. The plaques enhanced by USPIO-R832 contained macrophages concentrated in the cap and a large necrotic core, whereas USPIO-R826 produced a negative enhancement of plaques rich in macrophages and neutral fats concentrated inside the plaque. Both USPIO derivatives colocalized with their target on histological sections and were able to detect plaques with a vulnerable morphology, but each one is detecting a specific environment. Conclusion— Our vascular cell adhesion molecule-1 and apoptotic cell targeted USPIO derivatives seem to be highly promising tools for atherosclerosis imaging contributing to the detection of vulnerable plaques. They are able to attain their target in low doses and as fast as 30 minutes after administration.
- Correction [Correction]
- Summing Up [Editorial]
- Apolipoprotein B Secretory Regulation by Degradation [His... In this short review, we discuss apolipoprotein B100 and the assembly of very low-density lipoproteins. In particular, we address the nature and importance of co- and posttranslational degradation of apolipoprotein B100 during the assembly process. We also provide a short historical background to the development of the current model for the degradation of apolipoprotein B100.
- Macrophage Heterogeneity: A Personal Scientific Journey [... Although already evident from the earliest days of macrophage research, the diversity of macrophage distribution, morphology, and function continues to attract immunologists interested in their role in physiology and disease. Contemporary tools of cellular and molecular analysis have begun to unravel their versatile and adaptable gene expression, the result of differentiation and modulation by their environment. In this brief account, I outline the history of my personal involvement in this subject.
- Endogenous Nitric Oxide Synthase Inhibitors in the Biolog... The asymmetric methylarginines inhibit nitric oxide synthesis in vivo by competing with L-arginine at the active site of nitric oxide synthase. High circulating levels of asymmetric dimethylarginine predict adverse outcomes, specifically vascular events but there is now increasing experimental and epidemiological evidence that these molecules, and the enzymes that regulate this pathway, play a mechanistic role in cardiovascular diseases. Recent data have provided insight into the impact of altered levels of these amino acids in both humans and rodents, however these reports also suggest a simplistic approach based on measuring, and modulating circulating asymmetric dimethylarginine alone is inadequate. This review outlines the basic biochemistry and physiology of endogenous methylarginines, examines both the experimental and observational evidence for a role in disease pathogenesis, and examines the potential for therapeutic regulation of these molecules.
- Role of Src Tyrosine Kinases in Experimental Pulmonary Hy... Objective— Pulmonary arterial hypertension is a progressive pulmonary vascular disorder with high morbidity and mortality. Compelling evidence suggests that receptor tyrosine kinases, such as platelet-derived growth factor (PDGF) are closely involved in the pathogenesis of pulmonary arterial hypertension. We investigated the effects of 2 novel PDGF inhibitors, nilotinib/AMN107 (Abl kinases/PDGF receptor inhibitor) and dasatinib/BMS-354825 (Abl kinases/PDGF receptor/Src inhibitor), on the proliferation and migration of pulmonary arterial smooth muscle cells (PASMCs) and on the hemodynamics and pulmonary vascular remodeling in experimental pulmonary hypertension, and determined the expression and regulation of Src family kinases. Methods and Results— Human PASMCs were stimulated by PDGF alone or multiple growth factors to induce proliferation and migration in vitro. Dasatinib (0.03 μmol/L), nilotinib (0.3 μmol/L), and imatinib (1 μmol/L) potently inhibited PDGF-induced signal transducer and activator of transcription 3 and Akt phosphorylation. All 3 inhibitors decreased PDGF-induced proliferation, cell cycle gene regulation, and migration. In contrast, only dasatinib inhibited multiple growth factor–induced PASMC proliferation, and this was associated with the inhibition of Src phosphorylation. Combination of specific Src inhibitors (phosphoprotein phosphatase 1, phosphoprotein phosphatase 2) with either imatinib or nilotinib reduced multiple growth factor–induced proliferation to a similar extent as dasatinib. Importantly, Src phosphorylation increased in pulmonary arterial hypertension PASMCs compared with control PASMCs. Finally, in vivo dasatinib (15 mg/kg per body weight) treatment caused a complete reversal of pulmonary vascular remodeling and achieved similar effectiveness as imatinib (100 mg/kg per body weight) in both monocrotaline- and hypoxia-induced pulmonary hypertension models. Conclusion— We suggest that dual inhibition of PDGF receptor and Src kinases potently inhibits mitogenic and motogenic responses to growth factors in PASMCs and pulmonary vascular remodeling in vivo so that dual inhibition may represent an alternative therapeutic approach for pulmonary arterial hypertension.
- Intense Physiological Light Upregulates Vascular Endothel... Objectives— Toxicity of intense light to facilitate the development of neovascular age-related macular degeneration has been a health concern although the mechanism remains unclear. Methods and Results— Effects of intense, but within physiological range, light on retinal pigment epithelium, a major pathogenic origin of age-related macular degeneration were studied in mice. Intense physiological light upregulated vascular endothelial growth factor (VEGF) expression in retinal pigment epithelium, independent of circadian rhythm, which resulted in enhancement of choroidal neovascularization. In rd1/rd1 mice or Crx–/– mice that do not possess outer segment structure, light exposure did not induce VEGF, indicating that VEGF upregulation by light depended on increased outer segment phagocytosis by retinal pigment epithelium. In retinal pigment epithelium cells phagocytosing increased amount of outer segment, peroxisome proliferator-activated receptor coactivator-1α (PGC-1α) not hypoxia-inducible factor-1α was induced, leading to VEGF upregulation. The VEGF upregulation and choroidal neovascularization enhancement were abrogated in PGC-1α–/– mice and estrogen-related receptor-α–/– mice, indicating the involvement of PGC-1α/estrogen-related receptor-α pathway. Conclusions— Intense physiological light is involved in choroidal neovascularization through excess outer segment phagocy-tosis and VEGF upregulation mediated by PGC-1α in vivo.
- Downregulation of Endothelial MicroRNA-200b Supports Cuta... Objective— MicroRNAs (miRs) regulate angiogenesis by posttranscriptional silencing of target genes. The significance of angiostatic miR-200b in switching on skin wound angiogenesis was tested. Methods and Results— Wounding caused imminent and transient downregulation of miR-200b in dermal wound-edge endothelial cells. Derailing this injury response by lentiviral delivery of miR-200b in vivo impaired wound angiogenesis. Computational prediction, target reporter luciferase assay, and Western blot analysis provided first evidence that miR-200b targets globin transcription factor binding protein 2 (GATA2) and vascular endothelial growth factor receptor 2 (VEGFR2). Overexpression of GATA2 or VEGFR2 in endothelial cells rescued the angiostatic effect of miR-200b in vitro. Downregulation of miR-200b derepressed GATA2 and VEGFR2 expression to switch on wound angiogenesis, which was disrupted in diabetic wounds. Treatment of endothelial cells with tumor necrosis factor-α, a proinflammatory cytokine abundant in diabetic wounds, induced miR-200b expression, silenced GATA2 and VEGFR2, and suppressed angiogenesis. These outcomes were attenuated using anti-miR-200b strategy. Neutralization of tumor necrosis factor-α in the diabetic wounds improved wound angiogenesis and closure, which was accompanied by downregulation of miR-200b expression and desilencing of GATA2 and VEGFR2. Conclusion— Injury-induced repression of miR-200b turned on wound angiogenesis. In mice with diabetes mellitus,excessive tumor necrosis factor-α induced miR-200b blunting proangiogenic functions of GATA2 and VEGFR2.
- Reactive Oxygen Species Regulate Osteopontin Expression i... Objective— Previous findings from our laboratory demonstrated that neovascularization was impaired in osteopontin (OPN) knockout animals. However, the mechanisms responsible for the regulation of OPN expression in the setting of ischemia remain undefined. Therefore, we sought to determine whether OPN is upregulated in response to ischemia and hypothesized that hydrogen peroxide (H2O2) is a critical component of the signaling mechanism by which OPN expression is upregulated in response to ischemia in vivo. Methods and Results— To determine whether ischemic injury upregulates OPN, we used a murine model of hindlimb ischemia. Femoral artery ligation in C57BL/6 mice significantly increased OPN expression and H2O2 production. Infusion of C57BL/6 mice with polyethylene glycol-catalase (10 000 U/kg per day) or the use of transgenic mice with smooth muscle cell-specific catalase overexpression blunted ischemia-induced OPN, suggesting ischemia-induced OPN expression is H2O2-dependent. Decreased H2O2-mediated OPN blunted reperfusion and collateral formation in vivo. In contrast, the overexpression of OPN using lentivirus restored neovascularization. Conclusion— Scavenging H2O2 blocks ischemia-induced OPN expression, providing evidence that ischemia-induced OPN expression is H2O2 dependent. Decreased OPN expression impaired neovascularization, whereas overexpression of OPN increased angiogenesis, supporting our hypothesis that OPN is a critical mediator of postischemic neovascularization and a potential novel therapeutic target for inducing new vessel growth.
Circulation
- European Perspectives [European Perspectives]
- Successful Fontan Completion After Cardiac Resynchronizat...
- Oral Presentations From the WORLD CONGRESS OF CARDIOLOGYS...
- Poster Presentations From the World Congress of Cardiolog...
- Stem Cells in Circulation and the Circulation Subspecialt... The following articles are being highlighted as part of Circulation's Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in Circulation and the Circulation subspecialty journals. The studies included in this article represent the articles related to stem cells that were published in Circulation and the Circulation subspecialty journals in 2010 and 2011.
- Letter by Farmakis and Aessopos Regarding Article, "Echoc...
- Letter by Kuller and Wong Regarding Article, "Comparative...
- Letter by Palmas Regarding Article, "Comparative Effectiv...
- Letter by Heston Regarding Article, "Comparative Effectiv...
- Response to Letters Regarding Article, "Comparative Effec...
Circulation Research
- The Future of Optical Mapping is Bright: RE: Review on: "...
- Cthrc1 Is a Novel Inhibitor of Transforming Growth Factor...
- In This Issue [In This Issue]
- Protective Role for Myeloid Specific KLF2 in Atherosclero...
- Myocardial Isl+land: A Place With Lots of Rhythm, but No ...
- An ACE Up Your Sleeve: 2 Is Better Than 1 [Editorials]
- Why Don't Macrophages Leave Atherosclerotic Lesions? [Com...
- Autophagy Mediates the Metabolic Benefits of Endurance Tr...
- Formin mDia1 Mediates Vascular Remodeling via Integration... Rationale: The mammalian diaphanous-related formin (mDia1), governs microtubule and microfilament dynamics while functioning as an effector for Rho small GTP-binding proteins during key cellular processes such as adhesion, cytokinesis, cell polarity, and morphogenesis. The cytoplasmic domain of the receptor for advanced glycation endproducts binds to the formin homology 1 domain of mDia1; mDia1 is required for receptor for advanced glycation endproducts ligand-induced cellular migration in transformed cells. Objective: Because a key mechanism in vascular remodeling is the induction of smooth muscle cell migration, we tested the role of mDia1 in this process. Methods and Results: We report that endothelial denudation injury to the murine femoral artery significantly upregulates mDia1 mRNA transcripts and protein in the injured vessel, particularly in vascular smooth muscle cells within the expanding neointima. Loss of mDia1 expression significantly reduces pathological neointimal expansion consequent to injury. In primary murine aortic smooth muscle cells, mDia1 is required for receptor for advanced glycation endproducts ligand-induced membrane translocation of c-Src, which leads to Rac1 activation, redox phosphorylation of AKT/glycogen synthase kinase 3β, and consequent smooth muscle cell migration. Conclusions: We conclude that mDia1 integrates oxidative and signal transduction pathways triggered, at least in part, by receptor for advanced glycation endproducts ligands, thereby regulating pathological neointimal expansion.
- Myeloid-Specific Kruppel-Like Factor 2 Inactivation Incre... Rationale: Hemizygous deficiency of the transcription factor Krüppel-like factor 2 (KLF2) has been shown previously to augment atherosclerosis in hypercholesterolemic mice. However, the cell type responsible for the increased atherosclerosis due to KLF2 deficiency has not been identified. This study examined the consequence of myeloid cell-specific KLF2 inactivation in atherosclerosis. Methods and Results: Cell-specific knockout mice were generated by Cre/loxP recombination. Macrophages isolated from myeloid-specific Klf2 knockout (myeKlf2–/–) mice were similar to myeKlf2+/+ macrophages in response to activation, polarization, and lipid accumulation. However, in comparison to myeKlf2+/+ macrophages, myeKlf2–/– macrophages adhered more robustly to endothelial cells. Neutrophils from myeKlf2–/– mice also adhered more robustly to endothelial cells, and fewer myeKlf2–/– neutrophils survived in culture over a 24-hour period in comparison with myeKlf2+/+ neutrophils. When myeKlf2–/– mice were mated to Ldlr–/– mice and then fed a high fat and high cholesterol diet, significant increase in atherosclerosis was observed in the myeKlf2–/–Ldlr–/– mice compared with myeKlf2+/+Ldlr–/– littermates. The increased atherosclerosis in myeKlf2–/–Ldlr–/– mice was associated with elevated presence of neutrophils and macrophages, with corresponding increase of myeloperoxidase as well as chlorinated and nitrosylated tyrosine epitopes in their lesion areas compared with myeKlf2+/+Ldlr–/– mice. Conclusions: This study documents a role for myeloid KLF2 expression in modulating atherosclerosis. The increased neutrophil accumulation and atherosclerosis progression with myeloid-specific KLF2 deficiency also underscores the importance of neutrophils in promoting vascular oxidative stress and atherosclerosis. Collectively, these results suggest that elevating KLF2 expression may be a novel strategy for prevention and treatment of atherosclerosis.
Hypertension
- Endothelial Nitric Oxide Synthase Polymorphism rs3918226 ...
- Response to Endothelial Nitric Oxide Synthase Polymorphis...
- Fructose Likely Does Have a Role in Hypertension [Letters...
- Response to Fructose Likely Does Have a Role in Hypertens...
- Role of Angiotensinogen and Relative Aldosterone Excess i...
- Response to Role of Angiotensinogen and Relative Aldoster...
- Correction [Correction]
- Thiazide and Thiazide-Like Diuretics: Perspectives on Ind...
- Calcium Antagonist Added to Angiotensin Receptor Blocker:...
- Pharmacogenetics of Antihypertensive Response [Editorial ...
Circulation Arrhythmia and Electrophysiology
- Three-Dimensional Delayed-Enhanced Cardiac MRI Reconstruc...
- Deglutition-Induced Atrial Tachycardia: Direct Visualizat...
- Bipolar Ablation of Ventricular Tachycardia in a Patient ...
- Catheter Ablation of Atrial Fibrillation in Transposition...
- Premature Beats and Unexpected Heart Block: An Unusual Me...
- Right Coronary Artery Fistula as a Result of Delayed Righ...
- Circulation: Arrhythmia and Electrophysiology Editors' Pi... The following articles are being highlighted as part of Circulation: Arrhythmia and Electrophysiology's Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in Circulation: Arrhythmia and Electrophysiology, Circulation, and the other Circulation subspecialty journals. The studies included in this article represent the most read manuscripts published on the topic of sudden death in 2010 and 2011.
- Letter by Casado-Arroyo et al Regarding Article, "Electro...
- Response to Letter Regarding Article, "Electrocardiograph...
- Correction [Correction]
Circulation Heart Failure
- Apical Pseudoaneurysm Following Continuous Flow Left Vent...
- Improvement in Myocardial Delayed Enhancement After Autol...
- Circulation: Heart Failure Editors' Picks: Most Important... The following are highlights from Circulation: Heart Failure Topic Review. This series will summarize the most important articles, as selected by the editors, that have published in the Circulation portfolio. The objective of this series is to provide our readership with a timely comprehensive selection of important papers that are relevant to the heart failure audience. The studies included in this article represent the most noteworthy research in the areas of heart failure and electrophysiology.
- Estimating Glomerular Filtration Rate Using the Chronic K...
- Fine-Tuning a Heart-Brain Connection: Anxiety in Atrial F...
- Renal Dysfunction in Patients With Heart Failure With Pre... Background— Prior studies in heart failure (HF) have used the Modification of Diet in Renal Disease (MDRD) equation to calculate estimated glomerular filtration rate (eGFR). The Chronic Kidney Disease-Epidemiology Collaboration Group (CKD-EPI) equation provides a more-accurate eGFR than the MDRD when compared against the radionuclide gold standard. The prevalence and prognostic import of renal dysfunction in HF if the CKD-EPI equation is used rather than the MDRD is uncertain. Methods and Results— We used individual patient data from 25 prospective studies to stratify patients with HF by eGFR using the CKD-EPI and the MDRD equations and examined survival across eGFR strata. In 20 754 patients (15 962 with HF with reduced ejection fraction [HF-REF] and 4792 with HF with preserved ejection fraction [HF-PEF]; mean age, 68 years; deaths per 1000 patient-years, 151; 95% CI, 146–155), 10 589 (51%) and 11 422 (55%) had an eGFR <60 mL/min using the MDRD and CKD-EPI equations, respectively. Use of the CKD-EPI equation resulted in 3760 (18%) patients being reclassified into different eGFR risk strata; 3089 (82%) were placed in a lower eGFR category and exhibited higher all-cause mortality rates (net reclassification improvement with CKD-EPI, 3.7%; 95% CI, 1.5%–5.9%). Reduced eGFR was a stronger predictor of all-cause mortality in HF-REF than in HF-PEF. Conclusions— Use of the CKD-EPI rather than the MDRD equation to calculate eGFR leads to higher estimates of renal dysfunction in HF and a more-accurate categorization of mortality risk. Renal function is more closely related to outcomes in HF-REF than in HF-PEF.
- Testosterone Supplementation in Heart Failure: A Meta-Ana... Background— Low testosterone is an independent predictor of reduced exercise capacity and poor clinical outcomes in patients with heart failure (HF). We sought to determine whether testosterone therapy improves exercise capacity in patients with stable chronic HF. Methods and Results— We searched Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (1980–2010). Eligible studies included randomized controlled trials (RCTs) reporting the effects of testosterone on exercise capacity in patients with HF. Reviewers determined the methodological quality of studies and collected descriptive, quality, and outcome data. Four trials (n=198; men, 84%; mean age, 67 years) were identified that reported the 6-minute walk test (2 RCTs), incremental shuttle walk test (2 RCTs), or peak oxygen consumption (2 RCTs) to assess exercise capacity after up to 52 weeks of treatment. Testosterone therapy was associated with a significant improvement in exercise capacity compared with placebo. The mean increase in the 6-minute walk test, incremental shuttle walk test, and peak oxygen consumption between the testosterone and placebo groups was 54.0 m (95% CI, 43.0–65.0 m), 46.7 m (95% CI, 12.6–80.9 m), and 2.70 mL/kg per min (95% CI, 2.68–2.72 mL/kg per min), respectively. Testosterone therapy was associated with a significant increase in exercise capacity as measured by units of pooled SDs (net effect, 0.52 SD; 95% CI, 0.10–0.94 SD). No significant adverse cardiovascular events were noted. Conclusions— Given the unmet clinical needs, testosterone appears to be a promising therapy to improve functional capacity in patients with HF. Adequately powered RCTs are required to assess the benefits of testosterone in this high-risk population with regard to quality of life, clinical events, and safety.
- Anxiety Sensitivity Moderates Prognostic Importance of Rh... Background— Patients with high anxiety sensitivity (AS) become extremely anxious with heart rate increases, palpitations, and symptoms of psychological arousal. AS predicts panic attacks. In atrial fibrillation (AF), AS correlates with symptom preoccupation and reduced quality of life. We assessed whether AS is associated with outcomes of rhythm-control versus rate-control in congestive heart failure (CHF) patients with AF. Methods and Results— Before random assignment, 933 participants (172 women) in the Atrial Fibrillation and Congestive Heart Failure Trial completed the Anxiety Sensitivity Inventory (ASI). Cox proportional hazards models showed no main effects of treatment (P=0.61) or AS (P=0.72) for time to cardiovascular death, but these factors interacted significantly (P=0.020). High AS patients (upper quartile, ASI ≥33) randomly assigned to rhythm-control had significantly lower cardiovascular mortality than those receiving rate-control (hazard ratio, 0.54; 95% confidence interval, 0.32–0.93; P=0.022). With lower ASI scores (<33), treatments did not differ (hazard ratio, 1.12; 95% confidence interval, 0.83–1.51; P=0.46). The interaction between treatment and dichotomized ASI scores remained significant (P=0.009) after adjustment for covariates including age, sex, hypertension, diabetes, creatinine, ejection fraction, time since first diagnosis of AF, New York Heart Association functional class, depression symptoms, marital status, and baseline β-blockers, angiotensin-converting enzyme inhibitors, oral anticoagulants, and implantable cardioverter-defibrillators. Conclusions— Atrial fibrillation and congestive heart failure patients with high AS had better long-term prognosis with rhythm- than rate-control. If replicated, AS should be considered in treatment selection. Research is also needed concerning mechanisms and possible joint AS-AF treatments. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT88597077.
- Short and Precise Patient Self-Assessment of Heart Failur... Background— Assessment of dyspnea, fatigue, and physical disability is fundamental to the monitoring of patients with heart failure (HF). A plethora of patient-reported measures exist, but most are too burdensome or imprecise to be useful in clinical practice. New techniques used for computer adaptive tests (CATs) may be able to address these problems. The purpose of this study was to build a CAT for patients with HF. Methods and Results— Item banks of 74 queries ("items") were developed to assess self-reported physical disability, fatigue, and dyspnea. All queries were administered to 658 adults with HF to build 3 item banks. The resulting HF-CAT was administered to 100 patients with ancillary HF (New York Heart Association I, 11%; II, 53%; III and IV, 36%). In addition, the physical function and vitality domains of the SF-36 Health Survey questionnaire, an established shortness-of-breath scale, and the Minnesota Living with Heart Failure Questionnaire were applied. The HF-CAT assessment took 3:09±1:52 minutes to complete and score. All HF-CAT scales demonstrated good construct validity through high correlations with the corresponding SF-36 Health Survey physical function (r=–0.87), vitality (r=–0.85), and shortness-of-breath (r=0.84) scales. Simulation studies showed a more precise measurement of all HF-CAT scales over a larger range than comparable static tools. The HF-CAT scales identified significant differences between patients classified by the New York Heart Association symptom criteria, similar to the Minnesota Living with Heart Failure Questionnaire. Conclusions— A new CAT for patients with HF was built using modern psychometric methods. Initial results demonstrate its potential to increase the feasibility and precision of patient self-assessments of symptoms of HF with minimized respondent burden. Clinical Trial Registration— URL: http://www.projectreporter.nih.gov. Unique identifier: 1R43HL083622-01.
- Adipose Tissue Inflammation and Adiponectin Resistance in... Background— Heart failure (HF) is characterized by inflammation, insulin resistance, and progressive catabolism. We hypothesized that patients with advanced HF also develop adipose tissue inflammation associated with impaired adipokine signaling and that hemodynamic correction through implantation of ventricular assist devices (VADs) would reverse adipocyte activation and correct adipokine signaling in advanced HF. Methods and Results— Circulating insulin, adiponectin, leptin, and resistin levels were measured in 36 patients with advanced HF before and after VAD implantation and 10 healthy control subjects. Serum adiponectin was higher in HF patients before VAD implantation compared with control subjects (13.3±4.9 versus 6.4±2.1 μg/mL, P=0.02). VAD implantation (mean, 129±99 days) reduced serum adiponectin (7.4±3.4 μg/mL, P<0.05) and improved insulin resistance (Homeostasis Assessment Model of insulin resistance: 6.3±5.8–3.6±2.9; P<0.05). Adiponectin expression in adipose tissue decreased after VAD implantation (–65%; P<0.03). Adiponectin receptor expression was suppressed in the failing myocardium compared with control subjects and increased after mechanical unloading. Histomorphometric analysis of adipose tissue specimens revealed reduced adipocyte size in patients with advanced HF compared with control subjects (1999±24 μm2 versus 5583±142 μm2 in control subjects; P<0.05), which increased after VAD placement. Of note, macrophage infiltration in adipose tissue was higher in advanced HF patients compared with control subjects (+25%; P<0.01), which normalized after VAD implantation. Conclusions— Adipose tissue inflammation and adiponectin resistance develop in advanced HF. Mechanical unloading of the failing myocardium reverses adipose tissue macrophage infiltration, inflammation, and adiponectin resistance in patients with advanced HF.
Circulation Cardiovascular Imaging
- Circulation: Cardiovascular Imaging's Editors' Picks: Mos...
- Letter by Ozkan Regarding Article, "Low-Flow, Low-Gradien...
- Response to Letter Regarding Article, "Low-Flow, Low-Grad...
- Letter by Aquaro et al Regarding Article, "Intermediate-S...
- Serial Echocardiographic Assessment of the Human Heart in...
- Normal Weight Obesity: Is Bigger Really Badder? [Editorial]
- Morphological and Functional Adaptation of the Maternal H... Background— Pregnancy provides a unique model to study the adaptation of the heart in a physiological situation of transient load changes. The aim of this study was to assess the performance of the left ventricle (LV) in normal, uncomplicated pregnancies while considering the actual LV load and shape. Methods and Results— Serial echocardiographic examinations were performed in 51 women in each pregnancy trimester and 3 to 6 months after delivery. Data from 10 nulliparous, age-matched women were used as the control. Conventional parameters of LV function (ejection fraction) as well as myocardial deformation (strain) were interpreted, taking into consideration maternal hemodynamics and LV shape. Cardiac output increased during pregnancy because of a higher stroke volume in early pregnancy and a late increase in heart rate, whereas total vascular resistance decreased. Progressive development of eccentric hypertrophy was observed, which subsequently recovered postpartum. Sphericity index decreased from the first to the third trimester (1.92±0.17 versus 1.71±0.17) and returned postpartum to values comparable to the control. Although higher LV stroke work was noted toward the third trimester (5.9±1.1 versus 5.3±1.0 Newton meter, P<0.001), ejection fraction showed no significant changes. LV strain decreased significantly in late pregnancy (–19.5±2% to –17.6±1.6%, P<0.001) and returned to baseline values after delivery (–19.5±2%). Conclusions— Pregnancy is a physiological process associated with increased cardiac performance and progressive LV remodeling. These changes are not directly reflected by parameters traditionally considered to describe systolic function, such as ejection fraction and longitudinal deformation. While ejection fraction was insensitive to the functional changes, the transient decrease in longitudinal deformation becomes only plausible when considering the changes in LV geometry.
- Prognostic Implication of Appropriateness Criteria for Ph... Background— Although appropriateness criteria for stress echocardiography have been developed to deliver high-quality care, the prognostic impact of these criteria remains undefined. Therefore, we sought to assess the prognostic implication of the American College of Cardiology/American Society of Echocardiography appropriateness criteria for pharmacological stress echo in a cohort of ambulatory patients. Methods and Results— The study population consisted of 1552 ambulatory patients who underwent pharmacological (752 dobutamine, 800 dipyridamole) stress echo for the evaluation of known (n=549) or suspected (n=1003) coronary artery disease at a single cardiology center. Patients were followed up for a median of 36 months. Indications were determined for consecutive studies by 2 reviewers and categorized as follows: 984 (63%) patients had appropriate, 145 (9%) uncertain, and 423 (27%) inappropriate indication for stress echo. Ischemia was present in 15% of patients with appropriate, 8% of those with uncertain, and 5% of those with inappropriate indication (P<0.0001). During follow-up, 146 events (89 deaths, 57 nonfatal infarctions) occurred. Annual event rate associated with appropriate, uncertain, and inappropriate study was 3.1%, 3.8%, and 1.3%, respectively. The abnormal test result in patients with appropriate, uncertain, and inappropriate study was associated with 5.0%, 5.6%, and 1.8% annual event rate, respectively, exerting an independent value only in the appropriate and uncertain subset. Conclusions— Inappropriate indication for pharmacological stress echo is common, being documented in about 1 of 4 patients evaluated in an ambulatory setting, and is associated with lower rate of positive results and better survival as compared with appropriate and uncertain indication.
- High-Resolution Versus Standard-Resolution Cardiovascular... Background— Although accelerated high-spatial-resolution cardiovascular MR (CMR) myocardial perfusion imaging has been shown to be clinically feasible, there has not yet been a direct comparison with standard-resolution methods. We hypothesized that higher spatial resolution detects more subendocardial ischemia and leads to greater diagnostic accuracy for the detection coronary artery disease. This study compared the diagnostic accuracy of high-resolution and standard-resolution CMR myocardial perfusion imaging in patients with suspected coronary artery disease. Methods and Results— A total of 111 patients were recruited to undergo 2 separate perfusion-CMR studies at 1.5 T, 1 with standard-resolution (2.5x2.5 mm in-plane) and 1 with high-resolution (1.6x1.6 mm in-plane) acquisition. High-resolution acquisition was facilitated by 8-fold k-t broad linear speed-up technique acceleration. Two observers visually graded perfusion in each myocardial segment on a 4-point scale. Segmental scores were summed to produce a perfusion score for each patient. All patients underwent invasive coronary angiography and coronary artery disease was defined as stenosis ≥50% luminal diameter (quantitative coronary angiography). CMR data were successfully obtained in 100 patients. In patients with coronary artery disease (n=70), more segments were determined to have subendocardial ischemia with high-resolution than with standard-resolution acquisition (279 versus 108; P<0.001). High-resolution acquisition had a greater diagnostic accuracy than standard resolution for identifying single-vessel disease (area under the curve, 0.88 versus 0.73; P<0.001) or multivessel disease (area under the curve, 0.98 versus 0.91; P=0.002) and overall (area under the curve, 0.93 versus 0.83; P<0.001). Conclusions— High-resolution perfusion-CMR has greater overall diagnostic accuracy than standard-resolution acquisition for the detection of coronary artery disease in both single- and multivessel disease and detects more subendocardial ischemia.
- Clinical Context and Mechanism of Functional Tricuspid Re... Background— Functional tricuspid regurgitation (FTR) with structurally normal valve is of poorly defined mechanisms. Prevalence and clinical context of idiopathic FTR (Id-FTR) (without overt TR cause) are unknown. Methods and Results— To investigate prevalence, clinical context, and mechanisms specific to FTR types, Id-FTR versus pulmonary hypertension-related (PHTN-FTR, systolic pulmonary pressure ≥50 mm Hg), we analyzed 1161 patients with prospectively quantified TR. Id-FTR (prevalence 12%) was associated with aging and atrial fibrillation. For mechanistic purposes, we measured valvular and right ventricular (RV) remodeling in 141 Id-FTR matched to 140 PHTN-FTR and to 99 controls with trivial TR for age, sex, atrial fibrillation, and ejection fraction. PHTN-FTR and Id-FTR were also matched for TR effective-regurgitant-orifice (ERO). Id-FTR valvular alterations (versus controls) were largest annular area (3.53±0.6 versus 2.74±0.4 cm2, P<0.0001) and lowest valvular/annular coverage ratio (1.06±0.1 versus 1.45±0.2, P<0.0001) but normal valve tenting height. PHTN-FTR had mild annular enlargement but excessive valve tenting height (0.8±0.3 versus 0.35±0.1 cm, P<0.0001). Valvular changes were linked to specific RV changes, largest basal dilatation, and normal length (RV conical deformation) in Id-FTR versus longest RV with elliptical/spherical deformation in PHTN-FTR. With increasing FTR severity (ERO ≥40 mm2), changes specific to each FTR type were accentuated, and RV function (index of myocardial performance) was consistently reduced. Conclusions— Id-FTR is frequent, linked to aging and atrial fibrillation, can be severe, and is of unique mechanism. In Id-FTR, excess annular and RV-basal enlargement exhausts valvular/annular coverage reserve, and RV conical deformation does not cause notable valvular tenting. Conversely, PHTN-FTR is determined by valvular tethering with tenting linked to RV elongation and elliptical/spherical deformation. These specific FTR-mechanisms may be important in considering surgical correction in FTR.
Circulation Cardiovascular Interventions
- Branch Pulmonary Artery Jailing With a Bare Metal Stent t...
- Delayed Perforation of Coronary Artery after Percutaneous...
- Most Important Papers in Intravascular Imaging [Circulati... The following are highlights from the series Circulation: Cardiovascular Interventions Topic Review. This series summarizes the most important manuscripts, as selected by the editors, that have published in the Circulation portfolio. The studies included in this article represent the most noteworthy research in the area of intravascular imaging.
- Lessons Learned from Recent Randomized Clinical Trials fo...
- The Prequel: Defining Prognostically Important Criteria i...
- On the Edge: Targeting Toll-Like Receptor 2 in Ischemia/R...
- Periprocedural Myocardial Infarction in a Randomized Tria... Background— A consensus definition for periprocedural myocardial infarction (MI) in coronary stent trials has not been established. Differences between a historic definition, based on modified World Health Organization (WHO) criteria, and a proposed universal definition have not been compared in a prospective clinical trial. Methods and Results— We randomly assigned 3687 patients with stable coronary artery disease to undergo stenting with either everolimus-eluting stents (2458 patients) or paclitaxel-eluting stents (1229 patients). Serial creatine kinase (CK) and CKMB or troponin measurements were obtained before and after stenting. MI was classified by protocol according to the WHO definition (total CK >2x normal with elevated CKMB) and post hoc according to the Universal/Academic Research Consortium (ARC) definition (CKMB or troponin >3x normal). Protocol MI was determined in 58 (1.6%) and universal/ARC MI in 287 (7.8%) patients within 48 hours post index procedure. There were substantial differences in frequency of universal/ARC MI if only CKMB (5.4%) or troponin (18.7%) data were included for evaluation. Total stent length was a strong predictor of both protocol and universal/ARC MI. Mortality at 2 years was low (2.3%) and was not different for either MI definition. The mortality rates did not increase with elevations of CKMB or troponin to >10x normal. Conclusions— There was a marked difference in periprocedural MI rates according to protocol or universal/ARC MI definitions. No association was present between periprocedural MI and mortality up to 2 years by either definition. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00307047.
- Prognostic Significance of Elevated Baseline Troponin in ... Background— Elevation of baseline cardiac troponin in patients presenting with acute coronary syndromes (ACS) confers an adverse prognosis. The prognostic value of troponin elevation in patients with chronic kidney disease (CKD) and ACS is less certain. Methods and Results— In the ACUITY (Acute Catheterization and Urgent Intervention Triage strategy) trial, 13 819 patients with moderate and high-risk ACS were assigned randomly to receive heparin plus a glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin monotherapy. Among 2179 patients with CKD (creatinine clearance <60 mL/min), baseline troponin elevation was present in 1291 patients (59.2%). Major bleeding and major adverse cardiac events (MACE), including death, myocardial infarction (MI), or unplanned revascularization, were examined according to baseline troponin status and randomization arm. Patients with CKD in whom the baseline troponin level was elevated had significantly higher rates of death, MI, and MACE at 30 days and 1 year compared with CKD patients without elevated baseline troponin. By multivariable analysis, baseline troponin elevation in patients with CKD was an independent predictor of composite death or MI at 30 days (hazard ratio [95% CI]=2.05 [1.48, 2.83], P<0.0001) and 1 year (1.72 [1.36, 2.17], P<0.0001). In CKD patients with baseline troponin elevation, bivalirudin monotherapy compared with heparin plus a GPI significantly reduced the 30-day rates of major bleeding with nonsignificantly different rates of MACE at 30 days and 1 year. Conclusions— In patients with ACS and CKD, baseline troponin elevation is associated with significantly worse short- and long-term clinical outcomes. Bivalirudin monotherapy safely reduces major bleeding in ACS patients with CKD and baseline troponin elevation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
- Impact of Completeness of Revascularization on Long-Term ... Background— Patients with diabetes have more extensive coronary disease than those without diabetes, resulting in more challenging percutaneous coronary intervention or surgical (coronary artery bypass graft) revascularization and more residual jeopardized myocardium. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial provided an opportunity to examine the long-term clinical impact of completeness of revascularization in patients with diabetes. Methods and Results— This is a post hoc, nonrandomized analysis of the completeness of revascularization in 751 patients who were randomly assigned to early revascularization, of whom 264 underwent coronary artery bypass graft surgery and 487 underwent percutaneous coronary intervention. The completeness of revascularization was determined by the residual postprocedure myocardial jeopardy index (RMJI). RMJI is a ratio of the number of myocardial territories supplied by a significantly diseased epicardial coronary artery or branch that was not successfully revascularized, divided by the total number of myocardial territories. Mean follow-up for mortality was 5.3 years. Complete revascularization (RMJI=0) was achieved in 37.9% of patients, mildly incomplete revascularization (RMJI >0≤33) in 46.6%, and moderately to severely incomplete revascularization (RMJI >33) in 15.4%. Adjusted event-free survival was higher in patients with more complete revascularization (hazard ratio, 1.14; P=0.0018). Conclusions— Patients with type 2 diabetes mellitus and less complete revascularization had more long-term cardiovascular events. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.
- Comparison of 5-Year Clinical Outcomes Between Sirolimus-... Background— The paclitaxel-eluting stent (PES) and sirolimus-eluting stent (SES) are first-generation drug-eluting stents (DES) that have been the most widely used; however, it is unclear whether there are differences in the long-term safety and efficacy between the 2 stents. The long-term effectiveness of DES in unselected people with diabetes is also currently unclear. Moreover, the possibility of late catch-up is suggested in the DES population. Methods and Results— This study is an 8-center collaborative network analysis of all comers who received SES and PES. All patients who received SES and PES from February 2003 to October 2006 were enrolled. We analyzed 9315 patients (33.3% with diabetes) treated with SES or PES in the major 8 centers representing whole area of Korea. The primary end point was a major adverse cardiac event (MACE) composite of overall death, myocardial infarction, and target lesion revascularization. All analyses were performed using multivariable, adjusted models and propensity score-matching methods. Long-term MACE for 5 years were significantly lower in the SES than the PES group (13.3% versus 15.6%; hazard ratio, 0.82; 95% confidence interval, 0.71 to 0.96; P=0.01), which was mainly driven by the difference of MACE within the first year (hazard ratio, 0.73; 95% CI, 0.59 to 0.90; P=0.003), but the rate of MACE between 1 and 5 years in the landmark analysis was not different between the 2 stents (1.9 versus 2.0%/yr). In the subpopulation of people with diabetes, in contrast to the whole population, PES was comparable to SES in terms of any clinical outcome, both within the first year and from 1 to 5 years (MACE for 5 years, 20.3 versus 17.9%; MACE within the first year, 9.6 versus 8.2%; MACE 1 to 5 years, 2.9 versus 2.6%/yr). Conclusions— The PES was inferior to the SES in the clinical follow-up of more than 9000 patients' cohort for 5 years, which was mainly driven by the difference in the first year. In the subpopulation of people with diabetes that showed higher MACE than people without diabetes, however, PES was comparable to SES in any clinical outcome for 5 years. Although these 2 stents are not frequently used as before, the data would be useful to expect the long-term clinical course of the current DES.
Circulation Cardiovascular Quality & Outcomes
- Most Important Outcomes Research Papers in Cardiovascular... The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.
- Correction [Correction]
- A Note to My Younger Colleagues. . .Be Brave [Editor's Pe...
- Shared Decision-Making and Patient Decision Aids: Is It T...
- Repeat Revascularization Is a Faulty End Point for Clinic...
- The Chest Pain Choice Decision Aid: A Randomized Trial [O... Background— Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. Methods and Results— The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24–72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34–1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6–21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%–31%). There were no major adverse cardiac events after discharge in either group. Conclusions— Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01077037.
- Radial Artery Versus Femoral Artery Access Options in Cor... Background— Vascular access options in coronary angiography can be considered a preference-sensitive decision, where the benefits/risks have different levels of significance, depending on the individual patient. For preference-sensitive healthcare options, patient decision aids (PtDA) significantly improve the process of decision-making. The purpose of this trial was to evaluate the effectiveness of an evidence-based PtDA compared with usual care in patients eligible for radial and femoral artery access. Methods and Results— We conducted a single-center, nonblinded, randomized controlled trial with patients eligible for both femoral and radial access as per their treating physician. The PtDA was designed to guide patients to make an informed choice, consistent with their preferences and values. The primary outcome, decisional conflict, was assessed using the validated decisional conflict scale. One hundred fifty patients were randomized (vascular access PtDA=76 versus usual care=74). The intervention group had a significantly reduced decisional conflict scale compared with control (unadjusted 14.8 versus 19.5, P=0.04) and were significantly more knowledgeable regarding risks/benefits associated with each vascular access (mean knowledge score 3/5 (95% confidence interval, 2.6 to 3.3) versus 2/5 (95% confidence interval, 1.7 to 2.3, P<0.01). PtDA patients had better informed value congruence with their vascular access received (47.3% versus 25.7%, P<0.01). There were no significant differences in procedural success or safety between the 2 groups. Conclusions— A vascular access PtDA for eligible patients undergoing coronary angiogram procedures reduces decisional conflict and improves value congruence and the patients' knowledge of their healthcare options; however, a multicenter study, powered to confirm these benefits and evaluate differences in procedural success or complications, is required. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01032551.
- Do Differences in Repeat Revascularization Explain the An... Background— Patients with multivessel coronary disease treated with coronary artery bypass graft (CABG) have less angina than those treated with percutaneous coronary intervention (PCI); however, there is uncertainty as to the mechanism of greater angina relief with CABG and whether more frequent repeat revascularization in patients treated with PCI could account for this treatment difference. Methods and Results— In the Synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery trial, 1800 patients with 3-vessel or left main coronary artery disease were randomized to CABG or PCI with paclitaxel-eluting stents. Health status was assessed at baseline, 1, 6, and 12 months, using the Seattle Angina Questionnaire and the Medical Outcomes Study Short Form General Health Survey, and the association between repeat revascularization and health status during follow-up was assessed using longitudinal models. In adjusted analyses, patients who underwent repeat revascularization had worse angina frequency scores than patients who did not in both treatment groups, with differences of 8.5 points at 6 months and 3.1 points at 12 months in patients treated with PCI and 19.8 points at 6 months and 11.2 points at 12 months in patients with patients treated with CABG. Among patients who did not require repeat revascularization, the adjusted effect of CABG versus PCI on 12-month angina frequency scores was nearly identical to the overall benefit in the intention-to-treat analysis. Conclusions— Among patients with multivessel coronary artery disease treated with PCI or CABG, the occurrence of repeat revascularization during follow-up did not fully explain the antianginal benefit of CABG in the overall population. The differential association between repeat revascularization and anginal status, according to the type of initial revascularization procedure, suggests that this end point should play a limited role in any direct comparison of the 2 treatment strategies. Clinical Trial Registration— http://www.clinicaltrials.gov. Unique identifier: NCT00114972.
- A Comparison Between Antihypertensive Medication Adherenc... Background— Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care provided. Whereas previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure (BP) control at the patient level, less is known about whether adherence and TI is associated with BP control at the clinic level. Methods and Results— We included 162 879 patients among 89 clinics in the Cardiovascular Research Network Hypertension Registry with incident hypertension who were started on antihypertensive medications. Adherence was measured by the proportion of days covered (PDC). TI was defined by the standard based method with scores ranging between –1 to 1 and categorized as: –1 indicated no TI occurred when BP was elevated; 0 indicated TI occurred when BP was elevated; and 1 indicated that TI was made at all visits, even when BP was not elevated. Logistic regression models assessed the association between adherence and TI with blood pressure control (BP ≤140/90 at the clinic visit closest to 12 months after study entry) at the patient and clinic levels. Mean adherence was 0.77±0.28 (PDC±SD) at the patient level and 0.78±0.05 at the clinic level. Mean TI was 0.026±0.23 at the patient level and 0.01±0.04 at the clinic level. At the patient level, for each 0.25 increase in adherence and TI, the odds (OR) of achieving blood pressure control increased by 28% and 55%, respectively [OR for adherence, 1.28 (1.26–1.29), and for TI, 1.55 (1.53–1.57)]. At the clinic level, each 0.04 increment increase in treatment intensification was associated with a 25% increased odds of achieving blood pressure control (OR, 1.24; 95% CI, 1.21–1.27). In contrast, there was an inverse association between increasing adherence and BP control (OR, 0.93; 95% confidence interval, 0.90–0.95). Conclusions— Patient adherence to antihypertensive medications is not associated with BP control at the clinic level and may not be suitable as a performance measure. TI is associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.
- Advance Directives in Community Patients With Heart Failu... Background— Although it is recommended that all patients with heart failure (HF) have advance directives (AD) in place before the end of life is imminent, the use of AD in HF has not been well studied. Methods and Results— We enrolled consecutive Olmsted County residents presenting with HF from October 2007 through October 2011 into a longitudinal study. Information from AD completed before enrollment and hospitalizations in the month before death were abstracted. Among 608 patients (mean age, 74.0 years; 54.9% men; 65.3%; New York Heart Association functional class 3 or 4), 164 (27.0%) patients died after a mean follow-up of 1.8 years. At enrollment, only 249 (41.0%) patients had an AD. Although most AD appointed a proxy decision-maker (90.4%), less than half addressed wishes regarding use of cardiopulmonary resuscitation (41.4%), mechanical ventilation (38.6%), or hemodialysis (10.0%) at the end of life. The independent predictors of AD completion were older age (adjusted odds ratio [OR] per 10-year increase, 1.82; 95% confidence interval [CI], 1.51–2.20), malignancy (OR, 1.58; 95% CI, 1.05–2.37), and renal dysfunction (OR for estimated glomerular filtration rate <60 mL/min 1.55; 95% CI, 1.05–2.29). At the end of life, patients with AD specifying limits in the aggressiveness of care less frequently received mechanical ventilation (OR, 0.26; 95% CI, 0.07–0.88), with a trend toward decreased intensive care unit admission (OR, 0.45; 95% CI, 0.16–1.29). Conclusions— Despite a high mortality rate, over half of patients with HF do not have an AD, and existing AD fail to address important end-of-life medical decisions.
Circulation Cardiovascular Genetics
- Stroke: Etiology, Risk Factors, Imaging, and Genetic Epid... The following articles are being highlighted as part of Circulation: Cardiovascular Genetics' Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in the Circulation portfolio and Circulation: Cardiovascular Genetics, in particular. The studies included in this article represent the most read manuscripts published on the topic of stroke in 2010 and 2011.
- Letter by Singh et al Regarding Article, "Apolipoprotein ...
- Response to the Letter by Singh et al Regarding "Apolipop...
- Paraoxonase 1 Q192R Variant and Clopidogrel Efficacy: Fac...
- Cardiac Myosin Binding Protein-C Mutations in Families Wi... Background— Small selected cohort studies suggest that mutations in the cardiac myosin binding protein-C (MYBPC3) gene cause late-onset, clinically benign hypertrophic cardiomyopathy (HCM). The aim of this study was to test this hypothesis in a large series of families with HCM associated with MYBPC3 mutations. Methods and Results— The initial study population comprised 57 probands with 42 mutations (26 [61.9%] novel) in MYBPC3. Missense mutations (15, 45.6%) were the most frequent, and multiple mutations occurred in 4 (7.0%) probands. Another 110 mutation carriers were identified during familial evaluation; 38 were clinically affected with left ventricular hypertrophy ≥13 mm. Disease penetrance was, therefore, incomplete (56.9% in all mutation carriers, 34.5% in relatives), related to age (38.4% <40 versus 68.6% ≥40 years, P<0.001), and was greater in males than females (65.1% versus 48.1%, P=0.03). In 9 families (25 individuals) with the R502W mutation, there was marked heterogeneity in age at diagnosis (5 to 80 years), pattern of hypertrophy (11 none, 9 asymmetrical, 3 concentric, 1 apical, 1 eccentric), and prognosis (premature sudden death in 2 individuals compared with survival to advanced age in 6 individuals). During follow up of 7.9+/–4.5 years, in 82 clinically affected individuals the annual risk of sudden death and all cause mortality was 0.46% and 0.93% per year, respectively. Conclusions— Disease expression in families with HCM related to MYBPC3 mutations shows marked heterogeneity with incomplete, age-related, and gender specific penetrance. Importantly, complex genetic status is observed and should be considered when mutation analysis and cascade screening is used in the evaluation of at risk family members.
- Evaluating Pathogenicity of Rare Variants From Dilated Ca... Background— Human exome sequencing is a recently developed tool to aid in the discovery of novel coding variants. Now broadly applied, exome sequencing data sets provide a novel opportunity to evaluate the allele frequencies of previously published pathogenic rare variants. Methods and Results— We examined the exome data set from the National Heart, Lung and Blood Institute Exome Sequencing Project and compared this data set with a catalog of 197 previously published rare variants reported as causative of dilated cardiomyopathy (DCM) from familial and sporadic cases. Of these 197, 33 (16.8%) were also present in the Exome Sequencing Project database, raising the question of whether they were uncommon polymorphisms. Supporting functional data has been published for 14 of the 33 (42%), suggesting they are unlikely to be false-positives. The frequencies of these functional variants in the Exome Sequencing Project data set ranged from 0.02 to 1.33% (median 0.04%), which when applied as a cutoff to filter variants in a DCM pedigree identified an additional DCM candidate gene. A greater proportion of sporadic DCM cases had variants that were present in the Exome Sequencing Project data set versus novel variants (ie, not in the Exome Sequencing Project; 44% versus 21%; P=0.002), suggesting some of the variants identified as disease causing in sporadic DCM are either false-positives or low penetrance alleles in human populations. Conclusions— Rare nonsynonymous variants identified in DCM subjects also present at very low frequencies in public databases are likely relevant for DCM. Allele frequencies >0.04% are of less certain pathogenicity, especially if identified in sporadic cases, although this cutoff should be viewed as preliminary.
- Exome Analysis of a Family With Pleiotropic Congenital He... Background— A number of single gene defects have been identified in patients with isolated or nonsyndromic congenital heart defects (CHDs). However, due to significant genetic heterogeneity, candidate gene approaches have had limited success in finding high-risk alleles in most cases. The purpose of this study was to use exome sequencing to identify high-risk gene variants in a family with highly penetrant pleiotropic CHD. Methods and Results— DNA samples from 2 members of a family with diverse CHD were analyzed by exome sequencing. Variants were filtered to eliminate common variants and sequencing artifacts and then prioritized based on the predicted effect of the variant and on gene function. The remainder of the family was screened using polymerase chain reaction, high-resolution melting analysis, and DNA sequencing to evaluate variant segregation. After filtering, >2000 rare variants (including single nucleotide substitutions and indels) were shared by the 2 individuals. Of these, 46 were nonsynonymous, 3 were predicted to alter splicing, and 6 resulted in a frameshift. Prioritization reduced the number of variants potentially involved in CHD to 18. None of the variants completely segregated with CHD in the kindred. However, 1 variant, Myh6 Ala290Pro, was identified in all but 1 affected individual. This variant was previously identified in a patient with tricuspid atresia and large secundum atrial septal defect. Conclusions— It is likely that next-generation sequencing will become the method of choice for unraveling the complex genetics of CHD, but information gained by analysis of transmission through families will be crucial.
- Mortality of Inherited Arrhythmia Syndromes: Insight Into... Background— For most arrhythmia syndromes, the risk of sudden cardiac death for asymptomatic mutation carriers is ill defined. Data on the natural history of these diseases, therefore, are essential. The family tree mortality ratio method offers the unique possibility to study the natural history at a time when the disease was not known and patients received no treatment. Methods and Results— In 6 inherited arrhythmia syndromes caused by specific mutations, we analyzed all-cause mortality with the family tree mortality ratio method (main outcome measure, standardized mortality ratio [SMR]). In long-QT syndrome (LQTS) type 1, severely increased mortality risk during all years of childhood was observed (1–19 years), in particular during the first 10 years of life (SMR, 2.9; 95% CI, 1.5–5.1). In LQTS type 2, we observed increasing SMRs starting from age 15 years, which just reached significance between age 30 and 39 (SMR, 4.0; 95% CI, 1.1–10.0). In LQTS type 3, the SMR was increased between age 15 and 19 years (SMR, 5.8; 95% CI, 1.2–16.9). In the SCN5A overlap syndrome, excess mortality was observed between age 10 and 59 years, with a peak between 20 and 39 years (SMR, 3.8; 95% CI, 2.5–5.7). In catecholaminergic polymorphic ventricular tachycardia, excess mortality was restricted to ages 20 to 39 years (SMR, 3.0; 95% CI, 1.3–6.0). In Brugada syndrome, excess mortality was observed between age 40 and 59 (SMR, 1.79; 95% CI, 1.2–2.4), particularly in men. Conclusions— We identified age ranges during which the mortality risk manifests in an unselected and untreated population, which can guide screening in these families.
- Genetic Analysis of Atherosclerosis and Glucose Homeostas... Background— Diabetic patients have an increased risk of developing atherosclerosis and related complications compared with nondiabetic individuals. The increased cardiovascular risk associated with diabetes is due in part to genetic variations that influence both glucose homeostasis and atherosclerotic lesion growth. Mouse strains C57BL/6J (B6) and BALB/cJ (BALB) exhibit distinct differences in fasting plasma glucose and atherosclerotic lesion size when deficient in apolipoprotein E (Apoe–/–). Quantitative trait locus (QTL) analysis was performed to determine genetic factors influencing the 2 phenotypes. Methods and Results— Female F2 mice (n=266) were generated from an intercross between B6.Apoe–/– and BALB.Apoe–/– mice and fed a Western diet for 12 weeks. Atherosclerotic lesions in the aortic root, fasting plasma glucose, and body weight were measured. 130 microsatellite markers across the entire genome were genotyped. Four significant QTLs, Ath1 on chromosome (Chr) 1, Ath41 on Chr2, Ath42 on Chr5, and Ath29 on Chr9, and 1 suggestive QTL on Chr4, were identified for atherosclerotic lesion size. Four significant QTLs, Bglu3 and Bglu12 on Chr1, Bglu13 on Chr5, Bglu15 on Chr12, and 2 suggestive QTLs on Chr9 and Chr15 were identified for fasting glucose levels on the chow diet. Two significant QTLs, Bglu3 and Bglu13, and 1 suggestive locus on Chr8 were identified for fasting glucose on the Western diet. One significant locus on Chr1 and 2 suggestive loci on Chr9 and Chr19 were identified for body weight. Ath1 and Ath42 coincided with Bglu3 and Bglu13, respectively, in the confidence interval. Conclusions— We have identified novel QTLs that have major influences on atherosclerotic lesion size and glucose homeostasis. The colocalization of QTLs for atherosclerosis and diabetes suggests possible genetic connections between the 2 diseases.
- Literature-Based Genetic Risk Scores for Coronary Heart D... Background— Genome-wide association studies (GWAS) have identified many single-nucleotide polymorphisms (SNPs) associated with coronary heart disease (CHD) or CHD risk factors (RF). Using a case-cohort study within the prospective Cardiovascular Registry Maastricht (CAREMA) cohort, we tested if genetic risk scores (GRS) based on GWAS-identified SNPs are associated with and predictive for future CHD. Methods and Results— Incident cases (n=742), that is, participants who developed CHD during a median follow-up of 12.1 years (range, 0.0–16.9 years), were compared with a randomly selected subcohort of 2221 participants selected from the total cohort (n=21 148). We genotyped 179 SNPs previously associated with CHD or CHD RF in GWAS as published up to May 2, 2011. The allele-count GRS, composed of all SNPs, the 153 RF SNPs, or the 29 CHD SNPs were not associated with CHD independent of CHD RF. The weighted 29 CHD SNP GRS, with weights obtained from GWAS for every SNP, were associated with CHD independent of CHD RF (hazard ratio, 1.12 per weighted risk allele; 95% confidence interval, 1.04–1.21) and improved risk reclassification with 2.8% (P=0.031). As an exploratory approach to achieve weighting, we performed least absolute shrinkage and selection operator (LASSO) regression analysis on all SNPs and the CHD SNPs. The CHD LASSO GRS performed equal to the weighted CHD GRS, whereas the Overall LASSO GRS performed slightly better than the weighted CHD GRS. Conclusions— A GRS composed of CHD SNPs improves risk prediction when adjusted for the effect sizes of the SNPs. Alternatively LASSO regression analysis may be used to achieve weighting; however, validation in independent populations is required.
Therapeutic Advances in Cardiovascular Disease
- Preventive aspects in peripheral artery disease The prevalence of peripheral artery disease is steadily increasing and is associated with significant morbidity, including a significant percentage of amputations. Peripheral artery disease often goes undiagnosed, making its prevention increasingly important. Patients with peripheral arterial disease are at increased risk of adverse cardiovascular outcomes which makes prevention even more important. Several risk factors have been identified in the pathophysiology of peripheral artery disease which should be modified to decrease risk. Smoking, hyperlipidemia, hypertension, and diabetes are among proven risk factors for the development of peripheral artery disease, thus smoking cessation, lipid control, blood pressure control, and glucose control have been tried and shown to be effective in preventing the morbidity associated with this disease. Pharmacologic agents such as aspirin and clopidogrel alone or in combination have been shown to be effective, though risk of bleeding might be increased with the combination. Anticoagulation use is recommended only for acute embolic cases. Other treatment modalities that have been tried or are under investigation are estrogen replacement, naftidrofuryl, pentoxifylline, hyperbaric oxygen, therapeutic angiogenesis, and advanced glycation inhibitors. The treatment for concomitant vascular diseases does not change in the presence of peripheral artery disease, but aggressive management of risk factors should be undertaken in such cases.
- Pathophysiologic mechanisms of calcific aortic stenosis Calcific aortic stenosis (CAS) comprises the leading indication for valve replacement in the Western world. Until recently, progressive calcification was considered to be a passive process. Emerging evidence, however, suggests that degenerative aortic stenosis constitutes an active process involving stimulation of several pathophysiologic pathways such as inflammation and osteogenesis. In addition, CAS and atherosclerosis share common features regarding histopathology of lesions. These novel data raise a new perspective on the prevention and treatment of disease. The current article reviews the most important pathophysiologic mechanisms of senile aortic stenosis.
- Beyond blood pressure: evidence for cardiovascular, cereb... For patients with hypertension, effective control of blood pressure (BP) reduces cardiovascular (CV), and renal risk. Antihypertensive agents that offer benefits that extend beyond those associated with BP reduction alone, to include tissue protective effects and effects on the vasculature, may be of benefit for many patients with increased CV risk due to comorbidities or prior history of CV events. Renin–angiotensin system (RAS) blockers [angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs)] are guideline-recognized, highly effective antihypertensive agents that exert their BP-lowering action through different mechanisms at different levels of the RAS. Large-scale clinical studies suggest that small, between-treatment differences in BP lowering do not account for observed outcome differences between RAS blockers and other antihypertensive agents. Analysis of data from seminal clinical studies and meta-analyses identify that, controlling for effects on BP control, RAS blockers may be more effective than calcium channel blockers (CCBs) in reducing risk of myocardial infarction and congestive heart failure; ARBs may be more effective than either ACEIs or β blockers in stroke prevention; CCBs may be more effective than RAS blockers in stroke prevention; and ARBs may be more effective than β blockers in reducing left ventricular hypertrophy. This review considers the rationale and evidence for benefits of RAS blockade beyond BP lowering, and highlights the differences between ARBs and ACEIs, and between agents within these drug classes.
Journal of Molecular and Cellular Cardiology
- Editorial Board
- Differentiation and enrichment of cardiomyocytes from hum... Abstract: Human cardiomyocytes derived from pluripotent stem cells hold great promise for cardiac cell therapy, disease modeling, drug discovery, and the study of developmental biology. Reaching these potentials fully requires the development of methods that enable efficient and robust generation of cardiomyocytes with expected characteristics. This review summarizes and discusses up-to-date methods that have been used to derive and enrich human cardiomyocytes from pluripotent stem cells, provides a brief overview of in vitro and in vivo characterization of these cardiomyocytes, and considers future advancement needed to further harness the power of these cells.Highlights: ► Described methods to derive and enrich cardiomyocytes from pluripotent stem cells. ► Discussed advantages and limitations of individual methods. ► Presented brief overview of in vitro and in vivo characterization of cardiomyocytes. ► Discussed future advancement needed to further harness the power of these cells.
- Doxorubicin-induced cardiomyopathy: From molecular mechan... Abstract: The utility of anthracycline antineoplastic agents in the clinic is compromised by the risk of cardiotoxicity. It has been calculated that approximately 10% of patients treated with doxorubicin or its derivatives will develop cardiac complications up to 10years after the cessation of chemotherapy. Oxidative stress has been established as the primary cause of cardiotoxicity. However, interventions reducing oxidative stress have not been successful at reducing the incidence of cardiotoxicity in patients treated with doxorubicin. New insights into the cardiomyocyte response to oxidative stress demonstrate that underlying differences between in vitro and in vivo toxicities may modulate the response to superoxide radicals and related compounds. This has led to potentially new uses for pre-existing drugs and new avenues of exploration to find better pharmacotherapies and interventions for the prevention of cardiotoxicity. However, much work still must be done to validate the clinical utility of these new approaches and proposed mechanisms. In this review, the authors have reviewed the molecular mechanisms of the pathogenesis of acute and chronic doxorubicin-induced cardiotoxicity and propose potential pharmacological interventions and treatment options to prevent or reverse this specific type of heart failure.Highlights: ► The pathogenesis of doxorubicin-induced cardiotoxicity is complex and multifactorial. ► Oxidative stress is a major cause of doxorubicin-induced cardiotoxicity. ► Doxorubicin-induced heart failure can appear very late after the last administration. ► There is no specific curative or preventive treatment available.
- Notch signaling and cardiac repair Abstract: Notch signaling is critical for proper heart development and recently has been reported to participate in adult cardiac repair. Notch resides at the cell surface as a single pass transmembrane receptor, transits through the cytoplasm following activation, and acts as a transcription factor upon entering the nucleus. This dynamic and widespread cellular distribution allows for potential interactions with many signaling and binding partners. Notch displays temporal as well as spatial versatility, acting as a strong developmental signal, controlling cell fate determination and lineage commitment, and playing a pivotal role in embryonic and adult stem cell proliferation and differentiation. This review serves as an update of recent literature addressing Notch signaling in the heart, with attention to findings from noncardiac research that provide clues for further interpretation of how the Notch pathway influences cardiac biology. Specific areas of focus include Notch signaling in adult myocardium following pathologic injury, the role of Notch in cardiac progenitor cells with respect to differentiation and cardiac repair, crosstalk between Notch and other cardiac signaling pathways, and emerging aspects of noncanonical Notch signaling in heart.Highlights: ► Activation of Notch promotes myocardial repair. ► Notch signaling controls cardiac progenitor specification and differentiation. ► Notch crosstalks with survival pathways in heart. ► Noncanonical Notch signaling may participate in cardiac repair.
- Ca2+-activated adenylyl cyclase 1 introduces Ca2+-depende... Abstract: Previous observations show that β-adrenergic modulation of pacemaker current (If) in sinoatrial node (SAN) cells is impaired by disruption of normal Ca2+-homeostasis with ryanodine or BAPTA. Recently, the presence of Ca2+-activated adenylyl cyclase (AC) 1 was reported in SAN, and was proposed as a possible mechanism of Ca2+-dependence of β-adrenergic modulation. However, direct evidence that pacemaker (HCN) channels can be regulated by Ca2+-activated AC and that such regulation introduces Ca2+ dependence, is lacking. Here we co-expressed AC1 or AC6 with HCN2 in neonatal rat ventricular myocytes, which lack AC1. Although both isoforms have equivalent expression level and ability to interact with HCN2, only AC1 increases intracellular cAMP content, accelerates spontaneous beating rate and modifies HCN2 biophysics. Measured HCN2 current in the AC1 group activated ~10mV more positive than in GFP or AC6. The β-adrenergic agonist isoproterenol induced a further positive shift under control conditions, but failed to do so after pretreatment with the Ca2+ chelator BAPTA. In the AC6 group, isoproterenol shifted the HCN2 activation relation to a similar extent in the absence and presence of BAPTA. Thus, AC1 but not AC6 over-expression introduces Ca2+-sensitivity to the β-adrenergic response of HCN2. These results demonstrate physical and functional interaction between AC isoforms and the HCN2 pacemaker channel and support a key role of Ca2+ activated AC1 as a molecular mechanism in Ca2+-dependent modulation of β-adrenergic response of heart rate.Highlights: ► HCN2 was co-expressed with Adenylyl Cylase 1 (AC1) or 6 (AC6) in cardiac myocytes. ► AC1 but not AC6 increased [cAMP]i, accelerated beating rate and shifted HCN2 positive. ► In both AC1 and AC6 groups, isoproterenol shifted HCN2 activation relation positive. ► BAPTA prevented the isoproterenol effect in the AC1 but not AC6 group. ► AC1 plays a key role in sensitivity of β-adrenergic stimulation of HCN to [Ca]i.
- Ankyrin-B reduction enhances Ca spark-mediated SR Ca rele... Abstract: Ankyrin-B (AnkB) loss-of-function may cause ventricular arrhythmias and sudden cardiac death in humans. Cardiac myocytes from AnkB heterozygous mice (AnkB+/−) show reduced expression and altered localization of Na/Ca exchanger (NCX) and Na/K-ATPase (NKA), key players in regulating [Na]i and [Ca]i. Here we investigate how AnkB reduction affects cardiac [Na]i, [Ca]i and SR Ca release. We found reduced NCX and NKA transport function but unaltered [Na]i and diastolic [Ca]i in myocytes from AnkB+/− vs. wild-type (WT) mice. Ca transients, SR Ca content and fractional SR Ca release were larger in AnkB+/− myocytes. The frequency of spontaneous, diastolic Ca sparks (CaSpF) was significantly higher in intact myocytes from AnkB+/− vs. WT myocytes (with and without isoproterenol), even when normalized for SR Ca load. However, total ryanodine receptor (RyR)-mediated SR Ca leak (tetracaine-sensitive) was not different between groups. Thus, in AnkB+/− mice SR Ca leak is biased towards more Ca sparks (vs. smaller release events), suggesting more coordinated openings of RyRs in a cluster. This is due to local cytosolic RyR regulation, rather than intrinsic RyR differences, since CaSpF was similar in saponin-permeabilized myocytes from WT and AnkB+/− mice. The more coordinated RyRs openings resulted in an increased propensity of pro-arrhythmic Ca waves in AnkB+/− myocytes. In conclusion, AnkB reduction alters cardiac Na and Ca transport and enhances the coupled RyR openings, resulting in more frequent Ca sparks and waves although the total SR Ca leak is unaffected. This could enhance the propensity for triggered arrhythmias in AnkB+/− mice.Highlights: ► Reduced Na and Ca transport but unaltered [Na]i and diastolic [Ca]i in AnkB+/− myocytes. ► Ca transients, SR Ca load and fractional SR Ca release are larger in AnkB+/− myocytes. ► Higher Ca spark frequency and unaltered total SR Ca leak in intact AnkB+/− myocytes. ► The bias towards Ca spark-mediated leak is due to different cytosolic RyR regulation. ► More coordinated RyR openings increase the propensity for Ca waves in AnkB+/− mice.
- Excitation–contraction coupling in ventricular myocytes... Abstract: In clinical trials mesenchymal stem cells (MSCs) are transplanted into cardiac ischemic regions to decrease infarct size and improve contractility. However, the mechanism and time course of MSC-mediated cardioprotection are incompletely understood. We tested the hypothesis that paracrine signaling by MSCs promotes changes in cardiac excitation–contraction (EC) coupling that protects myocytes from cell death and enhances contractility. Isolated mouse ventricular myocytes (VMs) were treated with control tyrode, MSC conditioned-tyrode (ConT) or co-cultured with MSCs. The Ca handling properties of VMs were monitored by laser scanning confocal microscopy and whole cell voltage clamp. ConT superfusion of VMs resulted in a time dependent increase of the Ca transient amplitude (ConT15min: ΔF/F0=3.52±0.38, n=14; Ctrl15min: ΔF/F0=2.41±0.35, n=14) and acceleration of the Ca transient decay (τ: ConT: 269±18ms n=14; vs. Ctrl: 315±57ms, n=14). Voltage clamp recordings confirmed a ConT induced increase in ICa,L (ConT: −5.9±0.5 pA/pF n=11; vs. Ctrl: −4.04±0.3 pA/pF, n=12). The change of τ resulted from increased SERCA activity. Changes in the Ca transient amplitude and τ were prevented by the PI3K inhibitors Wortmannin (100nmol/L) and LY294002 (10μmol/L) and the Akt inhibitor V (20μmol/L) indicating regulation through PI3K signal transduction and Akt activation which was confirmed by western blotting. A change in τ was also prevented in eNOS−/− myocytes or by inhibition of eNOS suggesting an NO mediated regulation of SERCA activity. Since paracrine signaling further resulted in increased survival of VMs we propose that the Akt induced change in Ca signaling is also a mechanism by which MSCs mediate an anti-apoptotic effect.Highlights: ► Bone marrow derived mesenchymal stem cells enhance cardiomyocyte E-CC. ► Changes in E-CC and survival are mediated by paracrine signaling. ► MSCs activate the PI3K/Akt pathway and eNOS dependent NO production. ► MSCs increase Ca transient amplitude by increasing ICa,L and SERCA activity. ► Increased SERCA activity depends on eNOS activity.
- Reduction of heart failure by pharmacological inhibition ... Abstract: Protein tyrosine phosphatase 1B (PTP1B) regulates tyrosine kinase receptor-mediated responses, and especially negatively influences insulin sensitivity, thus PTP1B inhibitors (PTP1Bi) are currently evaluated in the context of diabetes. We recently revealed another important target for PTP1Bi, consisting in endothelial protection. The present study was designed to test whether reduction of PTP1B activity may be beneficial in chronic heart failure (CHF).We evaluated the impact of either a 2month pharmacological inhibition, or a gene deletion of PTP1B (PTP1B−/−) in CHF mice (2months post-myocardial infarction). PTP1Bi and PTP1B deficiency reduced adverse LV remodeling, and improved LV function, as shown by the increased LV fractional shortening and cardiac output (measured by echocardiography), the increased LV end systolic pressure, and the decreased LV end diastolic pressure, at identical infarct sizes. This was accompanied by reduced cardiac fibrosis, myocyte hypertrophy and cardiac expression of ANP. In vitro vascular studies performed in small mesenteric artery segments showed a restored endothelial function (i.e. improved NO-dependent, flow-mediated dilatation, increased eNOS phosphorylation) after either pharmacological inhibition or gene deletion. PTP1B−/− CHF also displayed an improved insulin sensitivity (assessed by euglycemic–hyperinsulinemic clamp studies), when compared to wild-type CHF associated with an increased insulin mediated mesenteric artery dilation.Thus, chronic pharmacological inhibition or gene deletion of PTP1B improves cardiac dysfunction and cardiac remodeling in the absence of changes in infarct size. Thus this enzyme may be a new therapeutic target in CHF. Diabetic patients with cardiac complications may potentially benefit from PTP1B inhibition via two different mechanisms, reduced diabetic complications, and reduced heart failure.Highlights: ► Protein tyrosine phosphatase 1B inhibition (PTP1Bi) was assessed in heart failure. ► PTP1Bi or gene deficiency reduced adverse LV remodeling, and improved LV function. ► PTP1Bi of gene deficiency reduced cardiac fibrosis and hypertrophy. ► PTP1Bi or gene deficiency restored endothelial function. ► PTP1B may be a new therapeutic target in CHF.
- Uterine cells are recruited to the infarcted heart and im... Abstract: We evaluated the hypothesis that uterine cells home to the heart after injury and improve cardiac outcomes. Premenopausal women have fewer cardiovascular complications than age-matched men, but the mechanisms responsible for this protection have not been conclusively identified. Hysterectomy was performed in young female rats (leaving the ovaries intact), and 7days later the left coronary artery was ligated to produce a myocardial infarction (MI). Cardiac function at 28days post-MI was measured using echocardiography. Fractional shortening was best in non-hysterectomized (non-Hx) females and lower in both Hx females and males. Uteri were then removed from GFP rats and heterotopically transplanted into non-GFP recipients to investigate homing of uterine cells to the infarcted myocardium. Seven days later, the uterine transplant recipients underwent coronary ligation. GFP+ cells were found in the recipient hearts 7days after MI and persisted for 6months. Confocal analysis showed that homed uterine cells were located around blood vessels, suggesting their involvement in neovascularization. We then evaluated uterine cell transplantation by intravenously injecting GFP+ uterine cells into Hx females immediately after MI. These GFP+ cells were found to home to the injured myocardium, stimulate angiogenesis, improve cardiac function, and increase survival. This study demonstrates that uterine cells can home to the injured myocardium, enhance tissue repair, and prevent cardiac dysfunction. Uterine cells may play a role in the prevention of cardiovascular complications in females.Highlights: ► Hysterectomy decreases cardiac recovery in female rats after MI. ► The uterus contains regenerative cells that home to the infarcted myocardium. ► These mobilized uterine cells persisted in the injured myocardial tissue. ► Transplanted uterine cells stimulated angiogenesis and prevented infarct scar thinning. ► Transplanted uterine cells prevented cardiac dysfunction after MI.
- Neuronal nitric oxide synthase is up-regulated by angiote... Abstract: Angiotensin II (Ang II) is critical in myocardial pathogenesis, mostly via stimulating NADPH oxidase. Neuronal nitric oxide synthase (nNOS) has recently been shown to play important roles in modulating myocardial oxidative stress and contractility. Here, we examine whether nNOS is regulated by Ang II and affects NADPH oxidase production of intracellular reactive oxygen species (ROSi) and contractile function in left ventricular (LV) myocytes. Our results showed that Ang II induced biphasic effects on ROSi and LV myocyte relaxation (TR50) without affecting the amplitude of sarcomere shortening and L-type Ca2+ current density: TR50 was prolonged at 30min but was shortened after 3h (or after Ang II treatment in vivo). Correspondingly, ROSi was increased, followed by a reduction to control level. Quantitative RT-PCR and immunoblotting experiments showed that Ang II (3h) increased the mRNA and protein expression of nNOS and increased NO production (nitrite assay) in LV myocyte homogenates, suggesting that nNOS activity may be enhanced and involved in mediating the effects of Ang II. Indeed, n(omega)-nitro-l-arginine methyl ester (l-NAME) or a selective nNOS inhibitor, S-methyl-l-thiocitrulline (SMTC) increased NADPH oxidase production of superoxide/ROSi and abolished faster myocyte relaxation induced by Ang II. The positive lusitropic effect of Ang II was not mediated by PKA-, CaMKII-dependent signaling or peroxynitrite. Conversely, inhibition of cGMP/PKG pathway abolished the Ang II-induced faster relaxation by reducing phospholamban (PLN) Ser16 phosphorylation. Taken together, these results clearly demonstrate that myocardial nNOS is up-regulated by Ang II and functions as an early adaptive mechanism to attenuate NADPH oxidase activity and facilitate myocardial relaxation.Highlights: ► Ang II activated NADPH oxidase (NOX2) and prolonged LV myocyte relaxation at 30min. ► nNOS is upregulated by Ang II (3h), inhibited NOX2 and shortened myocyte relaxation. ► Myocyte contraction and L-type Ca2+ current density were not affected by Ang II (3h). ► cGMP/PKG-dependent PLN-p mediated faster relaxation induced by nNOS and Ang II. ► PKA, CaMKII-pathway or peroxynitrite did not prevent the lusitropic effect of nNOS.
Journal of Nuclear Cardiology
- Comparative assessment of rest and post-stress left ventr... Abstract Background Transient ischaemic dilation (TID) on myocardial perfusion imaging (MPI) is an important finding, conveying a high risk of subsequent cardiac events. However, the mechanism leading to TID on MPI is not well elucidated. This study aimed to determine if TID is due to true LV cavity dilation and ventricular stunning, or is due to relative subendocardial hypoperfusion. Methods 31 patients undergoing single-day Tc-99m adenosine sestamibi MPI were recruited. All had routine ECG-gated single-day rest-stress adenosine MPI, with transthoracic echocardiograms (echo) acquired concurrently at rest, and both immediately, and 2 hours, post-stress. Echocardiography was performed using a Vivid-7 (GE). LV volumes and LVEF were quantified blinded to MPI results, using biplane Simpson method on echo, and quantitatively (including TID) with QGS®, on MPI. Results Patients were divided into quartiles for TID, with the top quartile considered TID positive [TID+ 9/31 (TID ratio 1.3 ± 0.09)], and TID negative [TID− 22/31 (TID ratio 1.01 ± 0.04)]. There was good correlation between resting echo and MPI physical measurements (LVEDV r 2 = 0.79, LVESV r 2 = 0.9, and LVEF r 2 = 0.75). On MPI, a significant drop in LVEF was observed between rest and early stress in the TID+ group (56.6% vs 46.5%, P < .002), as well as an increase in both LVESV (62 vs 79 mls, P < .0001) and LVEDV (113 vs 131 mls, P < .0001). However, no statistically significant change in LVEF, LVESV or LVEDV was identified on concurrent echo imaging (LVEF 57% vs 56%, P < .66; LVESV 48 vs 54 mls, P < .26; LVEDV 87 vs 97 mls, P < .299). No significant change in LVEF or ventricular volumes was noted in the TID− group by either echo or MPI. Conclusion Transient dilation of the left ventricle on adenosine MPI is not related to chamber enlargement and myocardial stunning, but is more likely a function of subendocardial hypoperfusion and impaired coronary flow reserve. Content Type Journal ArticleCategory Original ArticlePages 1-8DOI 10.1007/s12350-012-9571-4Authors Louise Emmett, Nuclear Medicine Department, Concord Hospital, University of Sydney, Hospital Rd, Concord, Sydney, NSW, AustraliaAustin Ng, Nuclear Medicine Department, Concord Hospital, University of Sydney, Hospital Rd, Concord, Sydney, NSW, AustraliaLeo Ha, Nuclear Medicine Department, Concord Hospital, University of Sydney, Hospital Rd, Concord, Sydney, NSW, AustraliaRobert Russo, Nuclear Medicine Department, Concord Hospital, University of Sydney, Hospital Rd, Concord, Sydney, NSW, AustraliaRobert Mansberg, Nuclear Medicine Department, Concord Hospital, University of Sydney, Hospital Rd, Concord, Sydney, NSW, AustraliaWei Zhao, Cardiology Department, Concord Hospital, University of Sydney, Sydney, AustraliaS. Vincent Chow, Cardiology Department, Concord Hospital, University of Sydney, Sydney, AustraliaLeonard Kritharides, Cardiology Department, Concord Hospital, University of Sydney, Sydney, Australia Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Safety and feasibility of regadenoson use for suboptimal ... Abstract Background Regadenoson during exercise stress test (ETT) can provide maximal hyperemia for myocardial perfusion imaging (MPI), along with exercise information. Our aim was to study the feasibility and safety of regadenoson injection at peak ETT for submaximal heart rate (HR) response. Methods Consecutive patients who underwent SPECT MPI with standard Bruce ETT or supine-regadenoson (Supine-Reg) were analyzed. ETT patients were grouped as ETT-Max [maximal HR > 0.85 * (220 − age), N = 1,522], ETT-Submax (submaximal HR no regadenoson, N = 504), ETT-Reg (submaximal HR and regadenoson, N = 211). Results The HR during ETT was submaximal in 715 (32%) patients. Of these, 211 patients (30%) underwent ETT-Reg (mean exercise duration: 5.5 ± 2.5 minutes). ETT-Reg patients had a higher frequency of hypertension, diabetes, smoking and beta-blocker use, similar rest systolic blood pressure (SBP), but lower rest and peak HR and peak SBP compared to ETT-Max patients. There were no serious complications with regadenoson. Side effects (49% vs 6%, P < .0001) were fewer and aminophylline use was lower with ETT-Reg compared to Supine-Reg (0.5% vs 8.1%, P = .001). Conclusions Submaximal HR response to ETT is common. ETT-Reg is safe, feasible, and well-tolerated. ETT-Reg facilitates a diagnostic MPI with reporting of functional capacity, exercise ECG/hemodynamic changes and MPI at maximal hyperemia. Content Type Journal ArticleCategory Original ArticlePages 1-9DOI 10.1007/s12350-012-9562-5Authors Sara L. Partington, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAViswanatha Lanka, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAJon Hainer, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USARon Blankstein, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAHicham Skali, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USADaniel E. Forman, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAMarcelo F. Di Carli, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USASharmila Dorbala, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Chest pain triage in the ED: Is CT coronary angiography t... Chest pain triage in the ED: Is CT coronary angiography the answer? Content Type Journal ArticleCategory Editorial Point of ViewPages 1-3DOI 10.1007/s12350-012-9567-0Authors Raymond J. Gibbons, Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Gonda 5, 200 First Street S.W., Rochester, MN 55905, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Developing an action plan for patient radiation safety in... Abstract Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert “think tank” reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences. Content Type Journal ArticleCategory ProceedingsPages 1-17DOI 10.1007/s12350-012-9545-6Authors Pamela S. Douglas, Duke University Medical Center, Durham, NC, USAJ. Jeffrey Carr, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USAManuel D. Cerqueira, Cleveland Clinic Foundation, Cleveland, OH, USAJennifer E. Cummings, Akron General Medical Center, Akron, OH, USAThomas C. Gerber, Mayo Clinic, Rochester, MN, USADebabrata Mukherjee, Texas Tech University Health Sciences Center, Amarillo, TX, USAAllen J. Taylor, Washington Hospital Center, Washington, DC, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Tests that may be overused or misused in cardiology: The ... Tests that may be overused or misused in cardiology: The Choosing Wisely® campaign Content Type Journal ArticleCategory Editor's PagePages 1-3DOI 10.1007/s12350-012-9569-yAuthors George A. Beller, University of Virginia, Charlottesville, VA, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Optimal reproducibility of gated sestamibi and thallium m... Abstract Aim To evaluate the reproducibility of serial re-acquisitions of gated Tl-201 and Tc-99m sestamibi left ventricular ejection fraction (LVEF) measurements obtained on a new generation solid-state cardiac camera system during myocardial perfusion imaging and the importance of manual operator optimization of left ventricular wall tracking. Methods Resting blinded automated (auto) and manual operator optimized (opt) LVEF measurements were measured using ECT toolbox (ECT) and Cedars-Sinai QGS software in two separate cohorts of 55 Tc-99m sestamibi (MIBI) and 50 thallium (Tl-201) myocardial perfusion studies (MPS) acquired in both supine and prone positions on a cadmium zinc telluride (CZT) solid-state camera system. Resting supine and prone automated LVEF measurements were similarly obtained in a further separate cohort of 52 gated cardiac blood pool scans (GCBPS) for validation of methodology and comparison. Appropriate use of Bland-Altman, chi-squared and Levene’s equality of variance tests was used to analyse the resultant data comparisons. Results For all radiotracer and software combinations, manual checking and optimization of valve planes (+/− centre radius with ECT software) resulted in significant improvement in MPS LVEF reproducibility that approached that of planar GCBPS. No difference was demonstrated between optimized MIBI/Tl-201 QGS and planar GCBPS LVEF reproducibility (P = .17 and P = .48, respectively). ECT required significantly more manual optimization compared to QGS software in both supine and prone positions independent of radiotracer used (P < .02). Conclusions Reproducibility of gated sestamibi and Tl-201 LVEF measurements obtained during myocardial perfusion imaging with ECT toolbox or QGS software packages using a new generation solid-state cardiac camera with improved image quality approaches that of planar GCBPS however requires visual quality control and operator optimization of left ventricular wall tracking for best results. Using this superior cardiac technology, Tl-201 reproducibility also appears at least equivalent to sestamibi for measuring LVEF. Content Type Journal ArticleCategory Original ArticlePages 1-6DOI 10.1007/s12350-012-9561-6Authors Martin H. Cherk, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaJason Ky, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaKenneth S. K. Yap, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaPatrina Campbell, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaCatherine McGrath, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaMichael Bailey, Department of Epidemiology & Preventative Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, AustraliaVictor Kalff, Department of Nuclear Medicine, Alfred Hospital, Monash University, Commercial Road, Melbourne, VIC 3004, Australia Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Matching between regional coronary vasodilator capacity a... Abstract Background To define the relationship between regional coronary vasodilator capacity and myocardial circumferential strain at rest in normal weight, overweight, and obese individuals with normal global left-ventricular function. Methods and Results Myocardial blood flow at rest and during pharmacologic vasodilation was measured with 13N-ammonia PET/CT in mL/g/minute in normal weight control (CON, n = 12), overweight (OW, n = 10), and obese individuals (OB, n = 10). In addition, resting myocardial function was evaluated as circumferential strain (Єc, %) by MRI. Global myocardial flow reserve (MFR) did not differ significantly between CON and OW (2.98 ± 0.96 vs 2.70 ± 0.66, P = .290), whereas it declined significantly in OB (1.98 ± 1.04, P = .030). Further, global Єc (%) was comparable between CON, OW, and OB (−0.24 ± 0.03, −0.23 ± 0.02, and −0.23 ± 0.04) but it was lowest in OB when normalized to the rate-pressure product (NЄc: −0.31 ± 0.06, −0.32 ± 0.05, and −0.26 ± 0.08). When MFR of the three major coronary territories was correlated with corresponding Єc, a positive association was observed in CON (r = 0.36, P = .030), in OW (r = 0.54, P = .002), and also in OB when relating NЄc to coronary vascular resistance during pharmacologic vasodilation (r = −0.46, P = .010). Conclusions Higher coronary vasodilator capacity is related to corresponding regional circumferential strain at rest in non-obese individuals, while this is also observed for reduced MFR in obesity. Content Type Journal ArticleCategory Original ArticlePages 1-11DOI 10.1007/s12350-012-9570-5Authors Gabriella M. Vincenti, Division of Cardiology, Nuclear Cardiology and Cardiac PET/CT, Department of Specialities in Medicine, University Hospital of Geneva, 6th Floor, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, SwitzerlandGiuseppe Ambrosio, Division of Cardiology, School of Medicine, University of Perugia, Perugia, ItalyJean-Noël Hyacinthe, Divisions of Nuclear Medicine and Radiology, Department of Medical Imaging and Information Science, University Hospital of Geneva, Geneva, SwitzerlandAlessandra Quercioli, Division of Cardiology, Nuclear Cardiology and Cardiac PET/CT, Department of Specialities in Medicine, University Hospital of Geneva, 6th Floor, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, SwitzerlandYann Seimbille, Divisions of Nuclear Medicine and Radiology, Department of Medical Imaging and Information Science, University Hospital of Geneva, Geneva, SwitzerlandFrançois Mach, Division of Cardiology, Nuclear Cardiology and Cardiac PET/CT, Department of Specialities in Medicine, University Hospital of Geneva, 6th Floor, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, SwitzerlandOsman Ratib, Divisions of Nuclear Medicine and Radiology, Department of Medical Imaging and Information Science, University Hospital of Geneva, Geneva, SwitzerlandJean-Paul Vallée, Divisions of Nuclear Medicine and Radiology, Department of Medical Imaging and Information Science, University Hospital of Geneva, Geneva, SwitzerlandThomas H. Schindler, Division of Cardiology, Nuclear Cardiology and Cardiac PET/CT, Department of Specialities in Medicine, University Hospital of Geneva, 6th Floor, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Use of high-risk features from exercise treadmill testing... Use of high-risk features from exercise treadmill testing to identify obstructive left main disease with normal myocardial perfusion imaging Content Type Journal ArticleCategory Nuclear Cardiology BulletPages 1-4DOI 10.1007/s12350-012-9572-3Authors Marcio Sommer Bittencourt, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USASharmila Dorbala, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USAMichael Steigner, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USAFrank Rybicki, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USAMarcelo Di Carli, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USARon Blankstein, Non-Invasive Cardiovascular Imaging Program, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Isolated cardiac metastasis in a patient with neuroendocr... Abstract We present an interesting image that demonstrates utility of 68Ga-DOTANOC PET/CT for demonstrating rare metastatic sites of neuroendocrime tumor. Content Type Journal ArticleCategory Images that TeachPages 1-2DOI 10.1007/s12350-012-9563-4Authors Bangkim Chandra Khangembam, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 IndiaNiraj Naswa, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 IndiaPunit Sharma, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 IndiaChandrasekhar Bal, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 IndiaArun Malhotra, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 IndiaRakesh Kumar, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi, 110029 India Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
- Lessons for Nuclear Cardiology from the DCRI/ACCF/AHA rad... Lessons for Nuclear Cardiology from the DCRI/ACCF/AHA radiation think tank Content Type Journal ArticleCategory EditorialPages 1-3DOI 10.1007/s12350-012-9566-1Authors Andrew J. Einstein, Division of Cardiology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH 10-203, New York, NY 10032, USA Journal Journal of Nuclear CardiologyOnline ISSN 1532-6551Print ISSN 1071-3581
Journal of the American Society of Echocardiography
- Persistent Reduction in Left Ventricular Strain Using Two... Background: The aim of this study was to investige serial changes of myocardial deformation using two-dimensional speckle-tracking echocardiographic (2DSTE) imaging in children undergoing balloon valvuloplasty for congenital valvular aortic stenosis (VAS).Methods: Thirty-seven children with isolated congenital VAS were enrolled in this study prospectively. Patients underwent echocardiographic evaluation at three instances: before balloon valvuloplasty, 6 months after intervention, and 3 years after intervention. Longitudinal, circumferential, and radial peak systolic strain values were determined, as well as systolic strain rate and the time to peak global systolic strain. Linear mixed statistical models were used to assess changes in 2DSTE parameters after balloon intervention. Using one-way analysis of variance, 2DSTE results at 3-year follow-up were compared with 2DSTE measurements in 74 healthy age-matched children and 76 children with uncorrected VAS whose severity of stenosis corresponded to residual stenosis of study subjects at 3-year follow-up.Results: Global peak strain and strain rate measurements in all three directions were decreased before intervention compared with healthy children. Global peak strain and strain rate measurements increased significantly (P < .001) several months after balloon valvuloplasty and continued to increase at 3-year follow-up. However, at 3-year follow-up, global peak strain and strain rate in the longitudinal and circumferential directions were significantly lower (P < .001) compared with both control groups. Measurements of time to peak global systolic strain were significantly shorter at early follow-up compared with measurements before intervention (P < .05).Conclusions: Shortly after balloon valvuloplasty for severe congenital VAS, there is an improvement in systolic myocardial deformation. However, 2DSTE parameters do not return to normal at 3-year follow-up. These abnormalities in systolic deformation cannot be fully attributed to residual stenosis or aortic regurgitation.
- Left Ventricular Systolic Dyssynchrony in Pediatric and A... Background: Echocardiographic measures of left ventricular (LV) dyssynchrony in pediatric patients with heart failure (HF) have not been adequately evaluated. The aim of this study was to evaluate LV systolic dyssynchrony in pediatric patients with HF and normal children.Methods: Among a total of 68 patients, 22 had HF and 46 were normal. Doppler tissue imaging, M-mode echocardiography, and pulsed-wave Doppler echocardiography were performed. Intraventricular dyssynchrony using the maximal difference in time to peak myocardial systolic contraction (Ts), the standard deviation of Ts of 12 LV segments, septal–to–posterior wall motion delay, and interventricular dyssynchrony by measuring aortic and pulmonary pre-ejection delays were obtained.Results: The maximal difference in Ts (patients with HF, 91.27 ± 31.18 msec; controls, 45.93 ± 21.29 msec; P 89 msec in normal controls and 18 patients with HF due to dilated cardiomyopathy was included for analysis of systolic dyssynchrony; it was present in three (6.5%) and two (4.3%) controls and in nine (50%) and 10 (55%) patients with HF due to dilated cardiomyopathy, respectively. Low ejection fraction, elevated LV end-diastolic volume, and elevated LV end-systolic volume had significant correlations with systolic dyssynchrony. QRS duration was not significantly correlated with measures of dyssynchrony.Conclusions: Systolic mechanical dyssynchrony is common in pediatric patients with HF. QRS duration is not a determinant of systolic dyssynchrony in pediatric patients. Echocardiographic measurements of systolic dyssynchrony are feasible in pediatric patients.
- Erratum In the article entitled “Assessment of transmitral vortex formation in patients with diastolic dysfunction” by Kheradvar et al (J Am Soc Echocardiogr 2012;25:220-7), there was an error in the text on page 221 and equation on page 222. The corrected text and equation is as follows:
- Impaired Left Ventricular Myocardial Mechanics and Their ... Background: Left ventricular (LV) dysfunction is common in adults late after repair of tetralogy of Fallot (TOF). The early detection of myocardial dysfunction may be important, but LV myocardial strain and dyssynchrony are not well studied in children with TOF. The objective of this study was to investigate LV strain and dyssynchrony in asymptomatic children and adolescents after contemporary repair of TOF. The hypothesis was that impaired LV myocardial mechanics are related to pulmonary regurgitation, right ventricular (RV) enlargement, and exercise capacity.Methods: Children and adolescents were prospectively studied after TOF repair. LV regional strain and dyssynchrony were assessed using two-dimensional speckle-tracking echocardiography. Ventricular volumes, ejection fraction, and pulmonary regurgitation were assessed using magnetic resonance imaging. Exercise capacity was determined using metabolic exercise testing.Results: One hundred twenty-four subjects (53 patients with TOF and 71 controls) were studied. Regional circumferential (e.g., basal lateral wall, −15.0 ± 7.0% vs −19.0 ± 7.0%, P = .02) and radial (e.g., basal posterior wall, 32.0 ± 18.0% vs 48.0 ± 21.0%, P < .001) LV strain and longitudinal septal strain (−18.5 ± 3.5% vs −20.2 ± 2.8%, P = .01) were significantly reduced in patients with TOF compared with controls. LV mechanical dyssynchrony indices were not significantly different between groups (e.g., standard deviation of time to peak circumferential strain, 52.5 ± 40.4 vs 50.5 ± 27.1 msec, P = .81). Higher pulmonary regurgitation volume and larger RV end-diastolic volume were associated with decreased LV radial strain (P = .09). There was no association between LV longitudinal, radial, or circumferential dyssynchrony and indexed pulmonary regurgitation flow volume, RV end-diastolic volume, or RV ejection fraction.Conclusions: LV circumferential and radial strain are significantly reduced in children and adolescents after TOF repair and are associated with pulmonary regurgitation and RV dilatation. Resting LV mechanical dyssynchrony does not appear to contribute to early impaired LV strain in this population.
- Value of Tissue Doppler Echocardiography in Children with... Background: The impact of pulmonary hypertension (PHT) on right ventricular and left ventricular (LV) function in children with PHT is unknown, and echocardiographic data combining conventional and Doppler tissue imaging (DTI) on PHT in children are sparse.Methods: Forty-one children (18 male; mean age, 7.9 ± 5.6 years) with PHT and structurally normal hearts (27 with idiopathic PHT, 14 with associated PHT) and 44 age-matched healthy controls were assessed using conventional echocardiography and DTI.Results: Children with PHT had enlarged tricuspid valve diameters, right atrial areas, pulmonary artery dimensions, and LV eccentricity indices. In addition, pulmonary acceleration time and tricuspid annular plane systolic excursion were significantly reduced in patients compared with controls. DTI revealed that children with PHT had significantly lower systolic (S) and early diastolic (E) velocities at the tricuspid and septal levels. Despite preserved LV ejection fractions, left lateral free wall systolic velocities were significantly reduced in patients with PHT. Significantly reduced LV rapid filling velocities (E) suggested an underloaded left ventricle or LV diastolic dysfunction in children with PHT compared with controls. Pulmonary acceleration time and tricuspid annular plane systolic excursion correlated best with DTI systolic tricuspid and septal velocities.Conclusions: Despite not being evident on conventional two-dimensional echocardiography, LV systolic performance appears to be impaired in children with PHT. Quantitative DTI assessment of ventricular function and ventricular-ventricular interactions in this setting might provide further insights into the mechanisms leading to end-stage PHT and may guide clinicians to optimize antifailure treatment.
- Right Ventricular Systolic Strain Is Altered in Children ... Background: Several adult studies have shown that sickle cell disease is associated with cardiac abnormalities and premature death. The aim of this study was to use speckle-tracking strain, a relatively load independent parameter, to evaluate systolic left ventricular (LV) and right ventricular (RV) function in a pediatric sickle cell disease population.Methods: Twenty-eight patients with sickle cell disease (mean age, 10.0 ± 3.6 years; mean body surface area, 1.14 ± 0.27 m2) and 29 controls matched for age and body surface area were compared. Cardiac output, LV dimension, wall thickness and circumferential strain, LV and RV longitudinal systolic strain, conventional and tissue Doppler parameters, and pulmonary pressure were assessed.Results: LV cardiac output was significantly higher in patients, as were indexed LV systolic diameter, indexed LV mass, and E/E′ septal ratio. Indexed LV diastolic diameter, wall thickness, LV shortening fraction, and global LV longitudinal and circumferential strains were similar in patients and controls. However, their global RV longitudinal strain was significantly lower, although tricuspid annular plane systolic excursion and color-coded tricuspid S-wave velocity were similar. Among patients, 21% had tricuspid regurgitation velocities > 2.5 m/sec, but none had tricuspid regurgitation velocities > 3 m/sec. Indexed LV diastolic dimension and systolic pulmonary artery pressure were significantly higher in patients whose hemoglobin was <80 g/L, but parameters of systolic and diastolic LV function were similar.Conclusions: In children with sickle cell disease, LV diastolic function is significantly altered, although LV systolic function, evaluated by global longitudinal strain, is normal. In addition, cardiac output is increased, and elevated tricuspid regurgitation velocity is common, whereas it is never found in controls. Most importantly, global RV longitudinal systolic strain is significantly altered.
- Can Simple Echocardiographic Measures Reduce the Number o... Background: Right ventricular (RV) enlargement is used as a criterion for the treatment of RV outflow tract dysfunction in patients with congenital heart disease. Although RV volumes are most accurately measured by cardiac magnetic resonance (CMR), CMR is a limited resource. The aim of this study was to investigate whether simple echocardiographic measurements can adequately predict RV volumes below clinical thresholds, thereby reducing the need for CMR in some patients.Methods: Children with repaired tetralogy of Fallot, double-outlet right ventricle, or truncus arteriosus who underwent CMR and echocardiography within a 4-week interval were retrospectively studied. From the four-chamber view, indexed RV lateral wall length, indexed RV end-diastolic perimeter length, and indexed RV end-diastolic area (RVEDAi), were measured. Results were compared with CMR indexed RV volume. The sensitivity and specifity of echocardiographic threshold values predicting RV volumes < 170 mL/m2 were determined.Results: Fifty-one children (mean age, 12.7 ± 3.5 years; 25 male, 26 female) were reviewed. RVEDAi was correlated with CMR indexed RV volume (r = 0.60, P < .0001). Indexed RV end-diastolic perimeter length and indexed RV lateral wall length were not correlated with CMR. RVEDAi < 20 cm2/m2 had 100% specificity to predict indexed RV volume ≤ 170 mL/m2 (area under the curve, 0.79), reducing the need for CMR in 15 of 51 patients (29%). A threshold RVEDAi of 22 cm2/m2 would reduce the need for CMR in 21 of 51 patients (41%) at the expense of one false-negative result. The coefficients of variation were 14.7% for intraobserver variability and 9.6% for interobserver variability.Conclusions: The specificity of echocardiography-measured RVEDAi can be set to predict RV volumes below a 170 mL/m2 threshold in 100% of cases. This may reduce the need for CMR to determine RV volumes in ≥25% of patients with congenital heart disease, potentially reducing patient burden and costs.
- Effect of Mitral Valve Repair on Mitral-Aortic Coupling: ... Background: The aortic valve and the mitral valve (MV) are coupled via fibrous tissue. Simultaneous dynamic analysis of the two valves' annuli has demonstrated that they have synchronous and reciprocal behavior. Accordingly, the aims of this study were to characterize mitral-aortic coupling (MAC) in three-dimensional space before and after MV repair and to identify the untoward effects of annuloplasty rings on MAC compared with normal valvular function.Methods: Real-time three-dimensional transesophageal echocardiography was performed on 28 consecutive patients with degenerative MV disease and severe mitral regurgitation before and after MV repair and in 25 age-matched control subjects. Custom software was used to semiautomatically identify the mitral and aortic annuli throughout the cardiac cycle and to measure parameters describing valvular dynamics.Results: Patients with mitral regurgitation before MV repair were characterized by altered morphology and function of the MV but preserved MAC because of the maintained ability of the mitral annulus to change size and position. MV repair together with annuloplasty ring implantation forced the mitral annulus to be smaller and less pulsatile, with decreased displacement ability compared with normal mitral annuli. Because of this alteration in MAC, the “unaffected” aortic annulus became less pulsatile and less mobile.Conclusions: This study shows unwanted and unexpected changes in aortic annular function secondary to mitral valve repair with an annuloplasty ring due to altered MAC mechanisms. These changes may alter the dynamic mechanism of the aortic root that facilitates blood ejection, so MAC should be considered and evaluated from diagnosis to treatment in MV disease.
- Towards an Integrated Echocardiographic Assessment of Val... Echocardiography is the most useful imaging modality for the noninvasive assessment of patients with valvular diseases, by integrating a thorough morphologic characterization with real-time dynamics in the beating heart. The routine use of conventional two-dimensional (2D) and Doppler echocardiography has greatly expanded our understanding of cardiac physiology and pathophysiology, and has improved our ability to assess the optimal timing for interventions and the prognosis of our patients. However, conventional 2D echocardiography is a tomographic imaging technique, basically providing the visualization of only one thin slice of the heart at a time. The assessment of the size and function of a particular cardiac structure taken as a whole can only be performed by making geometric assumptions about its shape and by applying specific formulas to calculate global indexes from measurements performed in multiple predefined tomographic views. In addition, the displacement and cyclic deformation of the moving cardiac structures displayed in these fixed predefined views can be fully captured only if occurring within the corresponding scan planes. Yet, cardiac valves lie in different planes, move in three-dimensional (3D) space and change in orientation and reciprocal spatial relationship continuously during the cardiac cycle; therefore there is no single 2D plane able to image en face two valves simultaneously. Consequently, the cardiac chambers and valves have been studied individually by 2D echocardiography, as if the function of one were independent from the other, and so clinicians have almost lost the ability to consider the heart as a whole and to assess the fascinating functional interplay among its components.
- Mechanisms and Predictors of Mitral Regurgitation after H... Background: Mitral regurgitation (MR) has been associated with adverse outcomes after myocardial infarction (MI). Without structural valve disease, functional MR has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus. The aims of this study were to elucidate the mechanistic components of MR after high-risk MI and to identify predictors of MR progression during follow-up.Methods: The Valsartan in Acute Myocardial Infarction Echo substudy prospectively enrolled 610 patients with LV dysfunction, heart failure, or both after MI. MR at baseline, 1 month, and 20 months was quantified by mapping jet expansion in the left atrium in 341 patients with good-quality echocardiograms. Indices of LV remodeling, left atrial size, and diastolic function and parameters of mitral valve deformation, including tenting area, coaptation depth, anterior leaflet concavity, annular diameters, and contractility, were assessed and related to baseline MR. The progression of MR was further analyzed, and predictors of worsening among the baseline characteristics were identified.Results: Tenting area, coaptation depth, annular dilatation, and left atrial size were all associated with the degree of baseline MR. Tenting area was the only significant and independent predictor of worsening MR; a tenting area of 4 cm2 was a useful cutoff to identify worsening of MR after MI and moderate to severe MR after 20 months.Conclusions: Increased mitral tenting and larger mitral annular area are determinants of MR degree at baseline, and tenting area is an independent predictor of progression of MR after MI. Although LV remodeling itself contributes to ischemic MR, this influence is directly dependent on alterations in mitral geometry.
Journal of the American Society of Hypertension
- From the Editor Type 2 diabetes mellitus is an increasingly frequent finding, and a major risk factor for cardiovascular morbidity and mortality. New drugs have been developed and many studies have been done with these agents. This issue of the Journal of the American Society of Hypertension begins with a timely review of the relationship between classes of antidiabetic agents and cardiovascular disease by Dr. Nancy Brown, chair of the Department of Medicine at Vanderbilt University and a renowned expert in this area. Because many hypertensive patients also are obese, have impaired carbohydrate tolerance, or frank type 2 diabetes, this information is very timely for all those who treat such patients.
- Cardiovascular effects of antidiabetic agents: focus on b... Abstract: Hyperglycemia is associated with increased risk of cardiovascular disease. Nevertheless, results of large clinical trials suggest that tight glucose control does not reduce the risk of macrovascular cardiovascular events in type 2 diabetes mellitus and may cause harm. This may reflect the adverse consequences of increased hypoglycemia or the adverse effects of many antidiabetic agents on weight gain. The consequences of intensive therapy may also depend on the mechanism of the antidiabetic agent(s) used to achieve tight control. Metformin, an antidiabetic agent that reduces weight and activates AMP-activated protein kinase, reduces risk of cardiovascular events in overweight diabetics. In contrast, the thiazolidinedione rosiglitazone increases cardiovascular risk. Sulfonylureas may increase the risk of cardiovascular events through effects on the SUR1 of the cardiac KATP channel. Stable analogues of glucagon-like peptide-1 reduce body weight and blood pressure, and have favorable effects on ischemia following reperfusion in animal models. The dipeptidyl peptidase IV inhibitors prevent the breakdown of glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide, but also decrease the degradation of several vasoactive peptides. Dipeptidyl peptidase IV inhibitors have favorable effects in animal models of ischemia/reperfusion. They have been reported both to decrease and to increase blood pressure. Clinical trials will address the effect of the incretin-based agents on macrovascular cardiovascular events.
- Activation of vascular p38MAPK by mechanical stretch is i... Abstract: Little is known about vascular MAPK regulation in response to mechanical strain. Whether mechanically-sensitive pathways are altered in hypertension is unclear. We examined effects of stretch and Ang II on activation of p38MAPK in vascular smooth muscle cells (VSMC) from WKY and SHR. The role of c-Src and redox-sensitive pathways in stretch-induced effects were examined. VSMC from mesenteric arteries were plated onto flexible silastic plates and exposed to acute or chronic cyclic stretch (10%, 1 Hz) with or without Ang II (0.1 uM). Acute stretch stimulated p38MAPK activation in WKY and SHR, independently of c-Src and reactive oxygen species (ROS), since PP2 (c-Src inhibitor) and apocynin (NADPH oxidase inhibitor), failed to alter stretch-mediated p38MAPK. Chronic stretch blunted p38MAPK phosphorylation in WKY and increased phosphorylation in SHR. Stretch, in the presence of Ang II, induced an increase in procollagen-1 expression. This was blocked by SB203580 (p38MAPK inhibitor). Accordingly, vascular p38MAPK is a mechano-sensitive MAPK, differentially regulated by acute and chronic stretch in WKY and SHR. Functionally, stretch and Ang II, amplify profibrotic responses in a p38MAPK-dependent manner, responses that are perturbed in SHR. Such molecular process may influence vascular fibrosis in hypertension and appear to be independent of c-Src and ROS.
- Angiotensin II type 2 receptor-interacting protein preven... Abstract: Angiotensin II type 2 (AT2) receptor-interacting protein (ATIP), which interacts with the C-terminal tail of the AT2 receptor, regulates the functions of the AT2 receptor. We have reported that AT2 receptor stimulation attenuated vascular senescence. Therefore, we examined the possible negative role of ATIP in regulating vascular senescence. We generated ATIP-transgenic (Tg) mice, and cultured vascular smooth muscle cells (VSMCs). Persistent angiotensin II stimulation induced increases in SA-β-gal–positive cells and the level of a DNA damage marker, 8-OHdG in VSMC, whereas these effects of angiotensin II were attenuated in VSMC prepared from ATIP-Tg mice. Angiotensin II treatment also upregulated the expression of methyl methanesulfonate-sensitive 2 (MMS2), a DNA repair factor, and Src homology 2 domain-containing protein-tyrosine phosphatase 1 (SHP-1) activity, whereas these effects of angiotensin II were further enhanced in ATIP-Tg VSMC. In vivo, x-ray irradiation to mice caused increases in SA-β-gal–positive area and 8-OHdG level in the thoracic aorta; however, these effects were reduced in ATIP-Tg mice, with a significant increase in MMS2 expression. These results suggest that ATIP could inhibit VSMC senescence, involving MMS2 expression and SHP-1 activity. ATIP might be a new therapeutic molecule to treat vascular aging and age-related vascular diseases.
- Cardiomyocyte size estimated from noninvasive measurement... Abstract: Noninvasive measurements of left ventricular wall thickness (LVT) and left ventricular chamber diameter (LVD) allow calculation of expected left ventricular weight (LVW), but not of myocyte breadth (MyB), so that specification of left ventricular hypertrophy (LVH) is not optimal. Hypertrophied hearts, excluding coronary heart disease, and comparison specimens without hypertrophy were compiled into a series of 78 forensic autopsies, wherein LVT, LVD, and LVW were measured. MyB was measured in hematoxylin and eosin–stained paraffin sections. A series of clinical cases tabulating LVD and LVT was assembled from readily available publications. From postmortem data, a regression equation was derived to predict MyB from LVD and LVT. Applying this equation to the clinical data produced a scatter plot closely resembling that in the postmortem dataset. The equation derived here appears to provide valid predictions of cardiomyocyte sizes expected in histological measurements. The finding is the first of its kind and requires further testing for validation or rejection. This is offered as a provisional way to improve the determination of LVH using noninvasive measurements. How this improvement might enhance understanding of the mechanisms for hypertrophy is briefly explored, thus generating working hypotheses.
- Left ventricular hypertrophy by electrocardiography and e... Abstract: Although electrocardiographic criteria for diagnosing left ventricular hypertrophy have a low sensitivity in the general population, their test characteristics have not been evaluated in the high-prevalence group of American Americans with chronic kidney disease. The purpose of the current study was to evaluate these test characteristics among African Americans (n = 645) with hypertensive kidney disease as part of the African-American Study of Kidney Disease and Hypertension cohort. Electrocardiograms were read by 2 cardiologists at an independent core laboratory using the 2 Sokolow-Lyon criteria and the Cornell criteria. Left ventricular hypertrophy on echocardiography was defined as left ventricular mass index greater than 49.2 and greater than 46.7 g/m2.7 in men and women, respectively. Sixty-nine percent of the population had left ventricular hypertrophy on echo, whereas 34% had left ventricular hypertrophy by any of the electrocardiographic criteria. Sensitivity by individual electrocardiographic criteria was 16.5% by Sokolow-Lyon-1, 19.3% by Sokolow-Lyon-2, and 24.7% by Cornell criteria, with specificity ranging from 89% to 92%. When using any of the 3 criteria, sensitivity increased to 40.4% with a decrease in specificity to 78.0%. Consistent with findings in a general population, left ventricular hypertrophy by electrocardiography had low sensitivity and high specificity in this cohort of African Americans with hypertensive kidney disease.
- Disparities in adherence to and persistence with antihype... Abstract: Despite the availability of effective antihypertensive therapies, adherence to and persistence with treatment is suboptimal. As such, there is a need to better understand factors associated with adherence and persistence, such as race/ethnicity. In a retrospective, exploratory analysis of 51,772 hypertensive adult subjects identified in the electronic medical record, we examined medication possession ratio and proportion of days covered as proxies for adherence and persistence, respectively. Logistic regression analyses were performed to assess the role of race/ethnicity in adherence to and persistence with antihypertensive treatments. Relative to white subjects, Asian American/Pacific Islander, black, Hispanic, and “other” subjects were significantly less likely to be adherent to and persistent with their antihypertensive regimens. Black and Hispanic subjects had the lowest odds of adherence (0.46, 95% CI: 0.43–0.49 and 0.58, 95% CI: 0.54–0.62, respectively) and persistence (0.70, 95% CI: 0.65–0.75 and 0.70, 95% CI: 0.66–0.74, respectively) relative to white subjects. Other factors significantly associated with both lower adherence and persistence included younger age and lower chronic disease score. Disparities were found with regard to adherence to and persistence with antihypertensive regimens. Future studies should address these disparities by designing interventions to improve medication-taking behavior in high-risk populations.
- Home and clinic blood pressure responses in elderly indiv... Abstract: Home blood pressure (BP) monitoring may enhance assessment of BP control. In this 16-week study, men and women 70 years or older with systolic BP between 150 and 200 mm Hg were randomized to receive valsartan/hydrochlorothiazide (V/HCTZ) 160/12.5 mg (n = 128), HCTZ 12.5 mg (n = 128), or V 160 mg (n = 128) for 4 weeks. Participants whose BP was 140/90 mm Hg or higher at weeks 4, 8, or 12 were uptitrated to a maximum of V/HCTZ 320/25 mg. Participants were evaluated by home BP monitoring using an automated device weekly before taking daily study medication (n = 301). Baseline BP ± SD for clinic (165.5 ± 11.8/85.1 ± 9.5 mm Hg) was approximately 3/1 mm Hg greater than home readings (162.5 ± 15.8/84.3 ± 10.2 mm Hg). Reductions in BP ± SEM at week 4 were similar for clinic (12.6 ± 1.0/4.7 ± 0.5 mm Hg) and home (10.9 ± 1.1/3.8 ± 0.5 mm Hg) readings (P = .25/P = .23; clinic versus home); differences between V/HCTZ and HCTZ or V were also similar for both home and clinic readings and results by either technique correlated significantly (P < .0001). Home BP measurements confirm that treatment initiated with V/HCTZ versus monotherapy resulted in greater antihypertensive efficacy. Home BP monitoring, if done with proper technique, provides a reliable indicator of BP control in elderly patients and may help guide drug dosing and titration.
- Aliskiren-based dual- and triple-combination therapies in... Abstract: Previously, we reported the efficacy of aliskiren/amlodipine in US minority adults with stage 2 hypertension, with additional blood pressure (BP) lowering from the addition of hydrochlorothiazide (HCTZ). A subgroup analysis in patients with hypertension and comorbidities of diabetes, cardiometabolic syndrome, or obesity, and in black participants is reported. This 8-week, multicenter, double-blind study included 412 self-identified minority patients with mean sitting systolic BP (msSBP) ≥160 mm Hg and <200 mm Hg). Patients were randomized to receive either combination aliskiren/amlodipine 150/5 mg or amlodipine 5 mg. Doses were forced-titrated to a maximum of aliskiren/amlodipine/HCTZ 300/10/25 mg or aliskiren/amlodipine 300/10 mg, respectively. There were 256 black (62%), 118 diabetic (29%), 284 cardiometabolic syndrome (69%), and 249 obese (60%) randomized patients. Baseline msSBP was ∼167 mm Hg across all subgroups. Least-square mean reductions in msSBP, the primary efficacy outcome, from baseline to week 8 across all subgroups, ranged from 35 to 37 mm Hg with aliskiren/amlodipine/HCTZ and 28 to 30 mm Hg with aliskiren/amlodipine (P < .01 for all between-treatment comparisons). Both regimens were well tolerated. Among high-risk patients, such as diabetics or those with cardiometabolic syndrome, combination aliskiren/amlodipine is effective in lowering BP; the addition of HCTZ provided incremental BP-lowering efficacy while maintaining tolerability. However, because our subgroups were not mutually exclusive, the generalization of our findings to the population seen in clinical practice is limited.
- Nebivolol withdrawal results in blood pressure returning ... Abstract: Rapid withdrawal of antihypertensive drugs may lead to blood pressure (BP) increase above pretreatment values or symptoms such as palpitations, chest pain, and tremor. This phase IV trial assessed the consequences of abrupt and stepwise withdrawal of nebivolol, a β1-selective blocker, in individuals with stage I-II hypertension. After a 4- to 5-week placebo washout phase and 12-week single-blind nebivolol treatment (10–40 mg/day, titrated based on BP response), participants achieving BP control (systolic BP [SBP]/diastolic BP [DBP] <140/90 mm Hg) or response (SBP decrease ≥10 mm Hg or DBP decrease ≥5 mm Hg) entered a 4-week, randomized, double-blind phase of continued nebivolol treatment (n = 102) or withdrawal to placebo (n = 105). Primary and secondary efficacy measures were changes in mean sitting DBP and SBP, respectively, analyzed using an analysis of covariance model. Safety and tolerability were also assessed. In the withdrawal phase, nebivolol and placebo groups demonstrated mean DBP increases of 1.8 and 7.7 mm Hg, respectively (P < .001), and SBP increases of 3.5 and 7.6 mm Hg (P = .011). Twenty-three (22.5%) nebivolol-treated and 18 (17.1%) placebo-treated participants experienced a treatment-emergent adverse event. No adverse events associated with β-blocker withdrawal and considered causally related to nebivolol were reported. Nebivolol withdrawal resulted in a mean BP increase near pretreatment levels and was not associated with rebound hypertension.
Journal of the CardioMetabolic Syndrome
- Association of Lipid Abnormalities With Measures and Seve... Obesity and lipid abnormalities in children may increase premature cardiovascular disease risk, but the relationship of dyslipidemia with adiposity among obese children is not well defined. The authors performed a cross-sectional analysis of children and adolescents (N=698) in 3 age groups (3–8 years, 9–11 years, and 12–18 years; 53% female, 81% African American, and 16% Hispanic) attending an obesity treatment program. More than 50% of the sample had abnormal levels of triglycerides (TG) or high-density lipoprotein (HDL) cholesterol or both. Only HDL cholesterol and TG were significantly associated with adiposity measures and insulin resistance (measured by homeostasis model assessment [HOMA]) and only in adolescents. All measures of adiposity, adjusted for age and sex, among adolescents were modest predictors of abnormal TG and HDL cholesterol, but these associations were attenuated when adjusting for HOMA. Despite the high prevalence of dyslipidemia in overweight children and adolescents, severity of adiposity appears to be a poor predictor of lipid values except among adolescents. Insulin resistance may in part mediate the relationship of adiposity and dyslipidemia among obese adolescents.
- When the Heart and the Mind Collide: Cardiovascular Risk ...
- Measures of Coronary Artery Calcification and Association... The authors compared the metabolic syndrome status and Framingham 10-year coronary heart disease risk score (FRS) with the coronary artery calcification (CAC) in subclinical atherosclerosis. In all, 356 consecutive patients who underwent coronary artery calcium scanning were studied. Participants’ metabolic syndrome status (by National Cholesterol Education Program Adult Treatment Panel III [NCEP ATP III] guidelines) and FRS were measured. The association between the metabolic syndrome, diabetes mellitus (DM), FRS, and CAC was analyzed by multivariable logistic regression analyses. These analyses were adjusted for demographics, age, sex, and conventional cardiovascular risk factors. The prevalence of significant CAC (CAC score ≥100) in those with DM, the metabolic syndrome, and neither condition was 64%, 43%, and 24%, respectively. The receiver operating characteristic C statistic for the prediction of significant CAC by the NCEP ATP III criteria for FRS, the metabolic syndrome, and DM was 0.61, 0.67, and 0.72, respectively, and increased significantly to 0.78 and 0.90 respectively for the metabolic syndrome and DM when added to the prediction models (P<.0001). This study suggests that the metabolic syndrome and DM are associated with increased risk of subclinical atherosclerosis. In addition, the presence of the metabolic syndrome or DM with increased FRS has incremental value over the FRS, DM, or the metabolic syndrome alone in predicting significant CAC.
- Waist Circumference, Body Mass Index, and Their Associati... Total body fat and adipose tissue distribution are associated with cardiometabolic risk, yet there are conflicting data as to whether waist circumference (WC) or body mass index (BMI) is a better predictor of cardiovascular risk. To determine whether WC or BMI was more strongly associated with cardiometabolic risk, family members of patients with cardiac disease were studied (N=501; mean age, 48 years; 66% female; 36% nonwhite). Height, weight, WC, BMI, blood pressure, high-density lipoprotein cholesterol, triglycerides, glucose, high-sensitivity C-reactive protein, and lipoprotein-associated phospholipase A2 were systematically measured. Global risk was calculated using the Framingham function. Increased WC and BMI were equally strong predictors of cardiometabolic and global risk. The prevalence of cardiometabolic risk factors and their correlation with WC and BMI varied by race/ethnicity. Our data support inclusion of WC and BMI in screening guidelines for diverse populations to identify individuals at increased cardiometabolic risk.
- Drugs Are Not Enough: The Metabolic Syndrome—A Call for... Whether intensive pharmacologic cardiovascular risk factor management reduces metabolic syndrome (MetS) prevalence is unknown. The authors compared the number of secondary prevention medications and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)–defined MetS prevalence in coronary artery disease patients entering cardiac rehabilitation from 1996 to 2001 (period 1, n=516) with those entering from 2002 to 2006 (period 2, n=609). Age, sex, and ethnicity were similar in both periods. From period 1 to period 2, participants took more secondary prevention medications (2.8±1.3 vs 3.5±1.0, P<.001). Prevalence of low high-density lipoprotein cholesterol (66% vs 66%), diabetes (37% vs 38%), and hypertension (81% vs 81%) were unchanged. The prevalence of hypertriglyceridemia decreased (48% vs 36%, P<.001), but the proportion meeting criteria for elevated waist circumference increased (51% vs 58%, P<.05), resulting in no change in overall MetS prevalence (60% vs 59%, P=NS). More emphasis on therapeutic lifestyle change in addition to intensive pharmacologic therapy is needed to reduce MetS prevalence in patients with coronary artery disease.
- Comparison Between Turkish Cardiovascular Risk Platform a... The Turkish Cardiovascular Risk Platform (TCRP) calls for the diagnosis of the metabolic syndrome (MS) if insulin resistance, impaired fasting glucose, impaired glucose tolerance, or diabetes mellitus and ≥2 other established criteria are present. TCRP defines insulin resistance as a homeostasis model assessment >2.7. The aim of this cross-sectional study was to compare TCRP guidelines with the United States National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition of MS in Turkish adults (N=1690). The age- and sex-adjusted prevalence of MS was 25% with the TCRP and 40% for the NCEP definition. Patients with MS identified by the NCEP definition but not by the TCRP definition had lower body mass index and less insulin resistance, but had a similarly adverse cardiovascular risk factor profile to those with TCRP-identified MS, with high blood pressure, waist circumference, triglycerides, and total cholesterol/high-density lipoprotein cholesterol ratio. Other national health organizations should avoid using homeostasis model assessment as a prerequisite for diagnosing MS. Modification of the NCEP definition would be more appropriate for ethnic groups with different body sizes.
- Coronary Artery Calcification and Inflammation According ... A number of metabolic syndrome (MS) definitions exist, and one’s cardiovascular disease risk may depend on the definition used. The authors compared the association of subclinical atherosclerosis (coronary artery calcification [CAC] score >0] and inflammation (white blood cell [WBC] count greater than or equal to the highest quartile) with 3 definitions of MS (those of the National Cholesterol Education Program Adult Treatment Panel III [NCEP ATP III], the American Heart Association/National Heart, Lung and Blood Institute [AHA/NHLBI], and the International Diabetes Federation [IDF]) in 458 asymptomatic men (mean age, 46±7 years). MS was present in 28%, 29%, and 34% according to NCEP ATP III, AHA/NHLBI, and IDF criteria, respectively. CAC was observed in 40% and high WBC count in 24%. After adjustment for age, smoking, and low-density lipoprotein cholesterol, the odds ratios for CAC scores >0 with MS by NCEP ATP III, AHA/NHLBI, and IDF definitions were 1.67 (95% confidence interval [CI], 1.02–2.72), 1.67 (95% CI, 1.03–2.70), and 1.63 (95% CI, 1.03–2.57), respectively. The multivariate odds ratios for high WBC count with MS by NCEP ATP III, AHA/NHLBI, and IDF definitions were 1.69 (95% CI, 1.04–2.73), 1.84 (95% CI, 1.14–2.95), and 1.66 (95% CI, 1.05–2.62), respectively. MS is associated with increased subclinical atherosclerosis and inflammation irrespective of various definitions.
- Insulin Resistance and the Cardiometabolic Syndrome in HI... Highly active antiretroviral therapy (HAART) has dramatically improved the prognosis of HIV-positive patients. However, long-term adverse effects of this therapy include dyslipidemia, insulin resistance (IR), changes in body fat distribution (lipodystrophy), and cardiometabolic syndrome (CMS). IR in HIV-positive patients does not seem to represent a significant independent risk factor for the development of cardiovascular disease; nevertheless, the association with other metabolic complications (dyslipidemia, fat redistribution) and CMS may increase the risk of type 2 diabetes and cardiovascular disease. The use of nucleoside analogue reverse transcriptase inhibitors is associated with the development of upper trunk and visceral fat accumulation and may cause IR. The progression of IR toward diabetes may be impeded with the choice of HAART regimens with less IR effects and encouraging patients to adhere to a healthy lifestyle. For patients with marked IR but relatively preserved fat, the use of metformin may consent the improvement of CMS and lipodystrophy, especially when combined with an appropriate exercise program. Therapy with rosiglitazone is not indicated in these patients.
- The Role of Adiponectin in Obesity, Diabetes, and Cardiov... Nearly 1 in 4 adults in the United States is obese. The connection between obesity and insulin resistance, type 2 diabetes, and cardiovascular disease is a well researched one. The increasing prevalence of each of these diseases has become a growing concern for the medical community. Adiponectin is a collagen-like plasma protein secreted by adipocytes that has been suggested to play a causal role in the development of insulin resistance and cardiovascular disease. The protein has been found to be decreased in cases of insulin resistance, diabetes, atherosclerosis, and coronary artery disease. Up-regulation of adiponectin and its receptor, through the use of thiazolidinediones, has been found to be partially related to insulin sensitization and thus antidiabetic effects. In this review, we discuss adiponectin’s antiatherogenic effects, its association with insulin resistance and obesity, and the possibility of using adiponectin and its receptor as a therapeutic target.
- Prevalence and Significance of Cardiometabolic Risk Facto... Type 1 diabetes (T1D) is a common disease of childhood with a current prevalence of almost 2 cases per 1000 adolescents, according to the third National Health and Nutrition Examination Survey. Modern insulin treatment has resulted in improved quality of life for children with this chronic disorder. However, T1D continues to carry a long-term burden of increased microvascular and macrovascular complications and mortality risk. Compared to the nondiabetic population, patients with T1D are more likely to have ≥1 cardiovascular risk factor and often at an earlier age. Since the prevalence of cardiovascular risk factors increases with age in young persons with T1D, there is a clear need for early screening and counseling to prevent their occurrence and manage long-term health ramifications. The purpose of this review is to describe how traditional risk factors for cardiovascular disease such as an abnormal lipid profile, hypertension, obesity, and insulin resistance contribute to the accelerated atherosclerosis seen in young persons with T1D. A summary is given of the guidelines and recommendations published for clinical care for these patients.
Atherosclerosis
- Editorial Board
- Adenosine improves post-procedural coronary flow but not ... Abstract: Aims: Adjunctive therapy with adenosine has been shown to improve coronary flow in patients with acute coronary syndromes (ACS); it is unclear, however, whether adenosine can effectively reduce adverse clinical events. The aim of our study was to perform a meta-analysis of all randomized controlled trials (RCTs) investigating angiographic and clinical outcomes in ACS patients undergoing PCI or thrombolysis and receiving adjunctive adenosine therapy vs. placebo.Methods: Medline/CENTRAL/EMBASE and Google Scholar database were scanned. The meta-analysis included ten RCTs (N=3821). All-cause mortality was chosen as primary endpoint. Secondary endpoints were re-infarction (MI), heart failure (HF) symptoms (NYHA class III/IV), no-reflow (defined as TIMI 0 flow) and >50% ST-resolution.Results: Adenosine compared to placebo was associated with a significant reduction of post-procedural no-reflow (OR [95% CI]=0.25 [0.08–0.73], p=0.01); however, at a median follow-up of 6 months, prior treatment with adenosine did not confer significant benefits in terms of reduction of mortality (ORFixed [95% CI]=0.87 [0.69–1.09], p=0.23), as well as re-MI (p=0.80), HF symptoms (p=0.44) and ST-resolution (p=0.09). Separate analyses conducted in the subgroups of ST-elevation MI patients treated with either PCI or thrombolysis confirmed the findings found in the overall population.Conclusions: This meta-analysis shows that adenosine adjunctive therapy does not improve survival nor reduce the rates of re-MI and HF symptoms in patients with ACS treated with PCI or thrombolysis. The beneficial effect on post-procedural coronary flow was not associated with consistent advantages on clinical outcomes.
- The urokinase system in the pathogenesis of atherosclerosis Abstract: Atherogenesis refers to the development of atheromatous plaques in the inner lining of the arteries. These atherosclerotic lesions are characterized by accumulation of monocyte-derived macrophage-foam cells loaded with cholesterol, which eventually undergo apoptotic death, leading finally to formation of the necrotic core of the plaque. Atheroma formation also involves the recruitment of smooth muscle cells (SMC) from the media into the intima, where they proliferate and form the neointima in a process called “remodeling”. Cells in the advanced atherosclerotic plaques express high levels of the serine protease urokinase-type plasminogen activator (uPA) and its receptor (uPAR). uPA is a multi-functional multi-domain protein that is not only a regulator of fibrinolysis, but it is also associated with several acute and chronic pathologic conditions. uPA mediate the extracellular matrix (ECM) degradation, and plays a pivotal role in cell adhesion, migration and proliferation, during tissue remodeling. On cell surface uPA binds to the high affinity urokinase receptor, providing a strictly localized proteolysis of ECM proteins. The uPA/uPAR complex also activates intracellular signaling, thus regulating cellular function. An imbalance in the uPA/uPAR system leads to dis-orders in tissue structure and function. This review summarizes recent progress in understanding the role and mechanisms of the uPA/uPAR system in atherogenesis.
- Statins as a possible cause of inflammatory and necrotizi... Abstract: Background: Hydroxy-methyl-glutaryl Co-A reductase (HMGCR) inhibitors or statins are a well recognized cause of a variety of skeletal myopathic effects which generally resolve on stopping the medication. Recent reports, however, suggest that statins are associated with a unique autoimmune myopathy wherein symptoms persist or even progress after statin discontinuation and require immunosuppressive therapy. We performed a systematic review to examine the association of statins with inflammatory (dermatomyositis/polymyositis) and necrotizing myopathies.Methods: We searched PubMed, Ovid and Scopus for English language articles addressing statin associated inflammatory and necrotizing myopathies. Given the paucity of cases, we extended the search to include articles in all languages.Results: The search yielded 14 articles reporting a possible association of statins with inflammatory myopathies describing 10 cases of polymyositis and 14 cases of dermatomyositis, and 4 articles reporting a possible association of statins with necrotizing myopathies describing 63 cases. One study identified a unique antibody directed against HMGCR in patients with necrotizing myopathy. Systemic immunosuppressive therapy was required in majority of these cases for resolution of symptoms.Conclusion: Statins have recently been associated with a variety of inflammatory myopathies including polymyositis, dermatomyositis, and a necrotizing myopathy. The association of statins with necrotizing myopathy is strengthened by the discovery that the serum of some of these patients contains an anti-HMGCR antibody. This suggests that statins can cause or unmask an immune mediated myopathy.
- The growing interest of fibrin imaging in atherosclerosis Atherosclerosis is a systemic, chronic and progressive inflammatory disease that is characterised by the build-up of lipid-rich plaques within the walls of large arteries. Atherosclerotic lesions (atheroma) consist not only of lipids but also of cells, connective-tissue elements, and debris. Atherosclerosis is a disease involving endothelial dysfunction, oxidative stress, immunity, inflammation, and thrombosis . The current opinion is that atherosclerosis is an immune/inflammatory response of the intima to endothelial injury initiated by blood flow shear stress typical in increased blood pressure, chronic inflammation or hyperlipidaemia, leading to lipid accumulation and transport of oxidized low-density lipoprotein (Ox-LDL) across the endothelium . Another important initial event is platelet interaction with the dysfunctional endothelium in a well-controlled process involving selectins and integrins which trigger monocyte and lymphocyte recruitment . Monocytes further differentiate into activated macrophages expressing scavenger receptors which then bind different forms of OxLDL . These lipid-laden foam cells are the main components of the early stages of atheroma. Thereafter, as the process continues, other blood cells, including B and T cells involved in adaptive immunity as well as platelets may play important roles in the self-perpetuating inflammatory process of atherosclerosis. The pathogenic immune/inflammatory response may then convert early atheroma to more advanced lipid-rich plaques with necrotic core enlargement . The stability and vulnerability of lipid-rich plaques are mainly determined by the overlying fibromuscular cap composed of smooth muscle cells and extracellular matrix . Thinning and rupture of the cap underlie the majority of cardiovascular diseases, including acute coronary syndromes and stroke, with the formation and release of thrombi that may ultimately occlude vessels.
- Endogenous hyperinsulinaemia and exogenous insulin: A com... Insulin is the oldest treatment for hyperglycaemia, and its value in type 1 diabetes is indisputable. However, although the goal of reducing microvascular and macrovascular complications remains the same, type 2 diabetes differs from type 1 diabetes as it is characterised by insulin resistance. Yet despite its high prevalence with approximately 311 million people suffering from type 2 diabetes worldwide , there are no straightforward randomised controlled trials (RCTs) comparing insulin to alternative oral drugs in type 2 diabetes. However, even without the evidence of direct head-to-head comparisons from randomised trials, it has been estimated that the volume of insulin prescribed to patients with type 2 diabetes has doubled from 2000 to 2009 . Furthermore, the ADA and EASD currently support the early initiation of insulin when escalation of treatment is necessary in order to maintain the recommended levels of glycaemic control (HbA1c<7%) . Considering the number of people affected by type 2 diabetes and the expense of insulin, any concern surrounding the safety of insulin in type 2 diabetes could represent a major public health issue.
- Dual effects of statins therapy in systemic lupus erythem... Abstract: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease associated with accelerated atherosclerosis independent of traditional risk factors. Statins, the 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors, have been widely prescribed for hyperlipidemia, which could slow the atherosclerosis progression, and reduce cardiovascular disease events. Nonetheless, accumulated evidences suggested that statins exert immunomodulatory and anti-inflammatory functions independent of their lipid-lowering effects. By the virtue of pleiotropic immunomodulatory property, statins may be applied for the treatment of both autoimmunity and atherosclerosis in patients with SLE. Interestingly, it has been well documented that regulatory T cells (Tregs) are involved in the pathogenesis of SLE as well as atherosclerosis. Meanwhile, studies have shown that statins could induce augmented number of Tregs with increased functional inhibitory properties. Thus, we hypothesized that the effect of statins ameliorating lupus disease manifestations and lupus-mediated atherogenesis might be mediated, at least partly, via the activation of Tregs.To our knowledge, this is the first hypothesis focused on that Tregs might be involved in the immunomodulatory effect of statins on SLE and SLE-related atherosclerosis.
- Leonurine protects against tumor necrosis factor-α-media... Abstract: Objective: Leonurine, a bioactive alkaloid compound in Herba leonuri, has various pharmacological activities, including antioxidant and anti-apoptotic capacities. This study was conducted to test the hypothesis that leonurine was able to attenuate tumor necrosis factor (TNF)-α-induced human umbilical vein endothelial cells (HUVEC) activation and the underlying molecular mechanisms.Methods: Mitogen-activated protein kinases (MAPK) activation, nuclear factor-κB (NF-κB) activation, and inflammatory mediators expression were detected by Western blot or enzyme-liked immunosorbent assay, intracellular reactive oxygen species (ROS) and NF-κB p65 translocation were measured by immunofluorescence, endothelial cell–monocyte interaction was detected by microscope.Results: Leonurine inhibited U937 cells adhesion to TNF-α-activated HUVEC in a concentration dependent manner. Treatment with leonurine blocked TNF-α-induced mRNA and protein expression of adhesion molecules (intercellular adhesion molecule-1 and vascular cell adhesion molecule-1), cyclooxygenase-2, and monocyte chemoattractant protein-1 in endothelial cells. In addition, leonurine attenuated TNF-α-induced intracellular ROS production in HUVEC. Furthermore, leonurine also suppressed the TNF-α-activated p38 phosphorylation and IκBα degradation. Subsequently, reduced NF-κB p65 phosphorylation, nuclear translocation, and DNA-binding activity were also observed.Conclusions: Our results demonstrated for the first time that the anti-inflammatory properties of leonurine in endothelial cells, at least in part, through suppression of NF-κB activation, which may have a potential therapeutic use for inflammatory vascular diseases.
- In vivo assessment of intraplaque and endothelial fibrin ... Highlights: ► A fibrin-targeted contrast agent (FTCA) allows in vivo imaging of atherosclerosis. ► Late stage plaques show the strongest signal enhancement after FTCA administration. ► FTCA enables the assessment of response to therapy.Abstract: Objective: Molecular magnetic resonance imaging (MRI) has emerged as a promising non-invasive modality to characterize atherosclerotic vessel wall changes on a morphological and molecular level. Intraplaque and endothelial fibrin has recently been recognized to play an important role in the progression of atherosclerosis. This study aimed to investigate the feasibility of intraplaque and endothelial fibrin detection using a fibrin-targeted contrast-agent, FTCA (EPIX Pharmaceuticals, Lexington, MA), in a mouse model of atherosclerosis.Methods: Male apolipoproteinE-knockout mice (ApoE−/−) were fed a high fat diet (HFD) for one to three months. MRI of the brachiocephalic artery was performed prior to and 90min after the administration of FTCA (n=8 per group). Contrast to noise ratios (CNR) and longitudinal relaxation rates (R1) of plaques were determined and compared to ex vivo fibrin density measurements on immunohistological sections stained with a fibrin-specific antibody and gadolinium concentrations measured by inductively coupled mass spectroscopy (ICP-MS).Results: Molecular MRI after FTCA administration demonstrated a significant increase (p<0.05) in contrast agent uptake in brachiocephalic artery plaques. In vivo CNR measurements were in good agreement with ex vivo fibrin density measurements on immunohistochemistry (y=2.4x+11.3, R2=0.82) and ICP-MS (y=0.95x+7.1, R2=0.70). Late stage atherosclerotic plaques displayed the strongest increase in CNR, R1, ex vivo fibrin staining and gadolinium concentration (p<0.05).Conclusion: This study demonstrated the feasibility of intraplaque and endothelial fibrin imaging using FTCA. Direct in vivo fibrin detection and quantification could be useful for characterization and staging of coronary and carotid atherosclerotic lesions, which may aid diagnosis and intervention.
- Coptisine exert cardioprotective effect through anti-oxid... Highlights: ► Using isoproterenol induced myocardial infarction rat models to elucidate the effect of coptisine and investigate its potential mechanism. ► Coptisine has strong antioxidant activity. ► Coptisine significantly inhibit RhoA/ROCK expression induced by isoproterenol.Abstract: Objective: Because myocardial infarction is a major cause of morbidity and mortality worldwide, protecting the heart from the ischemia is the focus of intense research. Coptisine is an isoquinoline alkaloid extracted form Coptidis Rhizoma. This study aims to elucidate if coptisine is responsible for cardioprotection using myocardial infarction (MI) rat models and investigate its potential mechanism of action.Methods: Myocardial infarction was produced in rats with 85mgkg−1 isoproterenol administered subcutaneously twice at an interval of 24h. The rats were randomized into 7 groups: (I) Normal; (II) ISO; (III) ISO+fasudil; (IV) ISO+isosorbide dinitrate (ISDN) and (V–VII) ISO+coptisine (25, 50 and 100mgkg−1). Cardiac function and markers of cardiac ischemic were assessed after MI.Results: Rats pretreated with coptisine (25, 50 and 100mgkg−1) for 21 days and received subcutaneously injected with ISO (85mgkg−1) on the 20th and 21st day at an interval of 24h. The results suggested that coptisine has strong antioxidant activity, and it can maintain cell membrane integrity, ameliorate mitochondrial respiratory dysfunction, reduce myocardial cells apoptosis, inhibit RhoA/ROCK expression induced by high-dose isoproterenol administration.Conclusions: Coptisine provided cardioprotection in a model of myocardial infarction, and therefore should be considered as a novel adjunctive therapy for attenuating myocardial damage.
BMC Cardiovascular Disorders
- Effectiveness of two intensive treatment methods for smok... Background: There is no more effective intervention for secondary prevention of coronary heart diseasethan smoking cessation. Yet, evidence about the (cost-)effectiveness of smoking cessationtreatment methods for cardiac inpatients that also suit nursing practice is scarce. This protocoldescribes the design of a study on the (cost-)effectiveness of two intensive smoking cessationinterventions for hospitalised cardiac patients as well as first results on the inclusion rates andthe characteristics of the study population. Methods: A quasi-experimental study design is used in eight cardiac wards of hospitals throughout theNetherlands to assess the (cost-)effectiveness of two intensive smoking cessation counsellingmethods both combined with nicotine replacement therapy. Randomization was conducted atthe ward level (cross-over). Baseline and follow-up measurements after six and 12 monthsare obtained. Upon admission to the cardiac ward, nurses assess patients' smoking behaviour,provide a quit advice and subsequently refer patients for either telephone counselling or faceto-face counselling. The counselling interventions have a comparable structure and contentbut differ in provider and delivery method, and in duration. Both counselling interventionsare compared with a control group receiving no additional treatment beyond the usual care.Between December 2009 and June 2011, 245 cardiac patients who smoked prior tohospitalisation were included in the usual care group, 223 in the telephone counselling groupand 157 in the face-to-face counselling group. Patients are predominantly male and have amean age of 57 years. Acute coronary syndrome is the most frequently reported admissiondiagnosis. The ultimate goal of the study is to assess the effects of the interventions onsmoking abstinence and their cost-effectiveness. Telephone counselling is expected to bemore (cost-)effective in highly motivated patients and patients with high SES, whereas faceto-face counselling is expected to be more (cost-)effective in less motivated patients andpatients with low SES.DiscussionThis study examines two intensive smoking cessation interventions for cardiac patients byusing a multi-centre trial with eight cardiac wards. Although not all eligible patients could beincluded and the distribution of patients is skewed in the different groups, the results will beable to provide valuable insight into effects and costs of counselling interventions varying indelivery mode and intensity.Trial registrationDutch Trial Register NTR2144
- Idiopathic premature ventricular contractions and ventric... Background: In recent years, catheter ablation has increasingly been used for ablation of idiopathicpremature ventricular complexes (PVCs) or ventricular tachycardias (IVTs). However, themapping and catheter ablation of the arrhythmias originating from the vicinity of tricuspidannulus (TA) may not be fully understood. This study aimed to investigate electrophysiologiccharacteristics and effects of radiofrequency catheter ablation (RFCA) for patients withsymptomatic PVCs and IVTs originating from the vicinity of TA. Methods: Characteristics of body surface electrocardiogram (ECG) and electrophysiologic recordingswere analyzed in 35 patients with symptomatic PVCs/ IVTs originating from the vicinity ofTA. RFCA was performed using pace mapping and activation mapping. Results: Among the 35 patients with PVCs/IVTs arising from the vicinity of TA, complete eliminationof PVCs/IVTs could be achieved by RFCA in 32 patients (success rate 91.43%) during amedian follow-up period of 21 months. PVCs/IVTs originating from the vicinity of TA haddistinctive ECG characteristics that were useful for identifying the precise origin. An rSpattern was recorded in lead V1 in 93.1% of patients with PVCs/IVTs from the free wall ofTA, vs 16.7% of patients with PVCs/IVTs from the septal TA, whereas a QS pattern in leadV1 occurred in 83.3% of patients with PVCs/IVTs from the septal TA vs 6.9% of patientswith PVCs from the free wall of the TA. The precordial R wave transition occurred by leadV3 or earlier in all patients with PVCs/IVTs originating from the septal portion of the TA, ascompared to transition beyond V3 in all patients with PVCs/IVTs from the free wall of theTA. Conclusions: RFCA is an effective curative therapy for symptomatic PVCs/IVTs originating from thevicinity of TA. There are specific characteristics in ECG and the ablation site could belocated by ECG analysis.
- Age - related treatment strategy and long-term outcome in... Background: Older age, as a factor we cannot affect, is consistently one of the main negative prognosticvalues in patients with acute myocardial infarction. One of the most powerful factors thatimproves outcomes in patients with acute coronary syndromes is the revascularizationpreferably performed by percutaneous coronary intervention. No data is currently availablefor the role of age in large groups of consecutive patients with PCI as the nearly sole methodof revascularization in AMI patients. The aim of this study was to analyze age-relateddifferences in treatment strategies, results of PCI procedures and both in-hospital and longtermoutcomes of consecutive patients with acute myocardial infarction. Methods: Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patientsdivided into two groups according to age (1800 patients [less than or equal to] 65 years and 2014 patients > 65years). Significantly more older patients had a history of diabetes mellitus and previousmyocardial infarctions. Results: The older population had a significantly lower rate of coronary angiographies (1726; 95.9%vs. 1860; 92.4%, p 65 years) was associated with a lesspronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomyby coronary angiography and proceed to PCI if suitable regardless of age is crucial in allpatients, though the primary success rate of PCI in the older age is lower. Age, when viewedas a risk factor, was a dominant discriminating factor in all patients.
- The prognostic importance of a history of hypertension in... Background: Hypertension is a common comorbidity in patients with heart failure and may contribute todevelopment and course of disease, but the importance of a history of hypertension inpatients with prevalent heart failure remains uncertain. Methods: 3078 consecutively hospitalized heart failure patients (NYHA classes II-IV) were screenedfor the EchoCardiography and Heart Outcome Study (ECHOS). The left ventricular ejectionfraction (LVEF) was estimated by 2 dimensional transthoracic echocardiography in allpatients and a subgroup of 878 patients had additional data on pulsed wave Dopplerassessment of transmitral flow available. A restrictive filling (RF) was defined as a mitralinflow deceleration time [less than or equal to]140 ms. Patients were followed for a median of 6.8 (Inter QuartileRange 6.6-7.0) years and multivariable Cox regression models were used to assess the risk ofall-cause mortality associated with hypertension. Results: The study population had a mean age of 73 +/- 11 years. 39% were female, 27% had a historyof hypertension and 48% had a RF. Over the study period, 64% of the population died.Hypertension was not associated with increased risk of mortality, hazard ratio (HR) 0.95(0.85-1.05). LVEF did not modify this relationship (p for interaction = 0.7), but RF patternsubstantially influenced the outcomes associated with hypertension (p forinteraction < 0.001); HR 0.75 (0.57-0.99) and 1.41 (1.08-1.84) in patients without and withRF, respectively. Conclusions: In patients with symptomatic heart failure, a history of hypertension is associated with asubstantially increased relative risk of mortality among patients with a restrictive transmitralfilling pattern.
- Associations among different functional and structural ar... Background: The arterial wall possesses several functional and structural properties that define arterialhealth. Once they become impaired, cardiovascular risk increases. We aimed to ascertain thepattern of correlations among different arterial wall properties and to explore their relations totraditional risk factors and cardiovascular risk stratification. To allow such an investigation amiddle-aged healthy population was recruited. Methods: This cross-sectional study included 100 healthy males (aged 41.9 +/- 6.4 years). Pulse wavevelocity (PWV), beta-stiffness and intima-media thickness (IMT) of the carotid artery, andbrachial artery flow-mediated dilation (FMD) were measured by a standardized ultrasoundapproach. Results: No correlation between FMD and IMT was found; only relatively poor correlations betweenPWV (or beta-stiffness) and FMD existed, as well as between PWV (or beta-stiffness) and IMT.PWV and beta-stiffness highly correlated. Unexpectedly, only weak associations between PWV,beta-stiffness, FMD, IMT and traditional risk factors were revealed. Hence, traditional riskfactors (mainly age) explained only 10-50% of variability for PWV, beta-stiffness, FMD andIMT. Although the subjects had low cardiovascular risk according to their Framingham score,their arterial wall properties were already impaired, particularly FMD. Conclusions: In healthy middle-age males we found: i) absent or poor correlations among arterial stiffness,IMT and endothelial function; ii) a low impact of traditional risk factors on the studiedvariables, and iii) the presence of impaired arterial wall properties despite low calculatedcardiovascular risk. These results provide a deepened understanding of arterial wallproperties and could help to improve cardiovascular risk stratification.
- Cardiac tamponade related to a coronary injury by a peric... Background: Cardiac tamponade is a rare but severe complication of pericardial effusion with a poor prognosis. Prompt diagnosis using transthoracic echocardiography allows guiding initial therapeutic management. Although etiologies are numerous, cardiac tamponade is more often due to a hemopericardium. Rarely, a coronary injury may result in such a hemopericardium with cardiac tamponade. Coronary artery aneurysm are the main etiologies but blunt, open chest trauma or complication of endovascular procedures have also been described.Case presentationA 83-year-old hypertensive man presented for dizziness and hypotension. The patient had oliguria and mottled skin. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium, confirmed by contrast-enhanced thoracic CT scan. A pig-tail catheter allowed to withdraw 500 mL of blood, resulting in a transient improvement of hemodynamics. Rapidly, recurrent hypotension prompted a reoperation. An active bleeding was identified at the level of the retroventricular coronary artery. The pericardium was thickened with several "sharping" calcified plaques in the vicinity of the bleeding areas. On day 2, vasopressors were stopped and the patient was successfully extubated. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a "sharping"calcified pericardial plaque. Conclusion: Cardiac tamponade secondary to the development of a hemopericardium may develop as the result of a myocardial and coronary artery injury induced by a calcified pericardial plaque.
- QRS pattern and improvement in right and left ventricular... Background: Predicting response to cardiac resynchronization therapy (CRT) remains a challenge. We evaluated the role of baseline QRS pattern to predict response in terms of improvement in biventricular ejection fraction (EF). Methods: Consecutive patients (pts) undergoing CRT implantation underwent radionuclide angiography at baseline and at mid-term follow-up. The relationship between baseline QRS pattern and mechanical dyssynchrony using phase analysis was evaluated. Changes in left and right ventricular EF (LVEF and RVEF) were analyzed with regard to baseline QRS pattern. Results: We enrolled 56 pts, 32 with left bundle branch block (LBBB), 4 with right bundle branch block (RBBB) and 20 with non-specific intraventricular conduction disturbance (IVCD). A total of 48 pts completed follow-up. LBBB pts had significantly greater improvement in LVEF compared to RBBB or non-specific IVCD pts (+9.6 ± 10.9% vs. +2.6 ± 7.6%, p = 0.003). Response (defined as ≥ 5% increase in LVEF) was observed in 68% of LBBB vs. 24% of non-specific IVCD pts (p = 0.006). None of the RBBB pts were responders. RVEF was significantly improved in LBBB (+5.0 ± 9.0%, p = 0.007), but not in non-specific IVCD and RBBB pts (+0.4 ± 5.8%, p = 0.76). At multivariate analysis, LBBB was the only predictor of LVEF response (OR, 7.45; 95% CI 1.80-30.94; p = 0.006), but not QRS duration or extent of mechanical dyssynchrony. Conclusions: Presence of a LBBB is a marker of a positive response to CRT in terms of biventricular improvement. Pts with non-LBBB pattern show significantly less benefit from CRT than those with LBBB.
- Choice of generic antihypertensive drugs for the primary ... Background: Hypertension is one of the leading causes of cardiovascular disease (CVD). A range of antihypertensive drugs exists, and their prices vary widely mainly due to patent rights. The objective of this study was to explore the cost-effectiveness of different generic antihypertensive drugs as first, second and third choice for primary prevention of cardiovascular disease. Methods: We used the Norwegian Cardiovascular Disease model (NorCaD) to simulate the cardiovascular life of patients from hypertension without symptoms until they were all dead or 100 years old. The risk of CVD events and costs were based on recent Norwegian sources. Results: In single-drug treatment, all antihypertensives are cost-effective compared to no drug treatment. In the base-case analysis, the first, second and third choice of antihypertensive were calcium channel blocker, thiazide and angiotensin-converting enzyme inhibitor. However the sensitivity and scenario analyses indicated considerable uncertainty in that angiotensin receptor blockers as well as, angiotensin-converting enzyme inhibitors, beta blockers and thiazides could be the most cost-effective antihypertensive drugs. Conclusions: Generic antihypertensives are cost-effective in a wide range of risk groups. There is considerable uncertainty, however, regarding which drug is the most cost-effective.
- The aging Canadian population and hospitalizations for ac... Background: The risk of experiencing an acute myocardial infarction (AMI) increases with age and Canada's population is aging. The objective of this analysis was to examine trends in the AMI hospitalization rate in Canada between 2002 and 2009 and to estimate the potential increase in the number of AMI hospitalizations over the next decade. Methods: Aggregated data on annual AMI hospitalizations were obtained from the Canadian Institute for Health Information for all provinces and territories, except Quebec, for 2002/03 and 2009/10. Using these data in a Poisson regression model to control for age, gender and year, the rate of AMI hospitalizations was extrapolated between 2010 and 2020. The extrapolated rate and Statistics Canada population projections were used to estimate the number of AMI hospitalizations in 2020. Results: The rates of AMI hospitalizations by gender and age group showed a decrease between 2002 and 2009 in patients aged [greater than or equal to]65 years and relatively stable rates in those aged <64 years in both males and females. However, the total number of AMI hospitalizations in Canada (excluding Quebec) is projected to increase by 4667 from 51847 in 2009 to 56514 in 2020, a 9.0% increase. Inflating this number to account for the unavailable Quebec data results in an increase of approximately 6200 for the whole of Canada. This would amount to an additional cost of between $46 and $54 million and sensitivity analyses indicate that it could be between $36 and $65 million. Conclusions: Despite projected decreasing or stable rates of AMI hospitalization, the number of hospitalizations is expected to increase substantially as a result of the aging of the Canadian population. The cost of these hospitalizations will be substantial. An increase of this extent in the number of AMI hospitalizations and the ensuing costs would significantly impact the already over-stretched Canadian healthcare system.
- Oversized vein grafts develop advanced atherosclerosis in... Background: Accelerated atherosclerosis is the main cause of late aortocoronary vein graft failure. We aimed to develop a large animal model for the study of pathogenesis and treatment of vein graft atherosclerosis. Methods: An autologous reversed jugular vein graft was inserted end-to-end into the transected common carotid artery of ten hypercholesteroemic minipigs. The vein grafts were investigated 12-14 weeks later with ultrasound and angiograpy in vivo and microscopy post mortem. Results: One minipig died during follow up (patent vein graft at autopsy), and one vein graft thrombosed early. In the remaining eight patent vein grafts, the mean (standard deviation) intima-media thickness was 712 μm (276 μm) versus 204 μm (74 μm) in the contralateral control internal jugular veins (P diameter of artery). No plaques were found in four non-oversized vein grafts (P < .05). Conclusions: Our model of jugular vein graft in the common carotid artery of hypercholesterolemic minipigs displayed the components of human vein graft disease, i.e. thrombosis, intimal hyperplasia, and atherosclerosis. Advanced atherosclerosis, the main cause of late failure of human aortocoronary vein grafts was only seen in oversized grafts. This finding suggests that oversized vein grafts may have detrimental effects on patient outcome.
Basic Research in Cardiology
- Inhibition of RIP1-dependent necrosis prevents adverse ca... Abstract Accumulating evidence indicatesthat programmed necrosis plays a critical role in cell death during ischemia–reperfusion. Necrostatin-1 (Nec-1), a small molecule capable of inhibiting a key regulator of programmed necrosis (RIP1), was shown to prevent necrotic cell death in experimental models including cardiac ischemia. However, no functional follow-up was performed and the action of Nec-1 remains unclear. Here, we studied whether Nec-1 inhibits RIP1-dependent necrosis and leads to long-term improvements after ischemia–reperfusion in vivo. Mice underwent 30 min of ischemia and received, 5 min before reperfusion, 3.3 mg/kg Nec-1 or vehicle treatment, followed by reperfusion. Nec-1 administration reduced infarct size to 26.3 ± 1.3 % (P = 0.001) compared to 38.6 ± 1.7 % in vehicle-treated animals. Furthermore, Nec-1 inhibited RIP1/RIP3 phosphorylation in vivo and significantly reduced necrotic cell death, while apoptotic cell death remained constant. By using MRI, cardiac dimensions and function were assessed before and 28 days after surgery. Nec-1-treated mice displayed less adverse remodeling (end-diastolic volume 63.5 ± 2.8 vs. 74.9 ± 2.8 μl, P = 0.031) and preserved cardiac performance (ejection fraction 45.81 ± 2.05 vs. 36.03 ± 2.37 %, P = 0.016). Nec-1 treatment significantly reduced inflammatory influx, tumor necrosis factor-α mRNA levels and oxidative stress levels. Interestingly, this was accompanied by significant changes in the expression signature of oxidative stress genes. Administration of Nec-1 at the onset of reperfusion inhibits RIP1-dependent necrosis in vivo, leading to infarct size reduction and preservation of cardiac function. The cardioprotective effect of Nec-1 highlights the importance of necrotic cell death in the ischemic heart, thereby opening a new direction for therapy in patients with myocardial infarction. Content Type Journal ArticleCategory Original ContributionPages 1-13DOI 10.1007/s00395-012-0270-8Authors Martinus I. F. J. Oerlemans, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsJia Liu, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsFatih Arslan, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsKrista den Ouden, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsBen J. van Middelaar, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsPieter A. Doevendans, Department of Cardiology, University Medical Center Utrecht, Utrecht, The NetherlandsJoost P. G. Sluijter, Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 4
- Toll-like receptor 7 stimulation by imiquimod induces mac... Abstract Atherosclerotic plaques tend to rupture as a consequence of a weakened fibrous cap, particularly in the shoulder regions where most macrophages reside. Macrophages express Toll-like receptors to recognize pathogens and eliminate intracellular pathogens by inducing autophagy. Because Toll-like receptor 7 (TLR7) is thought to be expressed in macrophages but not in smooth muscle cells (SMCs), we investigated whether induction of macrophage autophagic death by TLR7 ligand imiquimod can affect the composition of atherosclerotic plaques in favor of their stability. Immunohistochemical staining of human carotid plaques as well as Western blotting of cultured macrophages and SMCs confirmed that TLR7 was expressed in macrophages, but not in SMCs. In vitro experiments showed that only TLR7 expressing cells underwent imiquimod-induced cell death, which was characterized by autophagosome formation. Imiquimod-treated macrophages activated nuclear factor-κB (NF-κB) and released pro-inflammatory cytokines and chemokines. This effect was inhibited by the glucocorticoid dexamethasone. Imiquimod-induced cytokine release was significantly decreased in autophagy-deficient macrophages because these cells died by necrosis at an accelerated pace. Local in vivo administration of imiquimod to established atherosclerotic lesions in rabbit carotid arteries induced macrophage autophagy without induction of cell death, and triggered cytokine production, upregulation of vascular adhesion molecule-1, infiltration of T-lymphocytes, accumulation of macrophages and enlargement of plaque area. Treatment with dexamethasone suppressed these pro-inflammatory effects in vivo. SMCs and endothelial cells in imiquimod-treated plaques were not affected. In conclusion, imiquimod induces macrophage autophagy in atherosclerotic plaques, but stimulates plaque progression through cytokine release and enhanced infiltration of inflammatory cells. Content Type Journal ArticleCategory Original ContributionPages 1-13DOI 10.1007/s00395-012-0269-1Authors Inge De Meyer, Laboratory of Physiopharmacology, University of Antwerp, Antwerp, BelgiumWim Martinet, Laboratory of Physiopharmacology, University of Antwerp, Antwerp, BelgiumDorien M. Schrijvers, Laboratory of Physiopharmacology, University of Antwerp, Antwerp, BelgiumJean-Pierre Timmermans, Laboratory of Cell Biology and Histology, University of Antwerp, Antwerp, BelgiumHidde Bult, Laboratory of Physiopharmacology, University of Antwerp, Antwerp, BelgiumGuido R. Y. De Meyer, Laboratory of Physiopharmacology, University of Antwerp, Antwerp, Belgium Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Metabolic adaptation to chronic hypoxia in cardiac mitoch... Abstract Chronic hypoxia decreases cardiomyocyte respiration, yet the mitochondrial mechanisms remain largely unknown. We investigated the mitochondrial metabolic pathways and enzymes that were decreased following in vivo hypoxia, and questioned whether hypoxic adaptation was protective for the mitochondria. Wistar rats were housed in hypoxia (7 days acclimatisation and 14 days at 11 % oxygen), while control rats were housed in normoxia. Chronic exposure to physiological hypoxia increased haematocrit and cardiac vascular endothelial growth factor, in the absence of weight loss and changes in cardiac mass. In both subsarcolemmal (SSM) and interfibrillar (IFM) mitochondria isolated from hypoxic hearts, state 3 respiration rates with fatty acid were decreased by 17–18 %, and with pyruvate were decreased by 29–15 %, respectively. State 3 respiration rates with electron transport chain (ETC) substrates were decreased only in hypoxic SSM, not in hypoxic IFM. SSM from hypoxic hearts had decreased activities of ETC complexes I, II and IV, which were associated with decreased reactive oxygen species generation and protection against mitochondrial permeability transition pore (MPTP) opening. In contrast, IFM from hypoxic hearts had decreased activity of the Krebs cycle enzyme, aconitase, which did not modify ROS production or MPTP opening. In conclusion, cardiac mitochondrial respiration was decreased following chronic hypoxia, associated with downregulation of different pathways in the two mitochondrial populations, determined by their subcellular location. Hypoxic adaptation was not deleterious for the mitochondria, in fact, SSM acquired increased protection against oxidative damage under the oxygen-limited conditions. Content Type Journal ArticleCategory Original ContributionPages 1-12DOI 10.1007/s00395-012-0268-2Authors Lisa C. Heather, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKMark A. Cole, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKJun-Jie Tan, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKLucy J. A. Ambrose, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKSimon Pope, Institute of Neurology, University College London, London, UKAmira H. Abd-Jamil, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKEmma E. Carter, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKMichael S. Dodd, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UKKar Kheng Yeoh, Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford, UKChristopher J. Schofield, Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford, UKKieran Clarke, Cardiac Metabolism Research Group, Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT UK Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Role of HMGB1 in doxorubicin-induced myocardial apoptosis... Abstract Doxorubicin (DOX) is a widely used anti-tumor agent. The clinical application of the medication is limited by its side effect which can elicit myocardial apoptosis and cardiac dysfunction. However, the underlying mechanism by which DOX causes cardiomyocyte apoptosis is not clear. The aim of present study is to investigate the role of high-mobility group box 1 (HMGB1) in DOX-induced myocardial injury, and signal pathway involved in regulation of HMGB1 expression in cardiomyocytes with DOX. We found treatment of isolated cardiomyocytes and naive mice with the DOX resulted in an increased HMGB1 expression which was associated with increased myocardial cell apoptosis. Pharmacological (A-box) or genetic blockade (TLR4 deficiency, TLR4−/−) of HMGB1 attenuated the DOX-induced myocardial apoptosis and cardiac dysfunction. In addition, our study showed that DOX resulted in an increment in the generation of peroxynitrite (ONOO−) and an elevation in phosphorylation of c-Jun N terminal kinase (JNK). Pretreatment of myocytes with FeTPPS, a peroxynitrite decomposition catalyst, prevented DOX-induced JNK phosphorylation, HMGB1 expression, myocardial apoptosis and cardiac dysfunction. Genetic (JNK−/−) or pharmacological (SP600125) inhibition of JNK ameliorated the DOX-induced HMGB1 expression and diminished myocardial apoptosis and cardiac dysfunction. Taken together, our results indicate that HMGB1 mediates the myocardial injury induced by DOX and ONOO−/JNK is a key regulatory pathway of myocardial HMGB1 expression induced by DOX. Content Type Journal ArticleCategory Original ContributionPages 1-12DOI 10.1007/s00395-012-0267-3Authors Yongwei Yao, Division of Cardiology, Department of Medicine, The Affiliated People’s Hospital of Jiangsu University, No. 8 Dianli Road, Zhenjiang, 212002 Jiangsu Province, People’s Republic of ChinaXuemei Xu, Critical Illness Research, Lawson Health Research Institute, 800 Commissioners Rd E., London, ON N6A 4G5, CanadaGuohui Zhang, Division of Cardiology, Department of Medicine, The Affiliated People’s Hospital of Jiangsu University, No. 8 Dianli Road, Zhenjiang, 212002 Jiangsu Province, People’s Republic of ChinaYingyu Zhang, Division of Cardiology, Department of Medicine, The Affiliated People’s Hospital of Jiangsu University, No. 8 Dianli Road, Zhenjiang, 212002 Jiangsu Province, People’s Republic of ChinaWei Qian, Key Laboratories, The Affiliated People’s Hospital of Jiangsu University, No. 8 Dianli Road, Zhenjiang, 212002 Jiangsu Province, People’s Republic of ChinaTao Rui, Division of Cardiology, Department of Medicine, The Affiliated People’s Hospital of Jiangsu University, No. 8 Dianli Road, Zhenjiang, 212002 Jiangsu Province, People’s Republic of China Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- A novel pathway of NADPH oxidase/vascular peroxidase 1 in... Abstract Vascular peroxidase 1 (VPO1) can utilize reactive oxygen species (ROS) generated from NADPH oxidase (NOX) to catalyze peroxidative reactions. This study was performed to identify a novel pathway of NOX/VPO1 in mediating the oxidative injury following myocardial ischemia reperfusion (IR). In a rat model of myocardial IR, the infarct size, serum creatine kinase (CK) activity, apoptosis, NOX activity, NOX2 and VPO1 expression were measured. In a cell (rat heart-derived H9c2 cells) model of hypoxia/reoxygenation (HR), the apoptosis, NOX activity, NOX2 and VPO1 expression, and H2O2 and HOCl levels were examined. In vivo, IR caused 54.8 ± 1.7 % infarct size in myocardium accompanied by elevated activities of CK, caspase-3 and NOX, up-regulated VPO1 expression and high numbers of myocardial apoptotic cells; these effects were attenuated by pretreatment with the inhibitor of NOX. In vitro, inhibition of NOX or silencing of NOX2 or VPO1 expression significantly suppressed HR-induced cellular apoptosis concomitantly with decreased HOCl production. Inhibition of NOX or silencing of NOX2 led to a decrease in H2O2 production accompanied by a decrease in VPO1 expression and HOCl production. However, silencing of VPO1 expression did not affect NOX2 expression and H2O2 production. H2O2-induced VPO1 expression was partially reversed by JNK or p38 MAPK inhibitor. Our results demonstrate a novel pathway of NOX2/VPO1 in myocardium, where VPO1 coordinates with NOX2 and amplifies the role of NOX-derived ROS in oxidative injury following IR. Content Type Journal ArticleCategory Original ContributionPages 1-19DOI 10.1007/s00395-012-0266-4Authors Yi-Shuai Zhang, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaLan He, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaBin Liu, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaNian-Sheng Li, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaXiu-Ju Luo, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaChang-Ping Hu, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaQi-Lin Ma, Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, 410008 ChinaGuo-Gang Zhang, Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, 410008 ChinaYuan-Jian Li, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 ChinaJun Peng, Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, No. 110 Xiang-Ya Road, Changsha, 410078 China Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Contribution of voltage-dependent K+ and Ca2+ channels to... Abstract The mechanisms responsible for coronary pressure-flow autoregulation, a critical physiologic phenomenon that maintains coronary blood flow relatively constant in the presence of changes in perfusion pressure, remain poorly understood. This investigation tested the hypothesis that voltage-sensitive K+ (KV) and Ca2+ (CaV1.2) channels play a critical role in coronary pressure-flow autoregulation in vivo. Experiments were performed in open-chest, anesthetized Ossabaw swine during step changes in coronary perfusion pressure (CPP) from 40 to 140 mmHg before and during inhibition of KV channels with 4-aminopyridine (4AP, 0.3 mM, ic) or CaV1.2 channels with diltiazem (10 μg/min, ic). 4AP significantly decreased vasodilatory responses to H2O2 (0.3–10 μM, ic) and coronary flow at CPPs = 60–140 mmHg. This decrease in coronary flow was associated with diminished ventricular contractile function (dP/dT) and myocardial oxygen consumption. However, the overall sensitivity to changes in CPP from 60 to 100 mmHg (i.e. autoregulatory gain; Gc) was unaltered by 4-AP administration (Gc = 0.46 ± 0.11 control vs. 0.46 ± 0.06 4-AP). In contrast, inhibition of CaV1.2 channels progressively increased coronary blood flow at CPPs > 80 mmHg and substantially diminished coronary Gc to −0.20 ± 0.11 (P < 0.01), with no effect on contractile function or oxygen consumption. Taken together, these findings demonstrate that (1) KV channels tonically contribute to the control of microvascular resistance over a wide range of CPPs, but do not contribute to coronary responses to changes in pressure; (2) progressive activation of CaV1.2 channels with increases in CPP represents a critical mechanism of coronary pressure-flow autoregulation. Content Type Journal ArticleCategory Original ContributionPages 1-11DOI 10.1007/s00395-012-0264-6Authors Zachary C. Berwick, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USASteven P. Moberly, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USAMeredith C. Kohr, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USAEthan B. Morrical, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USAMichelle M. Kurian, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USAGregory M. Dick, Department of Exercise Physiology, Center for Cardiovascular and Respiratory Sciences, West Virginia University School of Medicine, Morgantown, USAJohnathan D. Tune, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USA Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- The effects of curcumin post-treatment against myocardial... Abstract In this study, we evaluated the effect of curcumin (Cur) post-treatment on isolated perfused rat hearts that had been subjected to a protocol of ischemia and reperfusion injury. We also examined whether the Janus kinase 2 and signal transducer and activator 3 of transcription (JAK2/STAT3) signaling pathway plays a role in the cardioprotective effects of Cur post-treatment. Isolated perfused rat hearts were subjected to 60 min of ischemia, followed by 60 min of reperfusion. The hearts were exposed to 1-μM Cur during the first 10 min of reperfusion in the absence or presence of the JAK kinase-specific inhibitor AG490 (AG, 1 μM). The Cur treatment conferred a cardioprotective effect, and the treated hearts demonstrated an improved post-ischemic cardiac functional recovery, a decreased myocardial infarct size and decreased lactate dehydrogenase release in the coronary flow, a reduced number of apoptotic cardiomyocytes, up-regulation of the anti-apoptotic protein Bcl2 and down-regulation of the pro-apoptotic protein Caspase3. AG blocked the Cur-mediated cardioprotection by inhibiting the JAK2/STAT3 signaling pathway, as reflected by the abrogation of the Cur-induced up-regulation of Bcl2 and down-regulation of Caspase3. The results suggest that Cur post-treatment can attenuate IR injury through the activation of the JAK2/STAT3 signaling pathway, which transmits a survival signal to the myocardium. Content Type Journal ArticleCategory Original ContributionPages 1-12DOI 10.1007/s00395-012-0263-7Authors Weixun Duan, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 ChinaYang Yang, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 ChinaJuanjuan Yan, Department of Prosthodontics, School of Stomatology, The Fourth Military Medical University, 145 Changle West Road, Xi’an, 710032 ChinaShiqiang Yu, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 ChinaJincheng Liu, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 ChinaJingjun Zhou, Department of Physiology and Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi’an, 710032 ChinaJianying Zhang, Department of Physiology and Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi’an, 710032 ChinaZhenxiao Jin, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 ChinaDinghua Yi, Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi’an, 710032 China Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Genetic suppression of Gαs protein provides rate control... Abstract Gene therapy-based modulation of atrioventricular (AV) conduction by overexpression of a constitutively active inhibitory Gα i protein effectively reduced heart rates in atrial fibrillation (AF). However, catecholamine stimulation caused an excessive increase in ventricular rate. We hypothesized that modest genetic suppression of a stimulatory G protein in the AV node would allow persistent rate control in acute AF and would prevent undesired heart rate acceleration during β-adrenergic activation. Atrial fibrillation was induced in 12 pigs by atrial burst pacing via an implanted cardiac pacemaker. Study animals were then assigned to receive either Ad-siRNA-Gαs gene therapy to inactivate Gαs protein or Ad-β-gal as control. Gαs protein inactivation resulted in a 20 % heart rate reduction (P < 0.01). AH and HV intervals were prolonged by 37 ms (P < 0.001) and 28 ms (P < 0.001), respectively, demonstrating atrioventricular conduction delay. Impairment of left ventricular ejection fraction (LVEF) during AF was attenuated by Gαs suppression (LVEF 49 %) compared with controls (LVEF 34 %; P = 0.03). Isoproterenol application accelerated ventricular heart rate from 233 to 281 bpm (P < 0.001) in control animals but did not significantly affect pigs treated with Ad-siRNA-Gαs (192 vs. 216 bpm; P = 0.19). In conclusion, genetic inhibition of Gαs protein in the AV node reduced heart rate and prevented AF-associated reduction of cardiac function in a porcine model. Rate control by gene therapy may provide an alternative to current pharmacological treatment of AF. Content Type Journal ArticleCategory Original ContributionPages 1-12DOI 10.1007/s00395-012-0265-5Authors Patrick Lugenbiel, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyDierk Thomas, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyKamilla Kelemen, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyKerstin Trappe, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyOlympia Bikou, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyPatrick A. Schweizer, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyFrederik Voss, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyRüdiger Becker, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyHugo A. Katus, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, GermanyAlexander Bauer, Department of Cardiology, University of Heidelberg, Medical University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Remote ischemic preconditioning in cardiac surgery: caugh... Remote ischemic preconditioning in cardiac surgery: caught between clinical relevance and statistical significance? Content Type Journal ArticleCategory Invited EditorialPages 1-4DOI 10.1007/s00395-012-0259-3Authors Matthias Thielmann, Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
- Exercise-induced cardioprotection is mediated by a bloodb... Abstract Exercise protects against myocardial ischemia-reperfusion (I-R) injury but the mechanism remains unclear. Protection can be transferred from a remotely preconditioned human donor to an isolated perfused rabbit heart using a dialysate of plasma. We hypothesized that physical exercise preconditioning also confers cardioprotection through a humorally mediated effector dependent on opioid receptor activation. Thirteen male volunteers performed vigorous exercise (four 2-minute bouts of high-intensity exercise) and 1 week later they underwent remote ischemic preconditioning (four cycles of 5 min upper limb ischemia and reperfusion). Dialysates were prepared from blood collected before (control) and after the two interventions. Isolated rabbit hearts were perfused with the dialysates without and with co-administration of naloxone (opioid receptor antagonist) prior to 40 min regional ischemia and 2 h reperfusion. Exercise and remote ischemic preconditioning (rIPC) reduced infarct size from 60 ± 5 to 35 ± 5 % and from 57 ± 7 to 27 ± 3 % of the area at risk, respectively (p < 0.05 and < 0.01). Furthermore, post-ischemic left ventricular developed pressure was improved compared with controls (p = 0.08 for exercise and p = 0.04 for rIPC). Co-perfusion with naloxone abrogated the protective effects of exercise and remote ischemic preconditioned dialysates. In conclusion, high-intensity exercise preconditioning elicits cardioprotection through a humorally mediated dependent on opioid receptor activation, similar to rIPC. Content Type Journal ArticleCategory Original ContributionPages 1-9DOI 10.1007/s00395-012-0260-xAuthors M. M. Michelsen, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, DenmarkN. B. Støttrup, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, DenmarkM. R. Schmidt, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, DenmarkB. Løfgren, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, DenmarkR. V. Jensen, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, DenmarkM. Tropak, Division of Cardiology, Hospital for Sick Children, Toronto, ON M5G 1X8, CanadaE. Jean St-Michel, Division of Cardiology, Hospital for Sick Children, Toronto, ON M5G 1X8, CanadaA. N. Redington, Division of Cardiology, Hospital for Sick Children, Toronto, ON M5G 1X8, CanadaH. E. Bøtker, Department of Cardiology, Aarhus University Hospital, Brendstrupgaardvej 100, Skejby, 8200 Aarhus N, Denmark Journal Basic Research in CardiologyOnline ISSN 1435-1803Print ISSN 0300-8428 Journal Volume Volume 107 Journal Issue Volume 107, Number 3
Cardiology in Review
- A New Feature for Cardiology in Review No abstract available
- Cardiovascular Pharmacologic Therapies Under Investigatio... Cardiovascular (CV) diseases and cerebrovascular diseases remain major causes of mortality and morbidity in the United States. Intensive efforts over the past 45 years to develop important pharmacologic treatments have reduced CV risk dramatically. Described in this article are over 150 drugs being developed to prevent and treat CV disease.
- Novel Biomarkers in Cardiovascular Disease: Research Tool... In recent years, a wide range of novel biomarkers have been evaluated for different cardiovascular disease states (eg, ischemia, congestion, and physiological stress), and many have shown promising results for the prediction of cardiovascular end points. However, to become useful for clinicians and to allow for personalized medicine, each novel biomarker must fulfill 3 fundamental criteria: (1) it must be easy to measure; (2) it must provide new information; and (3) it must help the clinician to manage patients. Although many biomarkers may be useful for prognostication, very few have been shown to improve the treatment of patients with cardiovascular disease when implemented in a clinical setting.
- The Evolution and Refinement of Traditional Risk Factors ... Traditional risk factors for cardiovascular disease such as systemic hypertension and hypercholesterolemia, all described more than half a century ago, are relatively few in number. Efforts to expand the epidemiologic canon have met with limited success because of the high hurdle of causality. Fortunately, another solution to current deficiencies in risk assessment—in particular, the underestimation of risk both before and after initiation of pharmacotherapy—may exist. Parallel to the investigation of novel biomarkers, such as high-sensitivity C-reactive protein, ongoing research has yielded improved metrics of known causative conditions. This evolution of traditional risk factors, heralded by measures such as ambulatory blood pressure, central hemodynamics, low density lipoprotein particle concentration, genetic testing, and “vascular age,” may better address the detection gap in cardiovascular disease.
- Systemic Hypertension: The Roles of Salt, Vascular Na+/K+... Essential hypertension has been shown to be significantly associated with an increased risk for cardiovascular disease and is not well controlled in many patients. In a large portion of people with essential hypertension, sodium intake has been shown to play a significant role in the production of their hypertension. The mechanism through which increased sodium intake manifests hypertension is unresolved and likely multifactorial. Endogenous cardiac glycosides such as endogenous ouabain (EO) and marinobufagenin have been proposed to play a role in salt-sensitive essential hypertension through their inhibition of Na+/K+ ATPase (NKA). The normal function of the NKA pump is to extrude Na+ from the intracellular environment and import K+. Blocking the NKA disrupts its normal maintenance function. EO is proposed to produce alteration in smooth muscle cell contractility by inhibiting the α2-isoform of NKA, altering Na+ in a microdomain of the cell. In this region of the plasma membrane the α2-isoform of the NKA colocalizes with another transmembrane protein, the Na+/Ca2+ exchanger (NCX). The normal function of NCX is to extrude Ca2+ and import Na+. Inhibition of NKA produces an increase in Na+ within the microdomain, which in turn alters the function of the NCX so that less Ca2+ is extruded, leading to increased intracellular Ca2+ and increased vascular contraction. EO has been shown to be synthesized and secreted by the adrenal cortex in response to chronically elevated sodium intake. The levels of EO have been shown to be significantly elevated in 40% of all untreated hypertensive patients. Marinobufagenin, another cardiac glycoside, has also been implicated as a possible cause of essential hypertension through its preferential inhibition of the α1-isoform of NKA. Antagonism of the endogenous inhibitors of NKA is currently a target of clinical research for the development of innovative antihypertensive treatments.
- Review of Radiation Reduction Strategies in Clinical Card... The use of ionizing radiation for medical diagnostic tests and interventional procedures has grown substantially over the past 2 decades, and there is now considerable concern expressed in both the medical literature and the lay press of the harmful effects of radiation exposure. Although there is some controversy regarding whether this medical radiation is actually harmful, minimizing the dose to the patient is logical and a basic part of proper care. To do this, clinicians must have an understanding of the amount of radiation that is involved with each test. Physicians have a responsibility to keep the level of radiation exposure as low as reasonably achievable. A number of simple and common sense measures can help achieve this goal. Encouragingly, there are also numerous new technologies which can substantially lower radiation dose, especially in cardiovascular studies. This review will highlight various ways to reduce radiation in cardiovascular imaging.
- Cervical Carotid Artery Dissection: Current Review of Dia... Carotid artery dissection is a cause of stroke, especially in young and middle-aged patients. A dissection occurs when there is an intimal tear or rupture of the vasa vasorum, leading to an intramural hematoma, which is thought to result from trauma or can occur spontaneously, and is likely multifactorial, involving environmental and intrinsic factors. The clinical diagnosis of carotid artery dissection can be challenging, with common presentations including pain, partial Horner syndrome, cranial nerve palsies, or cerebral ischemia. With the use of noninvasive imaging, including magnetic resonance and computed tomography angiography, the diagnosis of carotid dissection has increased in frequency. Treatment options include thrombolysis, antiplatelet or anticoagulation therapy, endovascular or surgical interventions. The choice of appropriate therapy remains controversial as most carotid dissections heal on their own and there are no randomized trials to compare treatment options.
- Vasopressor Use in Adult Patients Vasopressors are a heterogeneous potent class of medications designed to increase blood pressure in emergent hypotensive situations. The goal of therapy is to increase blood pressure and maintain adequate perfusion, allowing nutrient and oxygen delivery to vital organs. Norepinephrine, phenylephrine, dopamine, epinephrine, and vasopressin are five vasopressors available in the United States. All vasopressors, with the exception of vasopressin, are titratable and dosed on a continuum according to clinical effect. With their different clinical features, adverse effects, and range of potency, the clinical situation usually guides therapy. Outcome data comparing different vasopressors have not demonstrated a clear mortality benefit of any one vasopressor over another, and physician preference also guides therapy. Norepinephrine, nonetheless, remains one of the preferred choices for a variety of hypotensive states, including cardiogenic and septic shock.
Cardiology in the Young
- Volume 22 Issue 03 Cardiology in the Young, Volume 22 Issue 03 Cardiology in the Young is devoted to cardiovascular issues affecting the young, and the older patient suffering the sequels of congenital heart disease, or other cardiac diseases acquired in childhood. The journal serves the interests of all professionals concerned with these topics. By design, the journal is international and multidisciplinary in its approach, and members of the editorial board take an active role in the its mission, helping to make it the essential journal in paediatric cardiology. All aspects of paediatric cardiology are covered within the journal. The content includes original articles, brief reports, editorials, reviews, and papers devoted to continuing professional development. High-quality colour figures are published on a regular basis, and without charge to the authors. Regular supplements are published containing the abstracts of the annual meetings of the Association for European Paediatric and Congenital Cardiology, along with other occasional supplements. These are supplied free to subscribers.
- CTY volume 22 issue 3 Cover and Front matter Miscellaneous Cardiology in the Young, Volume 22 Issue 03, pp f1-f4Abstract
- CTY volume 22 issue 3 Cover and Back matter Miscellaneous Cardiology in the Young, Volume 22 Issue 03, pp b1-b3Abstract
- Paediatric cardiac rehabilitation in congenital heart dis... Review Articles Ana Ubeda Tikkanen, Ainhoa Rodriguez Oyaga, Olga Arroyo Riaño, Enrique Maroto Álvaro, Jonathan Rhodes, Cardiology in the Young, Volume 22 Issue 03, pp 241-250Abstract
- Pulsatile venous waveform quality affects the conduit per... Research Articles Onur Dur, Ergin Kocyildirim, Ozlem Soran, Peter D. Wearden, Victor O. Morell, Curt G. DeGroff, Kerem Pekkan, Cardiology in the Young, Volume 22 Issue 03, pp 251-262Abstract
- Follow-up of rheumatic carditis treated with steroids Research Articles Gesmar V. H. Herdy, Rafael S. Gomes, Anna E. A. Silva, Leandro S. Silva, Vânia G. S. Lopes, Cardiology in the Young, Volume 22 Issue 03, pp 263-269Abstract
- Inferior-type caval vein defect – echocardiographic and... Research Articles Munesh Tomar, Sitaraman Radhakrishnan, Sunil K. Kaushal, Kulbhushan S. Dagar, Krishna S. Iyer, Savitri Shrivastava, Cardiology in the Young, Volume 22 Issue 03, pp 270-278Abstract
- Right pulmonary artery to left atrial fistula: a descript... Research Articles Gabriel Diaz, Alicia Marquez, Javier Gentile, Cardiology in the Young, Volume 22 Issue 03, pp 279-284Abstract
- Heart rate variability in children with acute rheumatic f... Research Articles Mehmet Karacan, Naci Ceviz, Haşim Olgun, Cardiology in the Young, Volume 22 Issue 03, pp 285-292Abstract
- Anaemia is a predictor of early death or cardiac transpla... Research Articles Issam Kammache, Giovanni Parrinello, Davide Marini, Damien Bonnet, Gabriella Agnoletti, Cardiology in the Young, Volume 22 Issue 03, pp 293-300Abstract
Cardiovascular Diabetology
- Let's Prevent Diabetes: study protocol for a cluster rand... Background: The prevention of type 2 diabetes is a globally recognised health care priority, but there is a lack of rigorous research investigating optimal methods of translating diabetes prevention programmes, based on the promotion of a healthy lifestyle, into routine primary care. The aim of the study is to establish whether a pragmatic structured education programme targeting lifestyle and behaviour change in conjunction with motivational maintenance via the telephone can reduce the incidence of type 2 diabetes in people with impaired glucose regulation (a composite of impaired glucose tolerance and/or impaired fasting glucose) identified through a validated risk score screening programme in primary care.DesignCluster randomised controlled trial undertaken at the level of primary care practices. Follow-up will be conducted at 12, 24 and 36 months. The primary outcome is the incidence of type 2 diabetes. Secondary outcomes include changes in HbA1c, Blood glucose levels, cardiovascular risk, the presence of the Metabolic Syndrome and the cost-effectiveness of the intervention. Methods: The study consists of screening and intervention phases within 44 general practices coordinated from a single academic research centre. Those at high risk of impaired glucose regulation or type 2 diabetes are identified using a risk score and invited for screening using a 75g-Oral Glucose Tolerance Test. Those with screen detected impaired glucose regulation will be invited to take part in the trial. Practices will be randomised to standard care or the intensive arm. Participants from intensive arm practices will receive a structured education programme with motivational maintenance via the telephone and annual refresher sessions. The study will run from 2009-2014.DiscussionThis study will provide new evidence surrounding the long-term effectiveness of a diabetes prevention programme conducted within routine primary care in the United Kingdom.
- Estimation of plasma apolipoprotein B concentration using... Background Increased low-density lipoprotein cholesterol (LDL) concentration is associated with increased risk of coronary heart disease (CHD) but a substantial risk of cardiovascular disease often remains after LDL concentrations have been treated to target. Apolipoprotein B (apo B) is the major apolipoprotein contained within atherogenic lipoproteins such as LDL, and apo B is a more reliable indicator of cardiovascular risk than LDL concentration.Aim and methodsOur aim was to develop a formula for calculating apo B using lipid biochemistry measurements that are commonly available in clinical practice. We examined the clinical and laboratory data from 73,047 Koreans who underwent a medical health check that included apolipoprotein B concentration. The study sample was randomly divided into a training set for prediction model building and a validation set of equal size. Multivariable linear regression analysis was used to develop a prediction model equation for estimating apo B and to validate the developed model. Results: The best results for estimating apo B were derived from an equation utilising LDL and triglyceride (TG) concentrations [ApoB=-33.12+0.675*LDL+11.95*ln(tg)]. This equation predicted the apo B result with a concordance correlation coefficient (CCC and 95%CIs) = 0.936 (0.935,0.937)) Conclusion: Our equation for predicting apo B concentrations from routine analytical lipid biochemistry provides a simple method for obtaining precise information about an important cardiovascular risk marker.
- Determinants of uncontrolled hypertension in adult type 2... Background: Uncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia. Methods: Between 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression. Results: The mean age of patients at diagnosis of diabetes was 52.3 +/- 11.1 years old. Most were women (59.0%) and of Malay ethnicity (61.9%). The mean duration of diabetes was 5.9 +/- 5.6 years. A total of 57.4% were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5%) patients had BP two anti-hypertensive agents. Health clinics without doctor, older age ([greater than or equal to] 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP [greater than or equal to]130/80mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP [greater than or equal to]130/80mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20% and 15% more likely to have their blood pressure treated to target respectively. Conclusions: Major independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.
- Comparative effect of angiotensin II type I receptor bloc... Background: Both angiotensin II type I receptor blockers (ARBs) and calcium channel blockers (CCBs) are widely used antihypertensive drugs. Many clinical studies have demonstrated and compared the organ-protection effects and adverse events of these drugs. However, few large-scale studies have focused on the effect of these drugs as monotherapy on laboratory parameters. We evaluated and compared the effects of ARB and CCB monotherapy on clinical laboratory parameters in patients with concomitant hypertension and type 2 diabetes mellitus. Methods: We used data from the Clinical Data Warehouse of Nihon University School of Medicine obtained between Nov 1, 2004 and July 31, 2011, to identify cohorts of new ARB users (n = 601) and propensity-score matched new CCB users (n = 601), with concomitant mild to moderate hypertension and type 2 diabetes mellitus. We used a multivariate-adjusted regression model to adjust for differences between ARB and CCB users, and compared laboratory parameters including serum levels of triglyceride (TG), total cholesterol (TC), non-fasting blood glucose, hemoglobin A1c (HbA1c), sodium, potassium, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), hemoglobin and hematocrit, and white blood cell (WBC), red blood cell (RBC) and platelet (PLT) counts up to 12 months after the start of ARB or CCB monotherapy. Results: We found a significant reduction of serum TC, HbA1c, hemoglobin and hematocrit and RBC count and a significant increase of serum potassium in ARB users, and a reduction of serum TC and hemoglobin in CCB users, from the baseline period to the exposure period. The reductions of RBC count, hemoglobin and hematocrit in ARB users were significantly greater than those in CCB users. The increase of serum potassium in ARB users was significantly greater than that in CCB users. Conclusions: Our study suggested that hematological adverse effects and electrolyte imbalance are greater with ARB monotherapy than with CCB monotherapy.
- Associations between retinol-binding protein 4 and cardio... Background: The published literature regarding the relationships between retinol-binding protein 4 (RBP4) and cardiometabolic risk factors and subclinical atherosclerosis is conflicting, likely due, in part, to limitations of frequently used RBP4 assays. Prior large studies have not utilized the gold-standard Western Blot analysis of RBP4 levels. Methods: Full-length serum RBP4 levels were measured by Western Blot in 709 postmenopausal women screened for the Kronos Early Estrogen Prevention Study. Cross-sectional analyses related RBP4 levels to cardiometabolic risk factors, carotid artery intima-media thickness (CIMT), and coronary artery calcification (CAC). Results: The mean age of women was 52.9 (+/- 2.6) years, and the median RBP4 level was 49.0 (interquartile range 36.9-61.5) ug/mL. Higher RBP4 levels were weakly associated with higher triglycerides (age, race, and smoking-adjusted partial Spearman correlation coefficient= 0.10; P=0.01), but were unrelated to blood pressure, cholesterol, C-reactive protein, glucose, insulin, and CIMT levels (all partial Spearman correlation coefficients [less than or equal to]0.06, P>0.05). Results suggested a curvilinear association between RBP4 levels and CAC, with women in the bottom and upper quartiles of RBP4 having higher odds of CAC (odds ratio [95% confidence interval] 2.10 [1.07-4.09], 2.00 [1.02-3.92], 1.64 [0.82-3.27] for the 1st, 3rd, and 4th RBP4 quartiles vs. the 2nd quartile). However, a squared RBP4 term in regression modeling was non-significant (P=0.10). Conclusions: In these healthy, recently postmenopausal women, higher RBP4 levels were weakly associated with elevations in triglycerides and with CAC, but not with other risk factors or CIMT. These data using the gold standard of RBP4 methodology only weakly support the possibility that perturbations in RBP4 homeostasis may be an additional risk factor for subclinical coronary atherosclerosis.Trial Registration: ClinicalTrials.gov number NCT00154180
- Gender difference in carotid intima-media thickness in ty... Background: Different population studies have reported gender difference in carotid intima-media thickness (CIMT), which is proved to be a risk factor of cardiovascular diseases. However, few longitudinal researches examine this gender difference in type 2 diabetes mellitus (T2DM) patients. Therefore, we prospectively analyzed CIMT in T2DM patients over a 4-year follow-up period. Methods: 355 T2DM patients (mean age 59 years; 54.9% women) were included in the present study. CIMT were measured using Color Doppler ultrasound. CIMT was measured at baseline (CIMT) in 2006 and at follow-up in 2010. Biochemical and clinical measurements were collected at baseline. Results: Mean value of CIMT1 and CIMT2 were 0.740+/-0.148mm and 0.842+/-0.179mm, respectively. Men had higher CIMT than women both at baseline and at follow-up (CIMT1: 0.762+/-0.149 vs 0.723+/-0.146 mm, P=0.0149; CIMT2: 0.880+/-0.189 vs 0.810+/-0.164 mm, P=0.0002). Mean annual progression of CIMT (dCIMT) was 0.025+/-0.022 mm/year. dCIMT was larger in men than in women (0.030+/-0.025 vs 0.022+/-0.019 mm, P=0.0006). In multiple regression analyses, age was an independent risk factor of CIMT in both genders, while dCIMT was associated with age only in men. Conclusions: Gender difference in CIMT was confirmed in T2DM patients. Moreover, impact of ageing on CIMT progression only existed in men, which might be the reason that gender difference in CIMT increased with age.
- Blood pressure and lipid management fall far short in per... Background Although most deaths among patients with type 2 diabetes (T2D) are attributable to cardiovascular disease, modifiable cardiovascular risk factors appear to be inadequately treated in medical practice. The aim of this study was to describe hypertension, dyslipidemia and medical treatment of these conditions in a large population-based sample.Methods The present analysis was based on the DIAB-Core project, in which data from five regional population-based studies and one nationwide German study were pooled. All studies were conducted between 1997 and 2006. We assessed the frequencies of risk factors and co-morbidities, especially hypertension and dyslipidemia, in participants with and without T2D. The odds of no or insufficient treatment and the odds of pharmacotherapy were computed using multivariable logistic regression models. Types of medication regimens were described.Results The pooled data set comprised individual data of 15,071 participants aged 45-74 years, including 1287 (8.5%) participants with T2D.Subjects with T2D were significantly more likely to have untreated or insufficiently treated hypertension, i.e. blood pressure of >= 140/90 mmHg (OR = 1.43, 95% CI 1.26-1.61) and dyslipidemia i.e. a total cholesterol/HDL-cholesterol ratio >= 5 (OR = 1.80, 95% CI 1.59-2.04) than participants without T2D.Untreated or insufficiently treated blood pressure was observed in 48.9% of participants without T2D and in 63.6% of participants with T2D. In this latter group, 28.0% did not receive anti-hypertensive medication and 72.0% were insufficiently treated.In non-T2D participants, 28.8% had untreated or insufficiently treated dyslipidemia. Of all participants with T2D 42.5% had currently elevated lipids, 80.3% of these were untreated and 19.7% were insufficiently treated.Conclusions Blood pressure and lipid management fall short especially in persons with T2D across Germany. The importance of sufficient risk factor control besides blood glucose monitoring in diabetes care needs to be emphasized in order to prevent cardiovascular sequelae and premature death.
- Ginkgo biloba extract reduces high-glucose-induced endoth... Background: Chronic elevation of glucose level activates vascular inflammation and increases endothelial adhesiveness to monocytes, an early sign of atherogenesis. This study aimed to elucidate the detailed mechanisms of high-glucose-induced endothelial inflammation, and to investigate the potential effects of Ginkgo biloba extract (GBE), an antioxidant herbal medicine, on such inflammation.Materials and methods: Human aortic endothelial cells were cultured in high glucose or mannitol as osmotic control for 4 days. The expression of cytokines and adhesion molecules and the adhesiveness of endothelial cells to monocytes were examined. The effects of pretreatment of GBE or N-acetylcysteine, an antioxidant, were also investigated. Results: Either high glucose or mannitol significantly increased reactive oxygen species (ROS) production, interleukin-6 secretion, intercellular adhesion molecule-1 (ICAM-1) expression, as well as endothelial adhesiveness to monocytes. The high-glucose-induced endothelial adhesiveness was significantly reduced either by an anti-ICAM-1 antibody or by an interleukin-6 neutralizing antibody. Interleukin-6 (5 ng/ml) significantly increased endothelial ICAM-1 expression. Piceatannol, a signal transducer and activator of transcription (STAT) 1/3 inhibitor, but not fludarabine, a STAT1 inhibitor, suppressed high-glucose-induced ICAM-1 expression. Pretreatment with GBE or N-acetylcysteine inhibited high-glucose-induced ROS, interleukin-6 production, STAT1/3 activation, ICAM-1 expression, and endothelial adhesiveness to monocytes. Conclusions: Long-term presence of high glucose induced STAT3 mediated ICAM-1 dependent endothelial adhesiveness to monocytes via the osmotic-related redox-dependent interleukin-6 pathways. GBE reduced high-glucose-induced endothelial inflammation mainly by inhibiting interleukin-6 activation. Future study is indicated to validate the antioxidant/anti-inflammatory strategy targeting on interleukin-6 for endothelial protection in in vivo and clinical hyperglycemia.
- Expression of fourteen novel obesity-related genes in Zuc... Background: Genome-wide association studies (GWAS) are useful to reveal an association between single nucleotide polymorphisms and different measures of obesity. A multitude of new loci has recently been reported, but the exact function of most of the according genes is not known. The aim of our study was to start elucidating the function of some of these genes. Methods: We performed an expression analysis of fourteen genes, namely BDNF, ETV5, FAIM2, FTO, GNPDA2, KCTD15, LYPLAL1, MCR4, MTCH2, NEGR1, NRXN3, TMEM18, SEC16B and TFAP2B, via real-time RT-PCR in adipose tissue of the kidney capsule, the mesenterium and subcutaneum as well as the hypothalamus of obese Zucker diabetic fatty (ZDF) and Zucker lean (ZL) rats at an age of 22 weeks. Results: All of our target genes except for SEC16B showed the highest expression in the hypothalamus. This suggests a critical role of these obesity-related genes in the central regulation of energy balance. Interestingly, the expression pattern in the hypothalamus showed no differences between obese ZDF and lean ZL rats. However, LYPLAL1, TFAP2B, SEC16B and FAIM2 were significantly lower expressed in the kidney fat of ZDF than ZL rats. NEGR1 was even lower expressed in subcutaneous and mesenterial fat, while MTCH2 was higher expressed in the subcutaneous and mesenterial fat of ZDF rats. Conclusion: The expression pattern of the investigated obesity genes implies for most of them a role in the central regulation of energy balance, but for some also a role in the adipose tissue itself. For the development of the ZDF phenotype peripheral rather than central mechanisms of the investigated genes seem to be relevant.
- In-hospital death in acute coronary syndrome was related ... Background: Admission hyperglycaemia is associated with mortality in patients with acute coronary syndrome (ACS), but controversy exists whether hyperglycaemia uniformly affects both genders. We evaluated coronary risk factors, gender, hyperglycaemia and their effect on hospital mortality. Methods: 959 ACS patients (363 women and 596 men) were grouped based on glycaemia ≥ or < 200 mg/dL and gender: men with glucose < 200 mg/dL (menG-); women with glucose < 200 mg/dL (womenG-); men with glucose ≥ 200 mg/dL (menG+); and women with glucose ≥ 200 mg/dL (womenG+). A logistic regression analysis compared the relation between gender and glycaemia groups and death, adjusted for coronary risk factors and laboratory data.Results groupmenG- had lower mortality than menG + (OR = 0.172, IC95% 0.062-0.478), and womenG + (OR = 0.275, IC95% 0.090-0.841); womenG- mortality was lower than menG + (OR = 0.230, IC95% 0.074-0.717). No difference was found between menG + vs womenG + (p = 0.461), or womenG- vs womenG + (p = 0.110). Age (OR = 1.067, IC95% 1.031–1.104), EF (OR = 0.942, IC95% 0.915-0.968), and serum creatinine (OR = 1.329, IC95% 1.128-1.566) were other independent factors related to in-hospital death. Conclusions: Death was greater in hyperglycemic men compared to lower blood glucose men and women groups, but there was no differences between women groups in respect to glycaemia after adjustment for coronary risk factors.
Expert Review of Cardiovascular Therapy
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- Thromboembolic prophylaxis in orthopedic surgery using da... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 423-427.
- No country for old stents? Improving long-term patient ou... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 429-432.
- Aspirin in stroke prevention in nonvalvular atrial fibril... Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 433-439.
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- Current imaging modalities for atherosclerosis Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 457-471.
- Novel drugs for oral anticoagulation pharmacotherapy Expert Review of Cardiovascular Therapy , April 2012, Vol. 10, No. 4, Pages 473-488.
Current Problems in Cardiology
- Editorial Board
- Title Page
- Information for Readers
- Table of Contents
- Foreword The measurement of biomarkers is an essential part of everyday clinical practice. It is a pivotal diagnostic step in the diagnosis of acute myocardial infarction. However, there are problems: (1) many other clinical situations are associated with elevated troponins; and (2) normal athletes.
- Troponin—Past, Present, and Future Abstract: Cardiac troponin is the analyte of choice for the diagnosis of cardiac injury. It is highly specific for the heart and much more sensitive than prior biomarkers. Because of this increased sensitivity, clinicians have had to struggle with elevations in novel clinical situations. We have developed new understandings about coronary artery disease but also have begun to appreciate that many other entities as well can result in cardiac injury. As assays have increased in sensitivity over time, this trend has, if anything, accelerated. This review attempts to put the past, the present, and the future into a clinical perspective that will help clinicians.
Current Opinion in Cardiology
- Editorial introductions No abstract available
- Elements of ‘missing heritability’ Purpose of review: To discuss the basis of ‘missing heritability’, which has emerged as an enigma in the post-genome-wide association studies (GWAS) era. Recent findings: Alleles identified through GWAS account for a relatively small fraction of heritability of the complex phenotypes. Accordingly, a significant part of heritability of the complex traits remains unaccounted for (‘missing heritability’). Recent findings offer several explanations, including overestimation of heritability of the complex traits and underestimation of the effects of alleles identified through GWAS. In addition, yet-to-be identified common as well as rare alleles might in part explain the ‘missing heritability’. Moreover, gene–gene (epistasis) and gene–environmental interactions might explain another fraction of heritability of complex traits. Moreover, transgenerational epigenetic changes, regulated in part by microRNAs, might also contribute to the ‘missing heritability’. Summary: The new findings suggest a multifarious nature of the ‘missing heritability’. The findings de-emphasize the focus on delineating the basis of ‘missing heritability’ and shift the focus to elucidation of the molecular mechanisms by which genomic and genetic factors govern the pathogenesis of the complex phenotypes.
- Deciphering the molecular basis of human cardiovascular d... Purpose of review: This review introduces the fundamental concepts of network medicine and explores the feasibility and potential impact of network-based methods on predicting and ameliorating individual manifestations of human cardiovascular disease. Recent findings: Complex cardiovascular diseases rarely result from an abnormality in a single molecular effector, but, rather, nearly always are the net result of multiple pathobiological pathways that interact through an interconnected network. In the postgenomic era, a framework has emerged of the potential complexity of the interacting pathways that govern molecular actions in the human cell. As a result, network approaches have been developed to understand more comprehensively those interconnections that influence human disease. ‘Network medicine’ has already led to tangible discoveries of novel disease genes and pathways as well as improved mechanisms for rational drug development. Summary: As methodologies evolve, network medicine may better capture the complexity of human pathogenesis and, thus, re-define personalized disease classification and therapies.
- Genome-wide studies of gene expression relevant to corona... Purpose of review: Genome-wide association studies have led to the discovery of many single nucleotide polymorphisms (SNPs) associated with coronary artery disease (CAD). However, many of these SNPs are in between genes (intergenic), and presumably function through the regulation of gene expression. Microarrays that measure the expression of thousands of mRNAs have allowed investigators to study how genetic variation alters gene expression at a genome-wide level. Combining these methods has led to progress in understanding the molecular basis for the genetic susceptibility to atherosclerosis. Recent findings: Recent studies confirm that gene expression differences due to genetic variation play an underlying role in atherosclerosis. Expression levels of SORT1 are negatively correlated with an intergenic risk allele on chromosome 1p13.3 that was previously associated with CAD. Increased SORT1 expression leads to lower hepatic secretion of low-density lipoprotein (LDL), providing a mechanistic link between a common risk variant and disease. In addition, three out of 13 newly identified CAD risk loci were found to strongly affect the expression of nearby genes. Another recent study detected variants adjacent to a newly identified atherosclerosis risk locus on chromosome 11q22 that were associated with the expression of platelet-derived growth factor D (PDGFD). Summary: Cataloging the genetics of gene expression provides a small but crucial molecular link between genetics and clinical phenotypes such as atherosclerosis. Thus, gene expression is an endophenotype that can lead to the discovery of the underlying genes responsible for increasing atherosclerosis risk and potential diagnostic and therapeutic targets.
- Next-generation sequencing to identify genetic causes of ... Purpose of review: This review examines the application of next-generation sequencing (NGS) technologies in the identification of the causation of nonsyndromic genetic cardiomyopathies. Recent findings: NGS sequencing of the entire genetic coding sequence (the exome) has successfully identified five novel genes and causative variants for cardiomyopathies without previously known cause within the last 12 months. Continual rapidly decreasing costs of NGS will shortly allow cost-effective sequencing of the entire genomes of affected individuals and their relatives to include noncoding and regulatory variant discovery and epigenetic profiling. Despite this rapid technological progress with sequencing, analysis of these large data sets remains challenging, particularly for assigning causality to novel rare variants identified in DNA samples from patients with cardiomyopathy. Summary: NGS technologies are rapidly moving to identify novel rare variants in patients with cardiomyopathy, but assigning pathogenicity to these novel variants remains challenging.
- The genetics of coronary artery disease Purpose of review: Prevention of coronary artery disease (CAD) is an appropriate goal for the 21st century. Randomized clinical studies consistently show a 30–40% reduction in mortality and morbidity by modifying known risk factors. However, genetic risk, estimated to account for 40–60% of susceptibility to CAD, has until recently been unknown. Comprehensive prevention will require knowledge of both. Recent findings: The 21st century technology has responded to the challenge. Whereas the first genetic risk variant was not discovered until 2007 (9p21), a total of 36 genetic risk factors for CAD have been discovered and verified in large sample sizes. A startling discovery was that over two-thirds of these factors do not act through known risk factors or mechanisms. This obviously has great implications for the pathogenesis of CAD and presents many potential targets for new therapy. These genetic risk factors occur more commonly in the population than expected, with over half of them occurring in more than 50% of the population, and 10 of them occurring in at least 75% of the population. Summary: The role of genetic risk factors in genetic screening for prevention of heart disease is yet to be defined. The technology is already available, but functional analysis may be a prerequisite for their clinical application.
- MicroRNAs and myocardial infarction Purpose of review: We will review the role of microRNAs (miRNAs), small noncoding RNAs with regulatory function, in myocardial infarction (MI). Specifically, we will examine the effect of MI on miRNAs’ expression in the heart, the effect of MI on circulating miRNAs, which miRNAs’ overexpression or downmodulation appears to have a therapeutic role in MI and which cardiac miRNAs are modulated by drugs/experimental molecules/cell transplantation strategies which have an established or potential therapeutic role in MI. Recent findings: A rapidly increasing number of studies are showing that cardiac and circulating miRNAs are markedly altered in MI. These novel findings shed new light on the mechanisms that lead to MI complications, post-MI ventricular remodeling and cardiac repair. Further, recent studies show that circulating miRNAs may represent novel and sensitive biomarkers of MI and, possibly, also an intercellular signaling mechanism. Overexpression and downregulation of specific miRNAs are being evaluated as a novel approach to the treatment of MI. Finally, it appears that some established and potential MI therapies (approved drugs/experimental molecules/cell therapy interventions) may act, at least in part, via modulation of specific miRNAs. Summary: Although miRNAs’ role in MI is still largely uncharacterized, recent studies suggest that miRNAs may represent novel therapeutic targets and MI biomarkers.
- Cardiac connexins, mutations and arrhythmias Purpose of review: Connexins are the pore forming subunits of gap junction channels. They are essential for cardiac action potential propagation. Connexins are modified at the transcriptional or posttranslational levels under pathological states such as cardiac hypertrophy or ischemia, thus contributing to the arrhythmogenic substrate. However, the relation between nucleotide substitutions in the connexin gene and the occurrence of cardiac arrhythmias remains largely unexplored. Recent findings: Recent studies have reported an association between nucleotide substitutions in the connexin40 (Cx40) and connexin43 (Cx43) genes (GJA5 and GJA1, respectively) and cardiac arrhythmias. Of note, however, germline mutations in Cx43 are considered causative of oculodentodigital dysplasia, a pleiotropic syndrome wherein cardiac manifestations are notoriously absent. Summary: Here, we review some of the current knowledge on the association between cardiac connexins and inherited arrhythmias.
- Genetics of ion-channel disorders Purpose of review: In this article, we summarize the main features of the most common inherited channelopathies, focusing on the findings that advanced the field in the last few years. Recent findings: The progress in genetics prompted the discovery of several new genes associated with ion-channel disorders, elucidating new molecular pathways and new arrhythmogenic mechanisms. The diffusion and availability of genetic screening gave a new relevance to the application of genetics not only for diagnosis, but also for risk assessment and therapeutic decisions. As a consequence, the present challenge in the field is represented by the need to use genetic data to develop personalized clinical approaches. Summary: Over a few years, the field of inherited arrhythmogenic diseases has rapidly expanded, thus reshaping clinical management for these conditions. It is now clear that to handle these patients a specialized expertise is needed, able to translate the discoveries derived from basic science studies into the clinical care of the patients.
- Genetic determinants of response to cardiovascular drugs Purpose of review: To survey genetic variation contributing to variable responsiveness and toxicity to important cardiovascular drugs and highlight recent developments in the field of cardiovascular pharmacogenomics and personalized medicine. Recent findings: Previously recognized pharmacogenomic associations with drug efficacy have been further validated (e.g. with clopidogrel and warfarin) and shown to influence clinically important outcomes. The clinical significance of variants modulating toxicity (e.g. SLCO1B1 with simvastatin) has also been confirmed. The genetic contribution to variable efficacy and toxicity of other important classes of cardiovascular drugs, such as beta-blockers, is becoming increasingly recognized. Prospective trials testing whether the use of genomic information improves clinical care are underway. Guidance based on the most well-established pharmacogenomic findings has appeared in prescribing labeling and is in the early stages of being implemented into routine clinical care. Summary: Clinically validated gene variants that modulate responsiveness to cardiovascular drugs continue to be discovered and validated. Early steps are underway to translate these discoveries into clinical care.
Congenital Heart Disease
- Longevity of Neonatal Ductal Stenting for Congenital Hear... Introduction. Ductal stent (DS) in duct-dependent pulmonary circulation is less morbid than neonatal Blalock–Taussig shunt. However, there is concern if DS provides an adequately long palliation before definitive repair.Methods. This is a retrospective review of clinical follow-up of all consecutive infants after successful DS performed by a single operator. They were divided into three anatomic groups. Group A neonates had balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum, who needed DS patency until the right ventricle was adequate to provide antegrade pulmonary flows. Group B patients with tetralogy of Fallot and pulmonary atresia suited for later biventricular repair needed ductal patency until conduit surgery was completed. Group C patients with functionally univentricular hearts needed DS patency until bidirectional Glenn shunt completion.Results. Among 22 infants, four Group A patients followed for 26–54 months after balloon pulmonary valvotomy had adequate oxygen saturation and needed only short-term DS patency. In six out of nine Group B patients, corrective biventricular repair using conduits was performed after 5–14 months at a body weight of 5–7.5 kg. Bidirectional Glenn shunt and confluence repair were performed in seven of nine Group C patients weighing 6–8.5 kg after 8–15 months. The hilar pulmonary artery growth in B and C groups was adequate for surgical repair. No patient needed stent redilatations or additional shunts on follow-up for hypoxia. Four patients had sudden death.Conclusions. The short-term patency of DS was adequate after balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum. Duration of palliation by DS was also sufficient in univentricular hearts to allow adequate somatic growth before Glenn surgery. In patients with biventricular anatomy treated by DS, conduit repair had to be performed at a relatively early age. Interstage mortality was 18%.
- Vascular and Autonomic Function in Preschool-aged Childre... Objective. To compare indices of vascular health and heart rate variability in preschool-aged children with repaired congenital heart disease (CHD) including tetralogy of Fallot (n = 6) and coarctation of the aorta (n = 6).Design. A cross-sectional study design was used. All measures were noninvasive and collected over a single testing session under the supervision of a parent/guardian.Setting. Data collection took place in a quiet, temperature-controlled room (23°± 1°C) with the participant in a supine position.Patients. Twelve (six females, six males) preschool-aged children with repaired CHD (CHD: 4 ± 1 years) and 12 age- and gender-matched healthy controls (CON: 5 ± 1 years) participated in the study.Outcome Measures. Supine, resting measures of heart rate variability (time, frequency, and nonlinear domains), whole-body pulse wave velocity (ventricular depolarization to dorsalis pedis artery), brachial blood pressures, and carotid artery distensibility, lumen diameter, intima-media thickness, and wall/lumen ratio were collected in both groups.Results. The groups were similar in age, height, and weight; however, CON had significantly higher body mass index values (CON: 16.9 ± 2.2, CHD: 15.1 ± 1.0, P .05). Carotid artery pulse pressures (CHD: 38 ± 6 mm Hg, CON: 31 ± 6 mm Hg, P < .05) and wall/lumen ratios (CHD: 0.091 ± 0.007, CON: 0.085 ± 0.006, P < .01) were significantly higher in the CHD group.Conclusions. These results may indicate that preschool-aged children with repaired CHD display early signs of vascular remodeling, but not autonomic or vascular dysfunction. The effects of larger wall/lumen ratios on cardiovascular disease risk require further investigation.
- Spontaneous Termination of Ventricular Fibrillation in a ... Sudden death is common in patients with congenital coronary artery anomalies mainly when the left main coronary artery originates from the right coronary sinus. Ventricular fibrillation in these patients is irreversible unless defibrillation can be rapidly performed.We describe a 57-year-old male with an anomalous origin of circumflex and the left anterior descending coronary arteries from the right coronary sinus. He developed two episodes of ventricular fibrillation that terminated spontaneously, 10 hours after percutaneous revascularization of the circumflex coronary artery.Computed tomography angiography, in addition to confirming the anomalous origin of the coronary arteries, showed a muscle bridge over the midportion of the left anterior descending coronary artery. This is the first report of spontaneous termination of ventricular fibrillation in a patient with congenital anomaly of the coronary arteries.
- Urinary Interleukin-18 and Urinary Neutrophil Gelatinase-... Background. It is becoming increasingly recognized that manifestations of congenital heart disease (CHD) extend beyond the cardiovascular system. The factors contributing to renal dysfunction in patients with CHD are multifactorial, with acute kidney injury (AKI) at time of cardiac surgery playing a major role. AKI is often diagnosed based on changes in serum creatinine and estimated glomerular filtration rate (eGFR). Such measurements are often late and imprecise. Recent data indicate that urinary biomarkers interleukin-18 (IL-18) and neutrophil gelatinase-associated lipocalin (NGAL) are earlier markers of AKI. We sought to determine the efficacy of urinary IL-18 and NGAL for detecting early AKI in patients undergoing surgical pulmonary valve replacement (PVR).Methods. Twenty patients presenting for surgical PVR with a history of previous repair of a conotruncal anomaly were enrolled. Preoperative clinical data were measured and urine samples and serum creatinine were collected at 6, 12, 24, and 72 hours post bypass. Urine was evaluated for NGAL and IL-18. AKI was determined using the Risk, Injury, Failure, Loss and End Stage Renal Disease (RIFLE) classification system.Results. Using the RIFLE classification system, seven patients (35%) were found to have AKI defined as a drop in the eGFR or an increase in serum creatinine. All seven patients with AKI had marked increase from preoperative baseline in urine IL-18 (sixfold) and NGAL (26-fold). Using NGAL and IL-18, AKI was detected at 6 hours postoperatively, resulting in AKI being identified 12–36 hours prior to detection by conventional methods. No preoperative predictors for AKI were identified.Conclusion. Both NGAL and IL-18 are early predictive biomarkers of AKI, and both increase in tandem after surgical PVR. Importantly, both rise before an increase in creatinine or a decrease in eGFR is present. Monitoring both biomarkers may allow for earlier detection and subsequent interventions to prevent AKI at time of surgery for CHD.
- Congenital Quadricuspid Pulmonary Valve in an Adult Patie... The quadricuspid pulmonary valve (QPV) is a rare congenital anomaly reported in the general population. There are less than 300 reported cases in the literature to date. It has been found in one in 400 to one in 2000 autopsies. We describe here the case of a 47-year-old patient who presents with a QPV with double valvular lesions (stenosis and insufficiency), causing a poststenotic dilatation of the trunk and the left branch of the pulmonary artery (PA).The diagnosis was made by transesophageal echocardiography (TEE) and confirmed by tomographic angiography (computed tomography). The English as well as the Spanish literature were reviewed.To the best of our knowledge, this is the first case of: (1) congenital QPV with double valvular lesions (stenosis and insufficiency), complicated with (2) aneurysmatic dilatation of the PA trunk as well as left branch, and (3) diagnosed by a TEE.
- Neonatal Myocardial Infarction: Case Report and Review of... Myocardial infarction in a neonate is rare. We describe the case of a full-term male who presented with respiratory distress. A chest radiograph demonstrated cardiomegaly. An electrocardiogram revealed ST segment changes suggestive of ischemia. Cardiac enzymes were elevated and an echocardiogram revealed a regional wall motion abnormality. Cardiac catheterization was performed demonstrating occlusion of the ramus intermedius branch of the left main coronary artery. The patient decompensated, requiring extracorporeal membrane oxygenation (ECMO). The infant was able to be decannulated from ECMO support in 5 days and was ultimately discharged on hospital day 25. We review this case as well as the literature on neonatal myocardial infarction.
- The Potential to Avoid Heart Transplantation in Children:... Pediatric mechanical circulatory support has evolved considerably in the past decade. Improvements in device design and availability have led to increased short-, medium-, and long-term support options for pediatric patients with heart failure. Most pediatric mechanical circulatory support is utilized as a bridge to transplant and as a bridge to recovery in patients with temporary etiologies of heart failure (i.e., myocarditis). Described herein is our recovery program, and we report our experience as an independent pediatric ventricular assist device program with an intracorporeal continuous-flow device employed as an out-of-hospital bridge to recovery for a child with end-stage chronic heart failure.
- Electrophysiology Procedures in Adults with Congenital He... Background. In adult congenital heart disease (CHD), arrhythmias contribute significantly to morbidity and mortality. Often, these adult patients are treated at a freestanding pediatric facility. Limited data exist looking at this cohort.Methods. A retrospective review was performed of all electrophysiology (EP) procedures performed in adults at our institution during a 5-year period from January 1, 2006 through December 31, 2010.Results. There were 99 cases performed in a total of 87 adults with CHD during this time period. The mean patient age was 27.1 years (18–51 years). The most common congenital cardiac diagnoses were: 27% with D-transposition of the great arteries (n = 27)—of which 85% (n = 23) have had a previous atrial switch procedure, 20% with tetralogy of Fallot (n = 20), and 16% with previous Rastelli repair (n = 16). Overall, 37 EP studies were performed, with the majority done in patients with complex CHD. There were 74 additional cases. These procedures consisted of: 38 pacemakers (51%), 26 implantable cardiac defibrillators (36%), six laser lead extractions (8%), two loop recorders (3%), and two pocket revisions (3%). During this 5-year period, there was one major complication (1%) and seven minor complications (7%).Conclusions. The complex care of adults with CHD requiring EP procedures can be safely and effectively accomplished in a freestanding pediatric hospital with low complications, provided institutional support of an adult CHD program.
- The Presentation and Diagnosis of Coronary Allograft Vasc... One of the most important causes for long-term graft failure in pediatric heart transplant recipients is coronary allograft vasculopathy (CAV). Graft survival is approximately 50% at 5 years postdiagnosis of CAV. CAV can be difficult to detect largely because of its variability in presentation and in the definition of CAV. Making the diagnosis of CAV can be challenging, and to date, the current gold standard test is angiography, which is an expensive and invasive procedure. A number of studies in the pediatric and adult heart transplant literature exist for noninvasive methods of diagnosing CAV, ranging from biochemical markers and echocardiographic techniques to computed tomography and magnetic resonance imaging. In addition, there is evidence to show that hemodynamic and function evaluation of the coronary arteries in transplanted patients may provide diagnostic clues to the potential development of CAV. These methodologies add to the armamentarium that can compliment angiography for the purposes of diagnosis. Clinical suspicion for CAV should be heightened in patients who have had recurrent rejection, new onset arrhythmias, unexplained recurrent chest or abdominal pain, and/or the development of systolic or diastolic dysfunction in the absence of rejection. This review strives to highlight the current literature with respect to the investigations available for the diagnosis of CAV, recognizing that our understanding of this disease process is still currently in evolution.
- Finding the “PR-fect” Solution: What Is the Best Tool... In the absence of structural heart disease, the great majority of cases with complete congenital heart block will be associated with the maternal autoantibodies directed to components of the SSA/Ro—SSB/La ribonucleoprotein complex. Usually presenting in fetal life before 26 weeks' gestation, once third-degree (complete) heart block develops, it is irreversible. Therefore, investigators over the past several years have attempted to predict which fetuses will be at risk for advanced conduction abnormalities by identifying a biomarker for less severe or incomplete disease, in this case, PR interval prolongation or first-degree atrioventricular block. In this state-of-the-art review, we critically analyze the various approaches to defining PR interval prolongation in the fetus, and then analyze several clinical trials that have attempted to address the question of whether complete heart block can be predicted and/or prevented. We find that, first and foremost, definitions of first-degree atrioventricular block vary but that the techniques themselves are all similarly valid and reliable. Nevertheless, the task of predicting those fetuses at risk, and who are therefore candidates for treatment, remains challenging. Of concern, despite anecdotal evidence, there is currently no conclusive proof that a prolonged PR interval predicts complete heart block.
Coronary Artery Disease
- How to interpret epicardial adipose tissue as a cause of ... Background: Experimental and clinical studies have suggested that epicardial adipose tissue (EAT) may cause coronary artery disease (CAD). A meta-analysis was conducted to investigate the relationship between EAT and CAD. Methods: A systematic literature search of Cochrane, Medline, Pubmed, Elsevier, Springerlink, Ovid, and Embase from their respective inceptions to August 2011 was conducted using specific search terms such as ‘epicardial adipose tissue’ and ‘epicardial fat’. Data were extracted from applicable articles and mean differences or risk ratio, including 95% confidence intervals (CI), were calculated using RevMan 5.1 software. Results: A total of 15 case–control studies and one case-sectional study (N=2872 patients) were identified. Compared with the non-CAD group, EAT thickness and volume were significantly higher in the CAD group (mean difference 1.57 mm, 95% CI: 0.74, 2.40, P<0.00001; mean difference 15.22 ml, 95% CI: 7.58, 22.87, P<0.0001). Patients in the higher EAT tertile (≥100 ml) were more likely to have CAD compared with those in the lower EAT tertile (<100 ml) (risk ratio 0.69, 95% CI: 0.52, 0.92, P=0.01). Patients with coronary plaque also had increased EAT volume compared with patients without coronary plaque (mean difference 24.90 ml, 95% CI: 9.99, 39.81 P=0.001). EAT volume was not different in patients whose coronary artery calcium scores were less than or equal to 10 or greater than 10 (mean difference −17.28 ml, 95% CI: −52.01, 17.44, P=0.33). Conclusion: On the basis of the current evidence, EAT seems to be an effective marker in the prediction of CAD.
- Analytical evaluation of plasma serotonin and sphingosine... Objectives: Serotonin stored in platelets is released into plasma on aggregation and activation in atherosclerotic diseases. Sphingosine 1-phosphate (S1P) in plasma is mainly derived from red blood cells and is responsible for the production of nitric oxide in endothelial cells and protects vasculature. The purpose of this study was to investigate the plasma levels of serotonin, S1P, and their clinical relationships with vascular endothelial function in patients with early atherosclerosis. Methods: Blood was withdrawn from patients with low-to-moderate risks of atherosclerotic diseases (n=49, 39±7 years). Platelet-poor plasma was immediately centrifuged. Serotonin levels in plasma were measured with high-performance liquid chromatography. S1P levels in plasma were measured by high-performance liquid chromatography after fluorescent derivatization with o-phthaldialdehyde. Endothelial function was assessed by endothelium-dependent flow-mediated dilation (FMD) and endothelium-independent dilation was measured by glycerol trinitrate-induced dilation using an ultrasound system. Results: Plasma serotonin was inversely correlated with the FMD value (r=−0.287, P<0.05). Fourteen patients with dyslipidemia, who had not shown improvements after lifestyle modifications, were subsequently treated with rosuvastatin (2.5 mg/day). After 4 weeks of treatment, rosuvastatin improved lipid profiles. Rosuvastatin increased FMD, whereas glycerol trinitrate-induced dilation was unchanged. Notably, percentage decrease in plasma serotonin was inversely correlated with percentage increase in plasma S1P (r=−0.557, P<0.05). Conclusion: Plasma serotonin was inversely correlated with FMD and a decrease in plasma serotonin was inversely correlated with an increase in plasma S1P after statin treatment. The results suggested that plasma levels of serotonin and S1P may be useful for the assessment of endothelial function of patients with low-to-moderate risks of atherosclerotic diseases.
- Impacts of conventional coronary risk factors, diabetes a... Objective: Patients with diabetes mellitus (DM) and hypertension (HT) are at a high risk of coronary artery disease. However, the mechanisms underlying this have not been well characterized. The purpose of the present study was to evaluate the impacts of DM and HT on coronary atherosclerosis during statin therapy. Materials and methods: The effects of 8-month statin therapy on coronary atherosclerosis were evaluated in the TRUTH study using virtual histology intravascular ultrasound. Analyzable intravascular ultrasound data were obtained from 119 patients who were divided into four subgroups, namely, group A: DM (+), HT (+); group B: DM (+), HT (−); group C: DM (−), HT (+); and group D: DM (−), HT (−). The pattern of arterial remodeling, extent of coronary atherosclerosis, and plaque composition were compared among the four subgroups. Results: Atheroma volume decreased significantly in group D (−3.9%, P=0.01), whereas it tended to increase in group A (1.0%, P=0.77). A significant difference in the mean percent change of atheroma volume was observed between groups A and D (1.0 vs. −3.9%, P=0.03). Furthermore, the frequency of progression in atheroma volume was significantly higher in group A (60, 33, 45, and 24% in groups A, B, C, and D, respectively; P=0.03). No significant differences in the changes in the four plaque components among the four subgroups were observed. Conclusion: A combination of DM and HT attenuates the degree of regression of coronary atherosclerosis, but does not influence changes in plaque composition during statin therapy.
- Ischemic postconditioning through percutaneous translumin... Background: Ischemic postconditioning (IPOC) has been suggested to reduce ischemic reperfusion injury. It remains unclear whether the activation of phosphatidylinositol 3 kinase (PI3K)/Akt is a causal mechanism in the cardioprotection afforded by IPOC, which was examined in the model of percutaneous transluminal coronary angioplasty (PTCA) minipigs. Methods and results: Minipigs underwent 45-min occlusion of the left anterior descending artery and 24-h reperfusion by PTCA. Postconditioning was elicited by three cycles of 30-s reperfusion followed by 30-s ischemia at the onset of reperfusion. Infarct size was determined by triphenyl tetrazolium chloride staining after 24-h reperfusion, and mRNA and protein expression levels of PI3K were ascertained by reverse transcriptase-PCR and western-blot analysis in biopsies. Infarct size was significantly reduced and myocardial PI3K (Akt and GSK-3β) phosphorylation was significantly increased with IPOC treatment compared with ischemic reperfusion. The administration of the PI3K inhibitor wortmannin (30 µg/kg) attenuated the protection of IPOC in the infarct size and decreased the expression of Akt and GSK-3β phosphorylation compared with IPOC. IPOC had no impact on mRNA expression of AKT and GSK-3β. Conclusion: Our findings show that IPOC is capable of protecting the myocardium against IR injury in the PTCA minipig model. The PI3K/Akt-signaling pathway is involved in the cardioprotective effect of IPOC.
- Serum myeloperoxidase is independent of the risk factors ... Objectives: The main hypothesis of the study was that as serum myeloperoxidase (MPO) concentration is known to indicate the progression of the atherosclerotic process, MPO may be associated with common risk factors of atherosclerosis. Therefore, the presence of these risk factors (especially elevated glucose and lipid concentrations) should predict an increased MPO level during the subsequent months. We also hypothesized an association of MPO with markers of other chronic diseases involving inflammation. Methods: Fifty-three patients with ischemic heart disease were followed for 24 weeks by biweekly visits, during which the basic MPO level was measured (500 measurements in total, 2–12 per patient). The association of the patients’ typical MPO with the risk factors of atherosclerosis and other personal determinants was examined by trend analysis and analysis of variance. Results: MPO was statistically significantly associated with blood leukocyte, neutrophil, and lymphocyte concentrations of the patients (P=0.001–0.003). MPO was also associated with high-sensitivity C-reactive protein (P=0.02). MPO was not associated with markers of lipid and glucose metabolism, of atherosclerosis, or of other chronic diseases. Conclusion: Contradictory to our hypotheses, the results indicate that the serum MPO level is independent of the commonly measured risk factors of atherosclerosis and markers of other chronic diseases. Consequently, the findings suggest that MPO-related acute pathologic events (such as plaque destabilization) are not associated with the preceding glucose or lipid values. However, the results support the third hypothesis and previously reported view that MPO is a marker of inflammation in patients of ischemic heart disease.
- Brain natriuretic peptide in apical ballooning syndrome (... Objectives: Apical ballooning syndrome (ABS) is a transient cause of ventricular dysfunction. The aim of this study was to determine the clinical and hemodynamic correlates of brain natriuretic peptide (BNP) levels in ABS and compare the biomarker profiles in ABS with acute myocardial infarction controls. Methods: Fifty-seven prospectively diagnosed patients with ABS whose BNP and troponin T level measurements were available were included. Fifty patients with ST-elevation myocardial infarction (STEMI) and 25 individuals with non-ST-elevation myocardial infarction (NSTEMI) were included as matched controls. Results: In the ABS cohort, the BNP levels were higher in patients older than 65 years compared with younger individuals: 767 (269, 951) versus 340 (131, 904.5), P=0.019. There were no significant correlations between BNP levels and hemodynamic parameters such as left ventricular ejection fraction and end diastolic pressure. There were no correlations between BNP and peak troponin T (r=0.03, P=0.8). BNP levels were significantly higher in ABS patients when compared with the STEMI and NSTEMI controls. The BNP to peak troponin T ratio was significantly higher in ABS compared with the STEMI controls 1089.4 (446.7, 3334.8) versus 97.4 (17.9, 264.7), P=0.04. Conclusion: BNP elevation is almost universal in ABS. Cardiac hemodynamic indices do not correlate with BNP levels. The magnitude of BNP elevation is higher in ABS compared with STEMI and NSTEMI.
- Intrarenal application of N-acetylcysteine for the preven... Objective: Contrast medium-induced nephropathy (CIN) is a well-known complication of coronary angiographic procedures, especially in patients treated with primary angioplasty. To prevent CIN, we examined using a local application of N-acetylcysteine (NAC) for the prevention of CIN during primary angioplasty. We hypothesized that a local application of NAC into the renal arteries would provide the benefit of a higher local concentration, lower first-pass metabolism, and faster efficacy. To evaluate the effects of NAC by the intrarenal route, we performed a prospective, randomized clinical study in patients with acute myocardial infarction treated with primary angioplasty. Methods: Participants were 312 patients with ST-segment elevation myocardial infarction undergoing primary angiography. Eligible patients were randomly assigned to receive intravenous NAC, intrarenal NAC, or placebo. Results: Overall, CIN occurred in 74 (23.7%) of the 312 patients. The rate of CIN was 25% in the intravenous NAC group, 22.9% in the intrarenal NAC group, and 23.2% in the placebo group, with no significant effect seen for either treatment (P=0.64). We did find a significant correlation between CIN and ejection fraction (P=0.05) and baseline renal function (P=0.01). Conclusion: Both intrarenal and intravenous applications of NAC failed to show any benefit over placebo in the prevention of CIN. This result shows that NAC application does not have any prophylactic effect, dose dependent or otherwise, on CIN, as previously reported. Our results suggest that more attention should be paid to optimize hemodynamic variables for the prevention of CIN.
- Differences in cardiovascular risk factors and clinical o... Objective: Percutaneous coronary interventions (PCIs) are increasingly being performed worldwide to treat patients with coronary artery disease. However, studies on the influence of ethnicity on clinical outcomes after PCI are scarce. In our current analysis, we evaluate the differences in baseline clinical, angiographic and procedural characteristics, and 12-month clinical outcomes in patients undergoing nonurgent PCI in Western Europe and in Asia. Methods: We analyzed all patients enrolled in the worldwide e-HEALING (electronic Healthy Endothelial Accelerated Lining Inhibits Neointimal Growth) registry living in Western Europe and Asia. All patients were treated with at least one endothelial progenitor cell capturing stent. The main study outcome was target vessel failure at the 12-month follow-up, defined as the composite of cardiac death or myocardial infarction and target vessel revascularization. Results: A total of 3504 patients, 2873 living in Western Europe and 731 living in Asia, were assessed in the current analysis. Almost all of the baseline clinical and angiographic characteristics differed significantly between both populations. Target vessel failure at the 12-month follow-up occurred in 11.4% of the Western Europe patients and in 5.6% of the Asian patients (P<0.01). Conclusion: We conclude that differences exist in the baseline, angiographic, and procedural characteristics between Western European and Asian patients undergoing nonurgent PCI. In addition, the 1-year clinical outcomes differ significantly after PCI between Western European and Asian patients. Our results indicate that reports from studies performed worldwide should include both overall and regional subgroup outcomes.
- Candesartan improves impaired endothelial function in the... Background: Endothelial dysfunction is closely related to cardiovascular events. Several studies have documented that angiotensin II type 1 receptor blockers (ARB) improve peripheral endothelial dysfunction. However, the effect of ARB on coronary endothelial function remains elusive. The purpose of this study was to ascertain the beneficial effects of ARB on human coronary artery endothelial function. Methods and Results: Twenty-seven patients were randomly assigned to either the candesartan group (n=14) or the control group (n=13) and followed for 12 months. Coronary blood flow velocity was measured in the left anterior descending artery without stenosis using an intracoronary Doppler-tipped guide-wire. We evaluated coronary endothelial function as the coronary blood flow velocity reserve (CFR), which was defined as the percent change in the coronary blood flow velocity after an intracoronary acetylcholine infusion. At baseline, the CFR in both groups was below 300%, implying that these patients had endothelial dysfunction. After treatment with candesartan for 6 months, the CFR increased significantly from 199±20 to 337±27% (P<0.001), whereas the CFR did not change in the control group (194±32 vs. 185±41%, P=0.52). During 12 months of observation, the cardiovascular event-free survival rate of the patients with an increased CFR was significantly greater than the rate in patients with a decreased CFR (P=0.02). Moreover, the cardiovascular event-free survival rate was greater in the candesartan group than in the control group (P=0.04). Conclusion: Our results suggest that candesartan improves coronary endothelial dysfunction of human coronary arteries and may prevent cardiac events.
- Safety and efficacy of transradial versus transfemoral pe... Background: The transradial approach has gained increasing popularity for elective percutaneous coronary intervention. However, the safety and feasibility of transradial coronary intervention (TRI) in acute myocardial infarction (AMI) remains uncertain. Hence, a meta-analysis of randomized trials was performed to compare outcomes of TRI with transfemoral coronary intervention (TFI) in patients with AMI. Methods: A systematic review of the literature revealed seven randomized trials involving 1306 patients. Endpoints extracted were access site complications, major adverse cardiovascular events, major bleeding, and procedural success. Combined relative risks (RRs) across all studies and 95% confidence intervals (CIs) were computed. A two-sided α error of less than 0.05 was considered to be statistically significant. Results: Baseline characteristics were similar in both groups. Compared with patients undergoing TFI, risk of major adverse cardiovascular events (RR: 0.83, CI: 0.51–1.35; P=0.45) and major bleeding (RR: 0.51, CI: 0.20–1.26; P=0.14) was similar in patients undergoing TRI. The procedural success was similar with both approaches (RR: 0.99, CI: 0.96–1.02; P=0.59). However, incidence of access site complications was significantly lower in the TRI group (RR: 0.31, CI: 0.17–0.58; P<0.001). Conclusion: The meta-analysis suggests that TRI may be superior to TFI in reducing access site complications in patients with AMI. However, there is no difference in procedural success and major bleeding between the two groups.
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- #141: Pfizer stops promoting Lipitor in US; moderate coff... Pfizer stops promoting Lipitor in US; moderate coffee intake protects against stroke; MagnaSafe: MRI with pacers, ICDs: Safe, a few minor issues; FAME II: FFR pinpoints stable CAD patients who fare worse with OMT; whistleblower suit implicates Nissen, Cle
- #6: What's new in acute pericarditis with Dr Jae Oh Dr Jae Oh, professor of medicine and director of cardiac imaging and the pericardial diseases clinic at Mayo, joins Dr Bernard Gersh for an update on the latest on acute pericarditis.
- #140: Ideal blood-pressure goals? "We have no idea"; more... Ideal blood-pressure goals? "We have no idea"; more adverse events seen on dabigatran vs warfarin; WHF defends Dubai WCC, reimburses Israelis denied visas; Roche stops dalcetrapib trial; bypass moderate coronary lesions? taking sides in the debate
- #139: CHA2DS2-VASc score gives best prediction of stroke ... CHA2DS2-VASc score gives best prediction of stroke risk in AF; subcutaneous ICD: thumbs up from FDA; DES or bare-metal stents for primary PCI?; beware valve involvement in device-related infective endocarditis; CMS restricts TAVI coverage to experie
- #5: Diagnosis and treatment of heart failure with preserv... Dr Bernard Gersh talks to Dr Barry Borlaug about the intricacies of diagnosis and treatment of heart failure with preserved ejection fraction (HFPEF), traditionally known as diastolic heart failure.
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Journal of Interventional Cardiac Electrophysiology
- Pacing polarity and left ventricular mechanical activatio... Abstract Objective The aim of this study is to evaluate the relationship between polarity of left ventricular (LV) pacing and the resultant regional, global, and transmural mechanical sequence of contraction. Background Cardiac resynchronization therapy (CRT) is widely utilized in patients with drug refractory congestive heart failure with systolic dysfunction (EF <35 %) and intraventricular conduction delay (QRS duration >120 ms). However, little is known about polarity of pacing stimulation and the resultant differences in LV mechanics. Methods The polarity of pacing was altered sequentially in 20 patients (73 ± 13, 16 males) with preexisting biventricular devices with potential choice of multiple vectors for pacing stimulation. Initial unipolar or extended bipolar configurations were switched to bipolar configuration or vice versa, and echocardiographic images were acquired for off-line analysis. Regional and global LV longitudinal and radial mechanics were assessed selectively from the subendocardial and subepicardial regions with 2D speckle-tracking echocardiography. Left ventricular capture by each vector configuration was confirmed by local lead capture and appropriate QRS alteration. Results Unipolar pacing resulted in increased dispersion of LV regional endocardial strains with a higher base-to-apex gradients of longitudinal shortening strains (P < 0.05). LV longitudinal shortening strain magnitude was higher at LV base with bipolar stimulation in comparison with unipolar stimulation (−10.5 ± 10.5 vs. −4.2 ± 6.3, P = 0.02). Conclusion There is a difference in the mechanical activation sequence of the LV between unipolar vs. bipolar pacing stimulation. This may have important implications for CRT. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9686-1Authors Hyan Suk Yang, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAGiuseppe Caracciolo, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAPartho P. Sengupta, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USARamil Goel, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAKrishnaswamy Chandrasekaran, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAKomandoor Srivathsan, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Canine left ventricle electromechanical behavior under di... Abstract Background Cardiac resynchronization therapy may improve survival and quality of life in patients suffering from heart failure with left ventricular (LV) contraction dyssynchrony. While several studies have investigated electrical or mechanical determinants of synchronous contraction, few have focused on activation contraction coupling at a macroscopic level. Objective The objective of the study was to characterize LV electromechanical behavior and response to pacing in a heart failure model. Methods We analyzed data from 3D electroanatomic non-contact mapping and blood pool SPECT for 12 dogs with right ventricular (RV) tachycardia pacing-induced dilated cardiomyopathy. Surfaces generated by the two modalities were registered. Electrical signals were analyzed, and endocardial wall displacement curves were portrayed. Results Rapid pacing decreased the mean LV ejection fraction (LVEF) to 20.9 % and prolonged the QRS duration to 79 ± 10 ms (normal range: 40–50 ms). QRS duration remained unchanged with biventricular pacing (88.5 ms), while single site pacing further prolonged the QRS duration (113.3 ms for RV pacing and 111.6 ms for LV pacing). No trend was observed in LV systolic function. Activation duration time was significantly increased with all pacing modes compared to baseline. Finally, electromechanical delay, as defined by the delay between electrical activation and mechanical response, was increased by single site pacing (172.9 ms for RV pacing and 174.6 ms for LV pacing) but not by biventricular pacing (162.4 ms). Conclusions Combined temporal and spatial coregistration electroanatomic maps and baseline gated blood pool SPECT imaging allowed us to quantify activation duration time, electromechanical delay, and LVEF for different pacing modes. Even if pacing modes did not significantly modify LVEF or activation duration, they produced alterations in electromechanical delay, with biventricular pacing significantly decreasing the electromechanical delay as measured by surface tracings and endocardial non-contact mapping. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-010-9532-2Authors Thanh-Thuy Vo Thang, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaBernard Thibault, Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, CanadaVincent Finnerty, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaMatthieu Pelletier-Galarneau, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaPaul Khairy, Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, CanadaJean Grégoire, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaFrançois Harel, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Reuse of infected cardiac rhythm management devices in th... Abstract Purpose Infected device explantation is increasingly necessary given the rapid growth in cardiac rhythm management device (CRMD) implantation in China. However, some patients with CRMD infection are unlikely to be capable of paying for a new device. Reassuringly, evidence suggests that reuse of cardiac devices can be safe and feasible. In this study, we evaluated whether explanted cardiac devices, due to infection, can be reimplanted safely within the same individuals. Methods All patients with CRMD infection between 2007 and 2010 were entered into a computer database. From these, patients that had need for CRMD implantation and reimplantation of their infected device were analyzed for safety and complications. Results Sixty patients had CRMD implantation after the infected device removal, and 44 (73.3 %) patients underwent procedures for reimplantation of their infected device. The mean age of the patients was 64.8 ± 16.5 years, and 32 (72.7 %) were male. Indications for device explantation were: pocket infection (86.6 %) and endocarditis (11.4 %). The average follow-up was 20.4 ± 9.0 months. Endocarditis recurred in one (2.3 %) patient with Brugada syndrome at 17 months after reimplantation of a refurbished implantable cardioverter-defibrillator. There were three deaths during the follow-up period secondary to myocardial infarction and cerebral vascular accident. No early battery depletion or device malfunction was identified during follow-up. Conclusions Our data emphasize that reimplantation of explanted CRMDs, due to infection, within the same individual is feasible, safe, and effective. Reuse of explanted CRMDs is an alternative choice for people in developing countries. Content Type Journal ArticlePages 1-6DOI 10.1007/s10840-012-9688-zAuthors Duan Jiangbo, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaLI Xuebin, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaZhang Ping, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaWang Long, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaLi Ding, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaChu Xianming, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, ChinaZe Feng, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaFang Yong, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaYuan Cuizhen, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaGuo Jihong, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, China Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Gender differences in accessory connections location: an ... Abstract Background Recent studies have shown that the pathogenesis of accessory connections (AC) formation may have a genetic component. Objective The purpose of the study was to examine whether AC location differs by gender in a large cohort of patients with AC undergoing radiofrequency ablation (RFA) in two Israeli electrophysiology (EP) laboratories. Methods All consecutive patients who underwent RFA of single ACs in Tel Aviv Sourasky Medical Center between 1992 and 2009 (n = 574) as well as the first consecutive 230 patients who underwent RFA in Sheba Medical Center between 1992 and 2001 were included in this study. Results The 804 patients in the two centers included 511 males (63.6 %) and 293 (36.4 %) females, mean age 34 + 16 years old. The AC was located in the left free wall, posteroseptal, right free wall, right anteroseptal, and in other areas in 57.8, 22.8, 9.3, 7 and 3.1 % of patients, respectively. The anatomical AC distribution was similar in the two EP laboratories. A right free wall location was more frequent in females (13 %) than in males (7.2 %; p = 0.008). A right anteroseptal location was more frequent in males (8.4 %) than in females (4.4 %) (p = 0.043). The left free wall and posteroseptal locations were similarly encountered in males (58.1 and 23.1 %, respectively) and in females (57.3 and 22.2 %, respectively). Conclusions In our Israeli population, females more commonly have right free wall ACs and males more commonly have right anteroseptal ACs. These findings support the possible role of a genetic component in the pathogenesis of AC formation. Content Type Journal ArticlePages 1-3DOI 10.1007/s10840-012-9683-4Authors Edo Y. Birati, Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelMichael Eldar, Leviev Heart Center, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelBernard Belhassen, Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Ablation of atrial tachycardia occurring after catheter a... Abstract Objective The purpose of this study is to investigate the mechanism and the effectiveness of ablation of atrial tachycardia (AT) recurring after atrial fibrillation (AF) ablation in patients with rheumatic valvular disease (RVD) and mitral valve prosthesis. Methods Twenty-eight consecutive patients with RVD and mitral valve prosthesis and a 1:2 matched control group (n = 56) without RVD underwent reablation for recurrent AT after catheter ablation of long-standing persistent AF. Results Macro- or localized reentrant ATs were identified in 47 (87 %) of 54 ATs from RVD group and in 65 (78.3 %) of 83 ATs from control. There were more average ATs per patient in the RVD group than in the control (1.9 ± 0.6 vs.1.5 ± 0.6, P = 0.002). The proportion of patients having ≥2 ATs was significantly higher in the RVD group than in the control (78.6 vs.41.1 %, P = 0.001). In the RVD group, ATs were successfully ablated in 44 (81.5 %) of 54 ATs and terminated in 18 (64.3 %) of 28 patients. In the control, ATs were successfully ablated in 72 (86.7 %) of 83 ATs and terminated in 45 (80.4 %) of 56 patients, P = 0.54 and 0.10, respectively. After a mean follow-up of 13 months, 16 patients (57.1 %) from the RVD group and 45 patients (80.4 %) from the control were free of further recurrence, P = 0.02. Conclusions Macro- or localized reentries were the predominant type of recurrent AT after long-standing persistent AF ablation in both the RVD and the control groups. Compared with patients without RVD, patients with RVD had more average number of ATs and had higher probability of further recurrence despite the similar acute effectiveness of reablation. Content Type Journal ArticlePages 1-12DOI 10.1007/s10840-012-9678-1Authors Xin-hua Wang, Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China 430060Cong-xin Huang, Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China 430060Xu Liu, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaHai-feng Shi, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaHong-wei Tan, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaWei-feng Jiang, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaYuan-long Wang, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, China Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Post-ablation prolongation of atrioventricular nodal refr... Abstract Purpose A residual slow pathway after successful cryoablation for atrioventricular nodal reentrant tachycardia (AVNRT) is correlated with a higher recurrence rate. We described determinants of recurrence in subjects with a residual jump. Methods We analyzed the data of subjects with acute successful slow pathway cryoablation for AVNRT using a 6-mm-tip cryocatheter. Success was defined as AVNRT non-inducibility. Patients with no baseline elicitable jump, no inducible AVNRT, and transient first atrioventricular (AV) block at the last site were excluded. Results From 371 patients who underwent cryoablation from May 2002 to March 2011, 303 fulfilled the entry criteria (mean age, 41 ± 16; 222 women). Baseline AV nodal effective refractory period (ERP) was 272 ± 57 ms, postprocedural 331 ± 64 (P < 0.001), and the mean of the difference (Δ ERP) 60 ± 41. At the end of the procedure, 64 patients (21 %) had a residual jump, of whom 22 with a single echo. At 12 months follow-up, the actuarial recurrence-free rate was 70.3 % in patients with a residual jump and 86 % in those without (P = 0.01). In patients with a jump, only Δ AV nodal ERP was correlated with recurrence (37 ± 41 vs. 68 ± 47 ms; P < 0.04) while a single echo was not. The actuarial rate of recurrence was 60.8 % in patients with a Δ AV nodal ERP ≤ 30 ms and 18.8 % in those with a Δ AV nodal ERP >30 ms (P < 0.01). Conclusions Suppression of slow pathway conduction is the optimal endpoint for AVNRT cryoablation. A residual jump can be tolerated if AV nodal ERP postcryoablation is prolonged >30 ms. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9680-7Authors Joelci Tonet, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceAntonio De Sisti, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceNatalia Pardo Restrepo, Universidad CES, Calle 10 A No. 22, Medellín, ColombiaDenis Raguin, Rhythmology Unit, Clinique de l’Europe, Amiens, FranceWalid Amara, Cardiology Department, le Raincy-Montfermeil Hospital, Montfermeil, FranceManlio F. Márquez, Departamento de Electrofisiología, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Col. Sección XVI, 14080 Mexico City, MexicoPhilip Aouate, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceXavier Waintraub, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceFaouzi Touil, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceFrancoise Hidden-Lucet, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, France Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Nearly uniform failure of atrial flutter ablation and con... Abstract Background Ablation for atrial flutter and continued pharmacologic therapy (hybrid therapy) is a management strategy when treatment with class I antiarrhythmic drugs organize atrial fibrillation (AF) into flutter. Previous studies with 2–3-year follow-up have reported satisfactory control of AF burden. Objective We evaluated the effectiveness of hybrid therapy after a follow-up of 5 years. We hypothesized that longer term follow-up would demonstrate eventual failure of this strategy to control AF. Methods A consecutive, retrospective evaluation of all first time ablations of right atrial flutter at the University of Pennsylvania between August 2003 and August 2005 was performed (n = 179). The study population consisted of 33 patients who had atrial flutter only after treatment of AF with class I antiarrhythmic drugs and was continued on them post-ablation. Follow-up data were obtained by reviewing records from our institution, from referring cardiologists, and from direct patient questionnaires. Results Atrial fibrillation recurrence was noted in 28 of 31 patients (90.3 %) who completed 5 years of follow-up. AF recurrence typically resulted in significant symptoms, although 21 % developed persistent AF and were eventually minimally symptomatic on a rate control strategy. A wide range of time to recurrence was observed (0.2–64.5 months) with 39 % recurring greater than 2 years post-ablation. Conclusion Hybrid therapy is not effective for long-term control of AF. Patients should be counseled about the likelihood of eventual AF recurrence and anticoagulation should be maintained indefinitely when this strategy is used. Content Type Journal ArticlePages 1-5DOI 10.1007/s10840-012-9679-0Authors Nicholas Anastasio, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid S. Frankel, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAMarc W. Deyell, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAErica Zado, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAEdward P. Gerstenfeld, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USASanjay Dixit, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAJoshua Cooper, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid Lin, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAFrancis E. Marchlinski, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid J. Callans, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- A novel approach to eliminate intraventricular lead place... Abstract Purpose We describe two patients with congenital heart disease who were referred for implantable cardioverter-defibrillator (ICD) placement. Both patients possessed factors causing the conventional transvenous approach to be undesirable. We therefore devised a technique which circumvented both intravascular ICD lead placement, as well as placement of leads across the tricuspid valve. Methods For both patients, a bipolar pace–sense lead was successfully placed in a branch of the coronary sinus. A shocking coil was then tunneled from the posterolateral margin of the device pocket, being positioned posterior and inferior to the cardiac silhouette. Defibrillation testing was carried out with goal of a 10-J safety margin. Results We were able to successfully achieve ICD implantation in both patients with complex congenital heart disease without requirement for surgical thoracotomy or a lead across the AV valve. R waves in excess of 5 mV were obtained and acceptable defibrillation characteristics were achieved. Both patients are doing well after mid-term follow-up. Conclusion A new implant approach is presented, which involves minimal intravascular hardware and eliminates passage across the atrioventricular valve for patients with congenital heart disease in whom conventional ICD implant techniques may be undesirable or not possible. This procedure is technically straightforward with proper technique and knowledge of the patient specific anatomy. Content Type Journal ArticlePages 1-4DOI 10.1007/s10840-012-9682-5Authors Nikhil Gupta, Los Angeles, CA, USAJeremy P. Moore, Los Angeles, CA, USAKevin Shannon, Los Angeles, CA, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Bifocal right ventricular pacing: an alternative way to a... Abstract Purpose Bifocal pacing in the right ventricle is an option for patients with end-stage heart failure in whom biventricular pacing is not possible, due to failure in left ventricular (LV) lead insertion. The purpose of this prospective study was to document the clinical response of these patients, after bifocal pacing. Methods From the patients referred for cardiac resynchronization therapy (CRT), from 2009 to 2010, 13 cardiac CRT candidates who underwent unsuccessful LV lead implantation were included. The bifocal system’s leads were implanted in the right atrium, the right ventricular (RV) apex, and the RV outflow tract. Initial patient assessment and follow-up evaluation after 6 months included clinical criteria, echocardiographic indices, and biochemical parameters. Results From 13 patients (age 68 ± 9 years, nine male), 10 improved clinically. New York Heart Association classification was reduced by one grade (from 3.6 ± 0.5 to 2.8 ± 0.8, p < 0.005 and respectively), while hospitalizations in 6-month time were reduced from three to one (p < 0.001). Six-minute walk test (in meters) increased from 176 ± 86 to 297 ± 91 (p < 0.001) and quality of life improved (EQ-VAS scale changed from 42 ± 12.5 % to 70.8 ± 20.3 %, p < 0.001). Mean shortening in QRS duration was 31.3 ms (from 165.1 ± 16.3 to 133.8 ± 12.7, p < 0.001) and B-type natriuretic peptide (in picograms per milliliter) dropped from 834 ± 350 to 621 ± 283 (p < 0.001). Ejection fraction (in percent) increased from 27.5 ± 4.6 to 33.3 ± 4.4 (p < 0.001), and mitral regurgitation severity decreased by one grade (from 2.7 ± 0.9 to 1.8 ± 0.7, p < 0.05). Conclusion RV bifocal pacing seems to offer a substantial clinical benefit to heart failure patients with traditional CRT indications and could be an alternative option when LV access is unsuccessful. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9681-6Authors Skevos Sideris, Cardiology Department, Hippokration Hospital, Athens, GreeceConstantina Aggeli, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceEmmanouil Poulidakis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceKostas Gatzoulis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIoannis Vlaseros, Cardiology Department, Hippokration Hospital, Athens, GreeceKaterina Avgeropoulou, Cardiology Department, Hippokration Hospital, Athens, GreeceIoannis Felekos, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIlias Sotiropoulos, Cardiology Department, Hippokration Hospital, Athens, GreeceChristodoulos Stefanadis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIoannis Kallikazaros, Cardiology Department, Hippokration Hospital, Athens, Greece Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Detection of inadvertent catheter movement into the coron... Abstract Objective The objective of this study was to evaluate the use of continuous catheter impedance monitoring prior to ablation to facilitate differentiation of the coronary sinus ostium (CSO) and the middle cardiac vein (MCV) from the right atrial posteroseptal region (RPS). Background Empiric observations have suggested that continuous catheter impedance monitoring could differentiate the CSO and MCV from the RPS region. Radiofrequency ablation in the MCV or coronary sinus has been associated with coronary artery injury. Differentiation of these areas may be difficult with either fluoroscopy or electrogram characteristics. Methods and results Continuous impedance measurements using a 4-mm Navistar (Biosense Webster) ablation catheter were conducted in 17 consecutive patients undergoing ablation for supraventricular tachycardia. The average impedance value was recorded at the right atrial septum (RS) posterior to the bundle of His, the RPS region, within 1 cm inside the CSO and in the MCV. These areas were confirmed and demarcated with 3-D mapping and biplane fluoroscopy. A significant increase in impedance was observed between the CSO (X = 146.6 ± 24.8) and RPS æè - x = 112.0 ± 12.6 öø regions (p < 0.001). Furthermore, a significant rise in impedance was seen between the MCV æè - x = 207.5 ± 45.8 öø and RPS and CSO, respectively (p < 0.001). No significant change in impedance was found between the RS æè - x = 112.9 ± 9.1 öø and RPS regions. Conclusions Continuous impedance measurements during mapping can facilitate differentiation of catheter locations inside the CSO and MCV from extracoronary sinus regions. This may reduce the risk of inadvertent coronary artery damage during the ablation procedure. Content Type Journal ArticlePages 1-5DOI 10.1007/s10840-012-9667-4Authors Scott J. Pollak, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAHeather Seckel, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAJoseph Monir, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAGeorge Ebra, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAGeorge Monir, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
Journal of Interventional Cardiology
- Effects of Myocardial Postconditioning on the Recruitment...
- Clinical Predictors for Failure of Percutaneous Coronary ...
- Long-Term Safety and Effectiveness of Drug-Eluting Stents...
- N-Terminal Pro-B-Type Natriuretic Peptide is Associated w...
- Impact of the Combined Left Ventricular Systolic and Rena...
- The Impact of Intra-Aortic Balloon Pump Weaning Protocols...
- Impact of Diabetes Mellitus on Long-term Clinical Outcome...
- Effect of Statins Therapy Prior to Percutaneous Coronary ...
- The Management of Patients on Oral Anticoagulation Underg...
- Iatrogenic Coronary Dissection Causing Flush Side Branch ...
JACC Cardiovascular Interventions
- Anterior ST-Segment Elevation Myocardial Infarction in a ...
- Fibromuscular Dysplasia of the Left Anterior Descending C...
- A Percutaneous Treatment Algorithm for Crossing Coronary ... Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challenging lesion group to treat. Patients with CTOs are frequently left unrevascularized due to perceptions of high failure rates and technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire–based, antegrade dissection re-entry–based, and retrograde (wire or dissection re-entry) techniques, the "hybrid" interventional strategy. After dual coronary injection is performed, 4 angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) lesion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collaterals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and effectiveness.
- Successful Recanalization of Chronic Total Occlusions Is ... Objectives This study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era. Background Despite advances in expertise and technologies, many patients with CTO are not offered PCI. Methods A total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death. Results A total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]). Conclusions Successful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.
- Percutaneous Revascularization of Chronic Total Coronary ...
- Use of a Novel Crossing and Re-Entry System in Coronary C... Objectives This study sought to examine the efficacy and safety of 3 novel devices to recanalize coronary chronic total occlusions (CTOs). Background Successful percutaneous coronary intervention (PCI) of CTOs improves clinical outcome in appropriately selected patients. CTO PCI success, however, remains suboptimal. Methods A new crossing catheter and re-entry system was evaluated in a prospective, multicenter, single-arm trial of CTO lesions refractory to standard PCI techniques. The primary efficacy endpoint was the frequency of true lumen guidewire placement distal to the CTO (technical success). Results Enrollment included 147 patients with 150 CTOs. The mean lesion length was 41 ± 17 mm. A crossing catheter crossed 56 lesions into the distal true lumen, and a re-entry catheter facilitated tapered-wire cannulation of the distal lumen in 59 CTOs initially crossed subintimally (77% technical success). Success in the first 75 CTOs was 67%, rising to 87% in the last 75 CTOs. Mean fluoroscopy and procedure times were 45 ± 16 min and 90 ± 12 min, respectively, each significantly shorter than in historical controls (p < 0.0001 for both). Coronary perforation occurred in 14 cases (9.3%), requiring treatment in 3 cases (prolonged balloon inflation, with additional coil embolization in 1 case). No tamponade or hemodynamic instability occurred. Six patients had periprocedural non–ST-segment elevation myocardial infarction. No emergency surgery, ST-segment elevation myocardial infarction, or cardiac reintervention occurred. Two deaths occurred within 30 days, neither as a direct result of the procedure. The 30-day major adverse cardiac event rate was 4.8%. Conclusions In CTOs failing standard techniques, use of a new crossing and re-entry system results in a high success rate without increasing complications.
- Maximal Hyperemia in the Assessment of Fractional Flow Re... Objectives This study sought to compare increasing doses of intracoronary (IC) adenosine or IC sodium nitroprusside versus intravenous (IV) adenosine for fractional flow reserve (FFR) assessment. Background Maximal hyperemia is the critical prerequisite for FFR assessment. Despite IV adenosine currently representing the recommended approach, IC administration of adenosine or other coronary vasodilators constitutes a valuable alternative in everyday practice. However, it is surprisingly unclear which IC strategy allows the achievement of FFR values comparable to IV adenosine. Methods Fifty intermediate coronary stenoses (n = 45) undergoing FFR measurement were prospectively and consecutively enrolled. Hyperemia was sequentially induced by incremental boli of IC adenosine (ADN) (60 μg ADN60, 300 μg ADN300, 600 μg ADN600), by IC sodium nitroprusside (NTP) (0.6 μg/kg bolus) and by IV adenosine infusion (IVADN) (140 μg/kg/min). FFR values, symptoms, and development of atrioventricular block were recorded. Results Incremental doses of IC adenosine and NTP were well tolerated and associated with fewer symptoms than IVADN. Intracoronary adenosine doses (0.881 ± 0.067, 0.871 ± 0.068, and 0.868 ± 0.070 with ADN60, ADN300, and ADN600, respectively) and NTP (0.892 ± 0.072) induced a significant decrease of FFR compared with baseline levels (p < 0.001). Notably, ADN600 only was associated with FFR values similar to IVADN (0.867 ± 0.072, p = 0.28). Among the 10 patients with FFR values ≤0.80 with IVADN, 5 were correctly identified also by ADN60, 6 by ADN300, 7 by ADN600, and 6 by NTP. Conclusions Intracoronary adenosine, at doses higher than currently suggested, allows obtaining FFR values similar to IV adenosine. Intravenous adenosine, which remains the gold standard, might thus be reserved for those lesions with equivocal FFR values after high (up to 600 μg) IC adenosine doses.
- Relationship Between Fractional Flow Reserve and Angiogra... Objectives This study sought to assess the relationship of coronary angiography, intravascular ultrasound (IVUS) and fractional flow reserve (FFR) between major epicardial vessel (MV) and side branch (SB) ostial lesions. Background Evaluation of ostial lesions is clinically very important. However, anatomical parameters have limitations in the prediction of the functional significance of coronary stenoses. Methods IVUS and FFR measurement were performed in 93 lesions (MV: 38, SB: 55). Optimal angiographic and IVUS criteria and their diagnostic accuracy for functionally significant stenoses (FFR ≤0.8) were assessed. Results In MV ostial lesions, FFR had correlation with angiographic percent diameter stenosis (r = –0.68, p < 0.001), minimum lumen area (MLA) by IVUS (r = 0.55, p < 0.001), percent plaque burden (r = –0.42, p = 0.011), and percent area stenosis (r = –0.49, p = 0.003). Meanwhile, FFR had no correlation with angiographic percent diameter stenosis (r = –0.067, p = 0.635) and weak correlation with MLA (r = 0.30, p = 0.026) in SB ostial lesions. In MV ostial lesions, best cutoff value of angiographic percent diameter stenosis, MLA, percent plaque burden, and percent area stenosis to determine the functional significance was 53%, 3.5 mm2, 70%, and 50%. However, a statistically significant cutoff value of percent diameter stenosis and MLA could not be found in SB ostial lesions. Conclusions The relations between angiographic/IVUS parameters and FFR were different between MV and SB ostial lesions. Angiographic and IVUS parameters had poor diagnostic accuracy in predicting the functional significance of SB ostial lesions. (Main Branch Versus Side Branch Ostial Lesion; NCT01335659)
- Provoked Exercise Desaturation in Patent Foramen Ovale an... Objectives This study was designed to assess the prevalence of provoked exercise desaturation (PED) in patients with patent foramen ovale (PFO) referred for cardiovascular evaluation and to evaluate the impact of PFO closure. Background Platypnea orthodeoxia syndrome is a rare, mechanistically obscure consequence of PFO that results in oxygen desaturation during postural changes. In our clinical experience, however, it is far less common than desaturation during exercise. Methods This was a single-center prospective study of 50 patients with newly diagnosed PFO. Each patient underwent standardized assessment for arterial oxygen saturation with pulse oximetry during postural changes and stair climbing exercise. Provoked exercise desaturation was defined as a desaturation of at least 8% from baseline to <90%. All patients who underwent closure were reevaluated 3 months after the procedure. Those with baseline PED were similarly reassessed for desaturation at follow-up. Results Mean age of the cohort was 46 ± 17 years, 74% were female, 30% had migraines, and 48% had experienced a cerebrovascular event. Seventeen patients (34%) demonstrated PED. Provoked exercise desaturation patients seemed demographically similar to non-PED patients. Ten PED patients underwent PFO closure (2 surgical, and 8 percutaneous). Drop in oxygen saturation was improved by an average of 10.1 ± 4.2% after closure (p < 0.001), and New York Heart Association functional class improved by a median of 1.5 classes (interquartile range: 0.75 to 2.00, p = 0.008). Conclusions One-third of patients referred for assessment of PFO experience oxygen desaturation during stair exercise. Closure of PFO seems to ameliorate this phenomenon and improve functional status.
- Some Air for Closure of the Patent Foramen Ovale
Journal of Cardiac Failure
- Plasma Pro-B-type Natriuretic Peptide Testing as a Screen... Publication year: 2012Source:Journal of Cardiac FailureFabio Fernandes, Edmundo Arteaga-Fernandez, Murillo de Oliveira Antunes, Paula Buck, Julia Daher Carneiro Marsiglia, Afonso Matsumoto, Luciano Nastari, Jose Eduardo Krieger, Alexandre Costa Pereira, Charles Mady Background Clinical multistage risk assessment associated with electrocardiogram (ECG) and NT-proBNP may be a feasible strategy to screen hypertrophic cardiomyopathy (HCM). We investigated the effectiveness of a screening based on ECG and NT-proBNP in first-degree relatives of patients with HCM. Methods and Results A total of 106 first-degree relatives were included. All individuals were evaluated by echocardiography, ECG, NT-proBNP, and molecular screening (available for 65 individuals). From the 106 individuals, 36 (34%) had diagnosis confirmed by echocardiography. Using echocardiography as the gold standard, ECG criteria had a sensitivity of 0.71, 0.42, and 0.52 for the Romhilt-Estes, Sokolow-Lyon, and Cornell criteria, respectively. Mean values of NT-ProBNP were higher in affected as compared with nonaffected relatives (26.1 vs. 1290.5, P < .001). The AUC of NT-proBNP was 0.98. Using a cutoff value of 70 pg/mL, we observed a sensitivity of 0.92 and specificity of 0.96. Using molecular genetics as the gold standard, ECG criteria had a sensitivity of 0.67, 0.37, and 0.42 for the Romhilt-Estes, Sokolow-Lyon, and Cornell criteria, respectively. Using a cutoff value of 70 pg/mL, we observed a sensitivity of 0.83 and specificity of 0.98. Conclusion Values of NT-proBNP above 70 pg/mL can be used to effectively select high-risk first-degree relatives for HCM screening.
- Circulating Heart-type Fatty Acid Binding Protein Levels ... Publication year: 2012Source:Journal of Cardiac FailureHyuma Daidoji, Takanori Arimoto, Joji Nitobe, Harutoshi Tamura, Daisuke Kutsuzawa, Daisuke Ishigaki, Mitsunori Ishino, Hiroki Takahashi, Tetsuro Shishido, Takehiko Miyashita, Takuya Miyamoto, Tetsu Watanabe, Isao Kubota Background The association between ongoing myocardial damage and outcomes in patients who have received an implantable cardioverter-defibrillator (ICD) is unclear. Methods and Results Consecutive patients with cardiomyopathy, who had received an ICD (n = 107, mean age 65 ± 11 years), were prospectively enrolled. Myocardial membrane injury (heart-type fatty acid binding protein [H-FABP] >4.3 ng/mL) and myofibrillar injury (troponin T >0.01 ng/mL) were defined using receiver operating characteristic curves. Patients were followed for a median of 33.6 months, to an end point of appropriate ICD shock or cardiac death. Myocardial membrane injury (45%) and myofibrillar injury (41%) were equally prevalent among patients with cardiomyopathy who had received ICDs. Appropriate ICD shocks or cardiac death occurred in 31% and 15% of patients, respectively. Multivariate Cox regression analysis showed that serum H-FABP levels >4.3 ng/mL, but not troponin T levels, were a significant independent prognostic factor for cardiac events (hazard ratio 5.502, 95% confidence interval 1.705–17.75, P = .004). Subgroup analysis revealed that measuring H-FABP levels was valuable for anticipating event-free survival among patients with ICDs who were receiving amiodarone. High H-FABP levels also predicted subsequent outcomes in patients who had received ICDs for primary or secondary prevention. Conclusion Evaluating myocardial damage using H-FABP may be a promising tool for predicting outcomes in patients with cardiomyopathy who have received ICDs.
- Editorial Board Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5
- Masthead Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5
- Table of Contents Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5
- Information for Authors Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5
- Plasma Copeptin Levels and Prediction of Outcome in Heart... Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5Louise Balling, Caroline Kistorp, Morten Schou, Michael Egstrup, Ida Gustafsson, Jens Peter Goetze, Per Hildebrandt, Finn Gustafsson Background Copeptin, a stable fragment of the vasopressin prohormone, has been shown to be a significant biomarker for morbidity and mortality in heart failure. The aims of this study were to evaluate the influence of plasma sodium on the prognostic significance of copeptin concentrations in heart failure outpatients and to determine whether increased copeptin concentrations predict future development of hyponatremia. Methods and Results A total of 340 heart failure patients with left ventricular systolic dysfunction were followed for 55 months (median) in a Danish heart failure clinic. A baseline measurement of plasma copeptin, N-terminal pro–B-type natriuretic peptide (NT-proBNP), and sodium was performed, and the sodium concentrations were recorded during 3 months after the baseline visit in the heart failure clinic. Patients were divided into 3 groups according to copeptin tertiles. In multivariate Cox proportional hazard models adjusted for confounders, including plasma sodium, loop diuretic dose, and NT-proBNP, copeptin was a significant predictor of hospitalization or death (hazard ratio 1.4, 95% confidence interval 1.1–1.9; P < .019) but did not predict mortality independently from NT-proBNP. Additionally, copeptin concentrations did not predict future development of hyponatremia. Conclusions Plasma copeptin levels predict mortality in outpatients with chronic heart failure independently from clinical variables, plasma sodium, and loop diuretic doses. Furthermore, copeptin predicts the combined end point of hospitalization or death independently from NT-proBNP.
- Dyads Affected by Chronic Heart Failure: A Randomized Stu... Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5Susanna Ågren, Lorraine S. Evangelista, Carina Hjelm, Anna Strömberg Background Chronic heart failure (CHF) causes great suffering for both patients and their partners. The aim of this study was to evaluate the effects of an integrated dyad care program with education and psychosocial support to patients with CHF and their partners during a postdischarge period after acute deterioration of CHF. Methods One hundred fifty-five patient-caregiver dyads were randomized to usual care (n = 71) or a psychoeducation intervention (n = 84) delivered in 3 modules through nurse-led face-to-face counseling, computer-based education, and other written teaching materials to assist dyads to develop problem-solving skills. Follow-up assessments were completed after 3 and 12 months to assess perceived control, perceived health, depressive symptoms, self-care, and caregiver burden. Results Baseline sociodemographic and clinical characteristics of dyads in the experimental and control groups were similar at baseline. Significant differences were observed in patients’ perceived control over the cardiac condition after 3 (P < .05) but not after 12 months, and no effect was seen for the caregivers.No group differences were observed over time in dyads’ health-related quality of life and depressive symptoms, patients’ self-care behaviors, and partners’ experiences of caregiver burden. Conclusions Integrated dyad care focusing on skill-building and problem-solving education and psychosocial support was effective in initially enhancing patients’ levels of perceived control. More frequent professional contact and ongoing skills training may be necessary to have a higher impact on dyad outcomes and warrants further research.
- IIIB or Not IIIB: A Previously Unanswered Question Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5Jennifer T. Thibodeau, Joseph D. Mishkin, Parag C. Patel, Pradeep P.A. Mammen, David W. Markham, Mark H. Drazner The term New York Heart Association (NYHA) class IIIB has been used increasingly in clinical medicine, including as an inclusion criteria for many clinical trials assessing left ventricular assist devices (LVADs). Indeed, NYHA class IIIB is incorporated in the Food and Drug Administration’s approved indication for the Heartmate II. However, on review of the medical literature, we found that there is no consensus definition of NYHA class IIIB. Until the ambiguity is resolved, we suggest that this designation not be used in clinical practice or by investigators leading clinical trials assessing therapies which convey substantial risk to patients and therefore require clarity in describing the enrolled patient population. With ongoing improvements in LVADs, this therapy will increasingly be considered in patients less sick than those who require inotropic support, providing urgency to establish a consensus system of classifying such patients who nevertheless fall within the spectrum of advanced heart failure. Herein we propose a modification of the standard NYHA classification system which can be used to fill this void.
- Comparison of Cardiac Resynchronization Therapy Outcomes ... Publication year: 2012Source:Journal of Cardiac Failure, Volume 18, Issue 5Alan J. Bank, Ariel Rischall, Ryan M. Gage, Kevin V. Burns, Spencer H. Kubo Background Several randomized trials have shown that cardiac resynchronization therapy (CRT) benefits New York Heart Association (NYHA) functional class I/II heart failure (HF) patients, but it is unknown if similar outcomes occur in the real-world. Methods and Results All patients receiving CRT between 2003 and 2008 with ejection fraction (EF) ≤35% and QRS duration ≥120 ms were included. Outcomes assessed were subjective clinical response, echocardiographic response, and survival free of cardiovascular (CV) hospitalization. Baseline demographics in functional class I/II (n = 155) and functional class III/IV (n = 512) were similar, except for differences in age and several comorbidities. Clinical response was similar in both groups. The functional class I/II group had a greater decrease in left ventricular (LV) end-diastolic dimension (P = .031), and trended toward greater improvements in LV end-systolic dimension (P = .056) and EF (P = .059). The functional class I/II group had a better 5-year survival rate (79 vs 54%; P < .0001) and survival free of CV hospitalization (45% vs 26%; P < .0001). Conclusions In this real-world clinical scenario, NYHA functional class I/II CRT patients improved clinical status, and LV function and size as good as or better than those in NYHA functional class III/IV patients. These observations provide further support for the use of CRT in patients with mild symptoms of HF.
European Journal of Echocardiography
- Journals on the move: launch of the ESC Journals App
- Unleashing the power of echocardiography: can we get clos...
- Coronary computed tomography: current role and future per... Coronary artery disease (CAD) is the major cause of morbidity and mortality worldwide. More than 50% of CAD deaths occur in previously asymptomatic individuals at intermediate cardiovascular risk, highlighting the need of more accurate individual risk assessment to decrease cardiovascular events. Cardiac computed tomography (CCT) has emerged as a valuable technique for risk stratification in asymptomatic subjects and in symptomatic patients without known CAD. The absence of coronary artery calcium (CAC) identifies asymptomatic subjects at very low cardiac risk and is reasonable in intermediate risk individuals, in whom CAC measurement reclassifies a substantial number of subjects to different risk categories. In symptomatic patients with suspected CAD, detection of non-obstructive or obstructive CAD by CCT angiography is associated with increased all-cause mortality, and provides incremental risk stratification to CAC. Further studies are needed to assess the impact of CCT on clinical outcomes and its cost-effectiveness in different clinical settings.
- Integrated backscatter as a fibrosis marker in the metabo... Aims Myocardial fibrosis is an important contributor to heterogeneity of left ventricular (LV) dysfunction in the metabolic syndrome (MS). Comparison of strain with calibrated integrated backscatter (cIB) and serological fibrosis markers could provide a means to understand the association of cardiac function with markers of fibrosis. Methods and results We studied 172 patients with MS (age 50 ± 13years) and 61 healthy controls in a prospective, cross-sectional study. Echocardiographic evaluation included myocardial velocities and deformation, and calibrated cIB. Procollagen type III amino-terminal propeptide (PIIINP) and procollagen type I carboxy-terminal propeptide (PICP) were measured from serum. MS patients demonstrated LV systolic and diastolic function, and myocardial echodensity disturbances, as well as elevated serum PIIINP and PICP levels. For most functional variables, calibrated cIB in the basal septum was the strongest determinant of impaired LV performance, independent of higher procollagen levels, LV mass index, age, body mass index, creatinine level, and C-reactive protein. Patients with increased abdominal fat deposit (assessed by the waist-to-hip ratio) presented higher levels of procollagen peptides and septal calibrated cIB, and with more profound LV dysfunction as indicated by lower myocardial deformation and early diastolic velocity, and higher E/e'. Conclusion Myocardial echodensity is a stronger correlate of LV systolic and diastolic dysfunction in MS, than circulating procollagen peptides. Both fibrosis and LV function abnormalities are increased at a higher waist-to-hip ratio, which might provide a rationale for the implementation of intensified therapy in this subset of patients.
- Cardiovascular risk assessment based on the quantificatio... Aims The extent of coronary artery calcification (CAC) has been shown to be a strong and independent predictor for cardiovascular events. Usually, CAC scoring is performed in non-contrast-enhanced computed tomography (CT) examinations. The ability and accuracy of cardiovascular risk classification according to the degree of CAC determined in contrast-enhanced coronary CT angiography (CCTA) has not been investigated so far. The aim of this analysis was to develop and validate a method for CAC risk classification in CCTA. Methods and results In a test series of 100 patients who underwent both non-enhanced CAC scoring and CCTA, we developed a method to assess the extent of coronary calcification and the associated cardiovascular risk category in CCTA. The accuracy of the developed approach of CAC assessment in CCTA was determined in 500 consecutive patients in comparison to CAC scoring in the non-enhanced scan. CAC scoring results in the non-enhanced scan and CCTA scan showed a high correlation (r = 0.954; P < 0.001). CAC quantification in CCTA correctly identified 98% of patients without CAC as shown in the non-enhanced scan (184 of 188 patients). When compared with non-enhanced CAC scoring, CAC scoring in CCTA grouped more than 95% of high-risk patients correctly into the same risk category according to the 75th age- and gender-specific percentiles or the absolute calcium scores. Conclusion Assessing cardiovascular risk associated with CAC is feasible and accurate in contrast-enhanced CCTA. This new technique may allow for reducing the radiation exposure of coronary CT studies while maintaining an accurate cardiovascular risk assessment, because the addition of non-enhanced scans to CCTA becomes unnecessary for comprehensive coronary CT studies.
- Dynamic assessment of 'valvular reserve capacity' in pati... Aims Mitral stenosis (MS) may exhibit a dynamic valvular reserve. When resting gradients and systolic pulmonary pressure (sPAP) do not reflect the real severity of the disease, a dynamic evaluation becomes necessary. The aim of the study was to assess the clinical utility of exercise echocardiography in symptomatic patients with apparently subcritical MS. Methods and results One hundred and thirty consecutive patients were referred for symptomatic MS. Patients with unimpressive resting MVA (>1–1.5 cm2) and mean PG (≥5–9 mmHg) underwent exercise echocardiography. Cardiac performance and mitral indices (MVA, peak/mean PG, sPAP) were measured. Exhaustion of valvular reserve capacity under exercise was defined as appearance of symptoms and sPAP > 60 mmHg. Forty-six patients (35%) (age: 53 ± 10 years; 74%, female) with resting MVA (1.2 ± 0.36 cm2), mean PG (6.8 ± 2.7 mmHg), and sPAP (38 ± 7 mmHg) inconsistent with symptoms underwent stress echocardiography. Exercise was stopped for dyspnoea (76%) or fatigue (24%). At peak workloads (57.2 ± 21.8 Watts), increased mean PG (17.2 ± 4.8 mmHg, P< 0.001) and sPAP (67.4 ± 11.4 mmHg; P< 0.0001) were observed, without change in MVA (1.25 ± 0.4 cm2; P= n.s.). At univariate analysis, predictors of adaptation to exercise were age (–0.345; P = 0.024), mean PG (0.339; P= 0.023), and sPAP (0.354; P= 0.024); at multivariate analysis, best predictor was resting mean PG, although correlation was poor (–0.339; P= 0.015). Conclusion In MS with limiting symptoms despite unimpressive findings at rest, valvular capacity exhaustion should be tested on a dynamic background, as no single resting index can predict potential haemodynamic adaptation to exercise. In such context, the contribution of exercise echocardiography remains extremely valuable.
- Different impacts of acute myocardial infarction on left ... Aims The impacts of acute myocardial infarction (AMI) with different regional wall motion abnormalities on left ventricular (LV) rotation have not been well investigated. We assessed the impacts of AMI on LV rotational mechanics and to compare the alterations in basal and apical rotation between patients with anterior and inferior AMI. Methods and results Thirty-five patients with anterior AMI and 31 patients with inferior AMI who had a single culprit lesion were analysed. Thirty age-matched subjects were included for controls. The apical and basal rotations were obtained and LV twist and torsion were measured by two-dimensional speckle tracking imaging. Compared with normal, LV twist was reduced in all AMI patients. The basal rotation was larger in anterior AMI than in inferior AMI and normal (–9.0 ± 2.6 vs. –3.4 ± 2.1° and –6.0 ± 1.9°, P < 0.001), although the apical rotation was lower in anterior AMI. As a result, LV twist and torsion were not different between anterior AMI and inferior AMI (17.0 ± 4.6 vs. 16.7 ± 3.3° and 2.08 ± 0.59 vs. 2.07 ± 0.44°/cm, P = NS, respectively), although LV ejection fraction was lower in anterior AMI. By multivariate analysis, LV torsion [odds ratio (OR) =0.13, 95% confidential interval (CI) = 0.02–0.75, P = 0.02] and basal rotation (OR = 0.67, 95% CI = 0.45–1.00, P = 0.05) were independently related to LV recovery in patients with anterior AMI and in patients with inferior AMI, respectively. Conclusion Although LV twist and torsion were decreased either by reduced apical and basal rotation in AMI patients; the basal rotation was rather increased in anterior AMI. LV functional recovery can be predicted by LV torsion in anterior AMI and by basal rotation in inferior AMI. The basal rotation has often been ignored; however, our findings suggest that the basal rotation has an important role in LV function.
- How to optimize intracardiac blood flow tracking by echoc... Aims Echocardiographic particle image velocimetry (EPIV) has been used for tracking contrast-enhanced intracavitary blood flow. Little is known, however, how basic imaging parameters (line density, frame rate, contrast bubble density) affect the quality of such tracking results. Our study aimed at investigating this by using simulated echo data sets. Methods and results A computational three-dimensional (3D) blood flow field of the left ventricle (LV) was built using Fluent 12.1 (ANSYS Inc., USA). Then, the 3D motion of contrast microbubbles was simulated and 2D B-mode image loops were obtained (f = 4.5 MHz; 50 sector angle) and analysed using flow tracking software (Omega Flow, Siemens, USA). Vorticity and the resulting in-plane velocity vector field was calculated at different frame rates (227, 113, 76, and 57 fps) and bubble densities (100, 63, 36, 19, 10, and 3 bubbles/mL) and compared with the ground truth known from the computational LV flow model. The normal distribution of the amplitude error and angle error histograms confirmed the overall good performance of the tracking method. In the standard deviation analysis of error histograms, tracked velocity amplitudes correlated best with the ground truth at 10 bubbles/mL and 227 fps (45.81 ± 3.43%, P < 0.05), while the best performance of flow direction estimates was at 10 bubbles/mL and 76 fps (25.41 ± 1.22°, P < 0.05). The correlation of estimated and true vorticity tended to grow with increasing frame rate and was optimal at 19 bubbles/mL and 113 fps (r = 0.79 ± 0.02). Conclusion To achieve accurate vorticity measurements, frame rate acquisitions as 113 fps and contrast bubble density of 19 bubbles/mL are needed.
- Use of multi-modality imaging in a patient with a persist...
- Ultrasound contrast and real-time perfusion in conjunctio... Aims We sought to evaluate the efficacy of ultrasound contrast (UC) and low mechanical index real-time perfusion (RTP) in the haemodynamic and anatomic assessment of repaired congenital heart disease (CHD) at rest and during supine bicycle stress echocardiography (BSE). Methods and results Patients with CHD (n = 51, median age 21.5 years) were prospectively studied. All had compromised image quality, 20 (39%) had arrhythmias, and 10 (20%) had pacemakers. RTP was performed at rest and during BSE using Definity and Contrast Pulse Sequencing, with assessment of Doppler pressure gradients. Diagnoses included tetralogy of Fallot (n = 27), transposition of the great arteries (TGA) atrial switch (n = 10), TGA arterial switch (n = 2), aortic valve disease (n = 4), Fontan (n = 4), and Kawasaki disease (n = 4). UC with RTP improved endocardial border definition, with increased number of left ventricular (LV) and right ventricular (RV) segments visualized at rest (P < 0.0001) and during stress. LV ejection fraction (EF) and RV fractional area change (FAC) were measurable at rest and peak stress, RV FAC correlating closely with same-day magnetic resonance EFs (r = 0.72; P < 0.001). UC enhanced Doppler signals, enabling subpulmonary ventricular systolic pressure measurements at rest and stress. In six patients, marked elevations of subpulmonary ventricular systolic pressure were detected with UC during BSE, and quantifiable ventricular dysfunction. No adverse events occurred, other than transient low back pain in one patient. Conclusion UC at rest and with supine BSE enables safe and comprehensive assessment of anatomy, haemodynamics, and biventricular functional and perfusion reserve in adolescents and young adults with surgically modified CHD. ClinicalTrials.gov Identifier: NCT00861848
BMJ Heart Asia
- Cardiovascular risk factors in middle age obese Indians: ... Objectives To determine the association of per cent total body fat (TBF), intra-abdominal fat (IAF) mass and subcutaneous abdominal fat with cardiovascular risk factors in middle age obese Indians. Design Cross-sectional study. Setting Hydrostatic Laboratory, Department of Sports Medicine and Physiotherapy, Guru Nanak Dev University, India. Participants: 51 subjects aged 30–55 years with a body mass index value 23 and above. Methodology In all the participants, TBF was estimated by underwater weighing machine and IAF and subcutaneous fat were measured by ultrasonography. Lipid profile was determined by a semiautomated analyser. Main outcome measures were: IAF, per cent body fat to TBF ratio, lipid profile and risk of developing cardiovascular diseases. Results IAF was found to be significantly associated with lipid variables (95% CI, p<0.01) and risk of developing cardiovascular diseases (95% CI, p≤0.05) in both male and female subjects. TBF and subcutaneous fat thickness showed no significant results (95% CI, p>0.05) with either lipid variables or risk of developing cardiovascular diseases (tables 1 and 2). IAF mass showed significant association with age (95% CI, p<0.01) and significant negative association with physical activity (95% CI, p<0.05) in male subjects (tables 3 and 4). Conclusion An ultrasonic measurement of IAF is a better predictor of the risk of developing cardiovascular diseases in middle aged Indian population. In male subjects, physical activity of 5 or more days a week showed lesser amount of IAF as compared with those with physical activity <5 days a week.
- Giant coronary artery aneurysm following Kawasaki disease... A 3-year-old boy presented with a history of 2 weeks fever 1 year ago. At that time he was found to have nasal discharge, bilateral non-exudative conjunctivitis, glossitis, bilateral cervical lymphadenopathy and rash with peeling of the skin of the hands and feet. His investigations showed polymorphonuclear leukocytosis and increased Erythrocyte sedimentation rate (ESR) and C reactive protein. The child was diagnosed as having Kawasaki disease and was treated with intravenous immunoglobulin, aspirin and clopidogrel. A 2D echocardiogram at that time showed a diffuse aneurysm of the left main coronary artery. The patient was advised medical follow-up. On evaluation now at our institute, he was asymptomatic with a normal clinical examination. His ECG showed sinus rhythm, T wave inversion in V1–V5 and no significant ST changes. His chest x-ray was normal. The 2D echocardiogram revealed normal left ventricular (LV) systolic function and size and normal valves. There was a giant fusiform...
- Antistreptokinase antibodies and the response to thrombol... Background and objective A large number of patients with ST elevation myocardial infarction (STEMI) continue to receive streptokinase (SK) in the developing countries. High levels of antistreptokinase (ASK) antibodies can result in failure of thrombolysis. This study was conducted to assess the presence of ASK antibodies in the general population and its effect on the outcome of thrombolysis with SK. Design Prospective observational study. Setting A tertiary care medical institute in Vellore, India. Patients 148 patients presenting with STEMI undergoing thrombolysis with SK were recruited. Main outcome measures The response to SK was assessed by reperfusion markers in the patients and they were categorised as good responders, probable responders and non-responders. Those who responded to SK and probable responders were considered to have benefited from thrombolysis. Results 60 patients (40%) had ASK antibody titres higher than the median. In patients with a window period <6 h, 73% of patients who benefited from thrombolysis had low ASK titres while 100% of the patients who did not benefit had high ASK titres (p=0.001). Similarly, in patients with a window period >6 h, 89% of patients who benefited from thrombolysis had low ASTK titres while 54% of those who did not benefit had high ASK titres (p=0.002). Conclusions ASK antibodies are present in significant titres in a large proportion of patients in developing countries, which leads to failure of thrombolysis in such patients. In endemic areas with high endemic streptococcal infection, alternative agents should be used for thrombolysis in STEMI.
- The relationship among brain natriuretic peptide (BNP), c... Objective To study the relationship among brain natriuretic peptide (BNP), cholesterol and lipoprotein. Design A retrospective, cross-sectional study. Setting Tokushima University Hospital area. Patients A retrospective study of 46 patients (nine inpatients and 37 outpatients) with angina pectoris or arrhythmias who were seen at Tokushima University Hospital Cardiovascular Division and had measurements of their BNP, fatty acid and lipid profile. The average age of patients was 57±17 years, and 39% were male subjects. Main outcome measures BNP, dihomo--linolenic acid, arachidonic acid, eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), apolipoproteinA1, apolipoprotein A2 (ApoA2), apolipoprotein B (ApoB), apolipoprotein C2, apolipoprotein C3, apolipoprotein E, total cholesterol (TC), triglyceride, high density lipoprotein cholesterol and low density lipoprotein cholesterol. Results The baseline characteristics of the patients were shown in table 1 and the data of lipoprotein were shown in table 2. Table 3 shows the relationship among BNP, cholesterol and lipoprotein. The authors found significant negative correlation between serum levels of BNP and ApoA2 (figure 1; r=–0.458, p=0.001), serum levels of BNP and ApoB (figure 2; r=–0.328, p=0.026) and serum levels of BNP and TC (figure 3; r=-0.383, p=0.010). There is a possibility that dietary EPA and DHA may modulate cardiac mitochondrial and autonomic nervous system dysfunction via fatty-acids-PPARs-PTEN-PI3K/Akt-SREBPs system and affect serum BNP levels indirectly. Conclusion BNP had significant negative correlation with ApoA2, ApoB and TC. The findings suggest that increasing serum levels of ApoA2, ApoB and TC may have an effect on improving heart function. But the mechanism is presently unclear.
- Positive inotropes in heart failure: a review article Increasing myocardial contractility has long been considered a big help for patients with systolic heart failure, conferring an augmented haemodynamic profile in terms of higher cardiac output, lower cardiac filling pressure and better organ perfusion. Though concerns have been raised over the safety issues regarding the clinical trials of different inotropes in hearts with systolic dysfunction, they still stand as a main therapeutic strategy in many centres dealing with such patients. They must be used as short in duration, low in dose and stopped as early as possible. Evidence-based guidelines have provided clinicians with valuable data for better applying inotropes in heart failure patients. In this paper, the authors address clinical trials with different agents used for increasing cardiac contractility in heart failure patients. Furthermore, the authors focus on recent guidelines on making the most out of inotropes in heart failure patients.
- The importance of P wave morphology on the ECG Introduction Focal atrial tachycardia (AT) is the least common form of supraventricular tachycardia. However, the surface 12-lead ECG is a very helpful tool and the use of P-wave morphology (PWM) on surface ECG to localise the site of focal AT is of paramount importance. Subtle ECG changes with respect to PWM in AT could be mistaken as sinus rhythm (SR). We report a case of a young woman with focal AT located at the tricuspid annulus in which the heart rate in both SR and AT were similar. The only subtle difference was in the PWM on surface ECG in lead V1. With the use of electroanatomical mapping the subtle surface ECG changes could be explained. Case A 17-year-old woman presented with a history of palpitations. She had been symptomatic since the age of 9 years and had been treated with digoxin previously. The only documentation of tachycardia was...
- Primary angioplasty followed by chemical thrombolysis for... Introduction Mortality rates associated with basilar artery occlusions, internal carotid artery ‘T’ occlusions and middle cerebral artery (MCA)–M1 segment occlusions are particularly high despite the best available medical therapy. The recanalisation rate of a patient with carotid T occlusion is 10%1 2 with intravenous thrombolysis and 33% with intra-arterial (IA) thrombolysis.3 We report a case of acute stroke in whom primary angioplasty of the left internal carotid artery followed by IA thrombolysis of MCA was done with a favourable outcome in our centre. This is the first reported case of such a procedure in India. Case report A 65-year-male subject who is a known diabetic and smoker presented with a history of blurring of vision of 6 h duration, followed by global aphasia and right sided hemiplegia of 2 h duration. The patient had global aphasia, gaze deviation to left side and right sided...
- Type 1 neurofibromatosis and pulmonary hypertension: a re... Pulmonary hypertension in type 1 neurofibromatosis is not well known and was previously attributed to diffuse fibrosing alveolitis and parenchymal tumours. More recently, cases of severe pulmonary hypertension due to pulmonary vasculopathy have been described. Involvement of vascular beds, both large and medium calibre vessels, but not pulmonary vasculature, in type 1 neurofibromatosis is well known. The authors describe two such cases and briefly review the literature. Pulmonary arterial hypertension in neurofibromatosis warrants further studies.
- Pericardial liposarcoma A 70-year-old Indian woman with hypertension presented with acute breathlessness. The chest radiograph revealed gross cardiomegaly (figure 1), ECG had fixed T wave inversion laterally and troponin-T was elevated (3.5 ng/ml). Echocardiography showed normal left ventricular (LV) size and good function; however, there was a large intrapericardial mass without effusion. Figure 1Chest radiograph: gross cardiomegaly. Cardiac catheterisation with left ventriculography demonstrated smooth coronary arteries significantly distant from the heart and infiltration of the LV apex (online supplementary video 1). Cardiac MRI revealed extensive mediastinal and intrapericardial lipomatosis (figure 2; arrows and arrowheads, respectively) with the heart ‘floating’ within the pericardial fat (online supplementary video 2). There was tethering and akinesis of the LV apex, LV base and anterolateral wall, together with interatrial septal infiltration. The patient was diagnosed as having pericardial liposarcoma but she declined surgical excision despite repeated...
- Comparison of the clinical and morphologic characteristic... Objective The aim of the study was to assess the differences in clinical and morphologic characteristics of culprit lesions among patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). Methods The authors included 174 consecutive patients who have been admitted due to UA or NSTEMI. All patients underwent coronary angiography during hospitalisation and angiographic characteristics were determined. Results The mean age of study patients was 57±9 years, and the majority were men. The frequency of single, two and three vessel disease was 35.6%, 28.7% and 28.1%, respectively. There was no significant difference between UA and NSTEMI patients in terms of the extent of coronary artery involvement and culprit lesion morphologic features (p value: 0.99 and 0.67, respectively). The only significant difference was the incidence of definite and possible thrombus in culprit lesion (40.7% vs 16.5%, p value<0.001). The authors also did not find any association between Braunwald clinical/severity classification and lesion morphology in the studied population. In multivariate analysis there was a significant association between Braunwald class II–III and increased risk of NSTEMI (OR (95% CI): 13.43 (1.12 to 160.63), p=0.04, OR (95% CI): 14.08 (1.21 to 163.11), p=0.03, for Braunwald severity class II and III, respectively). Conclusion Clinical characteristics of patients with acute coronary syndrome including enzyme rising cannot predict the extent of coronary artery involvement and the morphology of culprit lesions. The only exception was the higher incidence of intracoronary thrombus in patients with NSTEMI as compared with UA.
Heart Failure Reviews
- Current management and future directions for the treatmen... Abstract Although patients hospitalized with heart failure have relatively low in-hospital mortality, the post-discharge rehospitalization and mortality rates remain high despite advances in treatment. Most patients admitted for heart failure have normal or high blood pressure, but 15–25 % have low systolic blood pressure with or without signs and/or symptoms of hypoperfusion. All pharmacological agents known to improve the prognosis of patients with heart failure also reduce blood pressure, and this limits their use in patients with heart failure and low blood pressure (HF-LBP). However, patients with HF-LBP have much higher in-hospital and post-discharge mortality. In these patients, a conceptually important therapeutic target is to improve cardiac output in order to alleviate signs of hypoperfusion. Accordingly, the majority of these patients will require an inotrope as cardiac dysfunction is the cause of their low cardiac output. However, the short-term use of currently available inotropes has been associated with further decreases in blood pressure and increases in heart rate, myocardial oxygen consumption and arrhythmias. Agents that improve cardiac contractility without this undesirable effects should be developed. To the best of our knowledge, the epidemiology, pathophysiology and therapy of patients with HF-LBP have not been addressed thoroughly. In June 2010, a workshop that included scientists and clinicians was held in Rome, Italy. The objectives of this meeting were to (1) develop a working definition for HF-LBP, (2) describe its clinical characteristics and pathophysiology, (3) review current therapies and their limitations, (4) discuss novel agents in development and (5) create a framework for the design and conduct of future clinical trials. Content Type Journal ArticlePages 1-16DOI 10.1007/s10741-012-9315-1Authors Mihai Gheorghiade, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAMuthiah Vaduganathan, Department of Medicine, Massachusetts General Hospital, Boston, MA, USAAndrew Ambrosy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USAMichael Böhm, Department of Internal Medicine III, University Hospital of Saarland, Homburg/Saar, GermanyUmberto Campia, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAJohn G. F. Cleland, Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston-upon-Hull, UKFrancesco Fedele, Department of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University, Rome, ItalyGregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USAAldo P. Maggioni, ANMCO Research Center, Florence, ItalyAlexandre Mebazaa, Department of Anesthesia and Intensive Care, Lariboisiere Hospital, University of Paris, Paris, FranceMandeep Mehra, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAMarco Metra, Cardiology, Department of Experimental and Applied Medicine, University and Civil Hospital of Brescia, Brescia, ItalySavina Nodari, Cardiology, Department of Experimental and Applied Medicine, University and Civil Hospital of Brescia, Brescia, ItalyPeter S. Pang, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAPiotr Ponikowski, Department of Cardiology, Wroclaw Medical University, Wroclaw, PolandHani N. Sabbah, Department of Medicine, Henry Ford Hospital, Detroit, MI, USAMichel Komajda, Assistance Publique Hopitaux de Paris, University Pierre et Marie Curie Paris, Paris, FranceJaved Butler, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Prognostic implications of renal dysfunction in patients ... Abstract Numerous studies over the last decade have demonstrated that renal dysfunction and worsening renal function (WRF) are common in patients hospitalized for heart failure (HHF) and appear to be associated with poor in-hospital and post-discharge outcomes. Unfortunately, its etiology has not been completely understood, and its prediction during hospitalization remains challenging. The evaluation of renal impairment during hospitalization should take into consideration the underlying renal substrate (e.g., predisposing clinical comorbidities such as diabetes and hypertension), initiating mechanisms (e.g., in-hospital therapies such as diuretics), and amplifying factors (neurohormonal and hemodynamic profile changes). Various patterns of WRF may have different prognostic implications and may require different therapeutic approaches. WRF may be initially classified by duration (transient vs. persistent) and by etiology (elevated venous pressures vs. arterial underfilling). Other critical contributing factors during hospitalization include progressive left ventricular dysfunction, neurohormonal activation, and medications. Transient WRF as a result of aggressive therapy targeting congestion may not be associated with poor outcomes. Persistent WRF seen in patients with severe hemodynamic derangements may be associated with poor post-discharge prognosis. Future investigations must clarify the pathophysiological correlates of various patterns of WRF. To date, there is an unmet clinical need to achieve adequate control over congestion while preserving renal function in HHF patients. Thus, the aim of this review is to provide an in-depth and critical interpretation of the available data on the prognostic importance of RD and WRF during hospitalization in an effort to improve HF management. Content Type Journal ArticlePages 1-10DOI 10.1007/s10741-012-9317-zAuthors Filippo Brandimarte, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyMuthiah Vaduganathan, Department of Medicine, Massachusetts General Hospital, Boston, MA, USAGian Francesco Mureddu, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyGiuseppe Cacciatore, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyHani N. Sabbah, Department of Medicine, Henry Ford Hospital, Detroit, MI, USAGregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USASteven R. Goldsmith, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USAJaved Butler, Heart Failure Research, Emory Clinical Cardiovascular Research Institute, Atlanta, GA, USAFrancesco Fedele, Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Diseases, Sapienza University, Rome, ItalyMihai Gheorghiade, Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Incretins as a novel therapeutic strategy in patients wit... Abstract Heart failure (HF) and diabetes mellitus (DM) commonly co-exist, with a prevalence of DM of up to 40 % in HF patients. Treatment of DM in patients with HF is challenging since many of the contemporary therapies used for the treatment of DM are either contraindicated in HF or are limited in their use due to the high prevalence of co-morbidities such as significant renal dysfunction. This article presents an overview of the physiology of the incretin system and how it can be targeted therapeutically, highlighting implications for the management of patients with DM and HF. Receptors for the incretin glucagon-like peptide-1 (GLP-1) are expressed throughout the cardiovascular system and the myocardium and are up-regulated in HF. GLP-1 therapy improves cardiac function in animal models of HF through augmented glucose uptake in the myocardium mediated through a p38 MAP kinase pathway. Small clinical studies have shown that GLP-1 improves ejection fraction, reduces BNP levels and enhances functional capacity in patients with chronic HF. A number of randomized controlled trials are currently underway to define the utility of targeting the incretin system in HF patients with DM. Incretin-based therapy may represent a novel therapeutic strategy in the treatment of HF patients with diabetes, in particular for their cardioprotective effects independent of those attributable to tight glycemic control. Content Type Journal ArticlePages 1-8DOI 10.1007/s10741-012-9318-yAuthors M. A. Khan, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKC. Deaton, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKM. K. Rutter, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKL. Neyses, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKM. A. Mamas, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Heart failure among South Asians: a narrative review of r... Abstract Individuals of South Asian descent have a high prevalence of comorbidities that are risk factors for the development of heart failure (HF), including diabetes mellitus and metabolic syndrome. However, little is known about the prevalence of HF, its management and prognosis for this population compared to Caucasians. Therefore, a literature review relating to the nature, outcome and treatment of HF in South Asian patients compared to Caucasians was conducted. It was anticipated that collating existing studies in this manner would be useful for guiding professionals in managing HF within this ethnic group, given that to achieve optimal care, regimens need to take into account cultural differences that may impact on adherence. Reviewed literature showed that South Asians with HF were more likely to be younger and have diabetes and hypertension. These papers also implied that outcomes for South Asians with HF were similar or even better than for Caucasians. The review highlighted the under-representation of South Asians in HF trials, meaning that evidence-based recommendations tailored to this specific population are limited. This is an important consideration because ethnic differences in response to medication have been reported; it cannot be assumed that treatments shown to work for Caucasians will be efficacious for those from minority ethnic groups. Content Type Journal ArticlePages 1-10DOI 10.1007/s10741-012-9319-xAuthors Stephanie Tierney, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UKChristi Deaton, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UKMamas Mamas, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UK Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Patient selection for mechanical circulatory support Abstract Heart failure continues to be associated with high morbidity and mortality. Over the past decade, left ventricular assist devices have been shown to improve the survival and quality of life. However, it is quite clear that very sick patients do not do as well, and it is therefore imperative to select patients at the proper time. In this article, we review both the indications for considering left ventricular assist device therapy as well as discuss the considerations and therapy that should be done pre-operatively to possibly improve post-insertion outcomes. Content Type Journal ArticlePages 1-8DOI 10.1007/s10741-012-9316-0Authors Nisha A. Gilotra, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 568, Baltimore, MD 21287, USAStuart D. Russell, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 568, Baltimore, MD 21287, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Diastolic ventricular support with cardiac support device... Abstract Heart failure is a global epidemic with limited therapy. Abnormal left ventricular wall stress in the diseased myocardium results in a biochemical positive feedback loop that results in global ventricular remodeling and further deterioration of myocardial function. Mechanical myocardial restraints such as the Acorn CorCap and Paracor HeartNet ventricular restraints have attempted to minimize diastolic ventricular wall stress and limit adverse ventricular remodeling. Unfortunately, these therapies have not yielded viable clinical therapies for heart failure. Cellular and novel biopolymer-based therapies aimed at stabilizing pathologic myocardium hold promise for translation to clinical therapy in the future. Content Type Journal ArticlePages 1-9DOI 10.1007/s10741-012-9312-4Authors Pavan Atluri, Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St., Philadelphia, PA 19104, USAMichael A. Acker, Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St., Philadelphia, PA 19104, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Diabetic cardiomyopathy: pathophysiology and clinical fea... Abstract Since diabetic cardiomyopathy was first reported four decades ago, substantial information on its pathogenesis and clinical features has accumulated. In the heart, diabetes enhances fatty acid metabolism, suppresses glucose oxidation, and modifies intracellular signaling, leading to impairments in multiple steps of excitation–contraction coupling, inefficient energy production, and increased susceptibility to ischemia/reperfusion injury. Loss of normal microvessels and remodeling of the extracellular matrix are also involved in contractile dysfunction of diabetic hearts. Use of sensitive echocardiographic techniques (tissue Doppler imaging and strain rate imaging) and magnetic resonance spectroscopy enables detection of diabetic cardiomyopathy at an early stage, and a combination of the modalities allows differentiation of this type of cardiomyopathy from other organic heart diseases. Circumstantial evidence to date indicates that diabetic cardiomyopathy is a common but frequently unrecognized pathological process in asymptomatic diabetic patients. However, a strategy for prevention or treatment of diabetic cardiomyopathy to improve its prognosis has not yet been established. Here, we review both basic and clinical studies on diabetic cardiomyopathy and summarize problems remaining to be solved for improving management of this type of cardiomyopathy. Content Type Journal ArticlePages 1-18DOI 10.1007/s10741-012-9313-3Authors Takayuki Miki, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanSatoshi Yuda, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanHidemichi Kouzu, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanTetsuji Miura, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 Japan Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Rodent models of heart failure: an updated review Abstract Heart failure (HF) is one of the major health and economic burdens worldwide, and its prevalence is continuously increasing. The study of HF requires reliable animal models to study the chronic changes and pharmacologic interventions in myocardial structure and function and to follow its progression toward HF. Indeed, during the past 40 years, basic and translational scientists have used small animal models to understand the pathophysiology of HF and find more efficient ways of preventing and managing patients suffering from congestive HF (CHF). Each species and each animal model has advantages and disadvantages, and the choice of one model over another should take them into account for a good experimental design. The aim of this review is to describe and highlight the advantages and drawbacks of some commonly used HF rodents models, including both non-genetically and genetically engineered models, with a specific subchapter concerning diastolic HF models. Content Type Journal ArticlePages 1-31DOI 10.1007/s10741-012-9305-3Authors A. C. Gomes, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalI. Falcão-Pires, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalA. L. Pires, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalC. Brás-Silva, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalA. F. Leite-Moreira, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- MR, CT, and PET imaging in pericardial disease Abstract Although echocardiography remains the standard diagnostic tool for identifying pericardial diseases, procedures with better delineation of morphology and heart function are often required. The pericardium consists of an inner visceral (epicardium) and outer parietal layer (pericardium), which constitute for the pericardial cavity. Pericardial effusion can occur as transudate, exudate, pyopneumopericardium, or hemopericardium. Potential causes are inflammatory processes, that is, pericarditis due to autoimmune or infective reasons, neoplasms, irradiation, or systemic disorders, chronic renal failure, endocrine, or metabolic diseases. Pericardial fat can mimic pericardial effusion. Using various image-acquisition sequences, MRI allows identifying and separating fluid and solid structures. Fast spin-echo T1-weighted sequences with black-blood preparation are favourably used for morphological evaluation. Fast spin-echo T2-weighted sequences, particularly with fat saturation, and short-tau inversion-recovery sequences are useful to visualize oedema and inflammation. For further tissue characterization, delayed inversion-recovery imaging is used. Therefore, image acquisition is performed at 5–20 min subsequent to contrast agent administration, the so-called technique of late gadolinium enhancement. Ventricular volumes and myocardial mass can be assessed accurately by steady-state free-precession sequences, which is required to measure cardiac function and ventricular wall stress. Constrictive pericarditis usually results from chronic inflammatory processes leading to increased stiffness, which impedes the slippage of both pericardial layers and thereby the normal cardiac filling. CT imaging can favourably assess pericardial calcification. Thus, MR and CT imaging allow a comprehensive delineation of the pericardium. Superior to echocardiography, both methods provide a larger field of view and depiction of the complete chest including abnormalities of the surrounding mediastinum and lungs. PET provides unique information on the in vivo metabolism of 18-fluorodeoxyglucose that can be superimposed on CT findings and is useful for identifying inflammatory processes or masses, for example neoplasms. These imaging techniques provide advanced information of anatomy and cardiac function to optimize the pericardial access, for example by the AttachLifter system, for diagnosis and treatment. Content Type Journal ArticlePages 1-18DOI 10.1007/s10741-012-9309-zAuthors Peter Alter, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyJens H. Figiel, Department of Radiology, Philipps University, Marburg, GermanyThomas P. Rupp, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyGeorg F. Bachmann, Department of Radiology, Kerckhoff Heart Center, Bad Nauheim, GermanyBernhard Maisch, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyMarga B. Rominger, Department of Radiology, Philipps University, Marburg, Germany Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Assessment and management of aortic valve disease in pati... Abstract The onset of symptoms or left ventricular systolic dysfunction heralds a poor prognosis for patients with either aortic stenosis or aortic regurgitation. Echocardiography is the primary imaging modality for assessment of aortic valvular lesions. Cardiac catheterization is indicated to determine the severity of the aortic valve lesion when there is a discrepancy between the clinical findings and the results of echocardiography in patients with either symptoms or left ventricular dysfunction. For patients with low-gradient, low-output aortic stenosis, dobutamine provocation should be used to differentiate truly severe aortic stenosis from patients with a primary cardiomyopathy and low aortic valve area due to low forward flow. Aortic valve surgery improves myocardial performance by relief of ventricular afterload in both patients with severe stenosis and those with severe regurgitation. Surgery should be pursued in both patients with severe aortic stenosis and those with severe regurgitation regardless of the degree of left ventricular dysfunction. Content Type Journal ArticlePages 1-14DOI 10.1007/s10741-012-9311-5Authors Mackram F. Eleid, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USASunil Mankad, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USAPaul Sorajja, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
Heart Rhythm
- Effect of electrocardiographic lead placement on localiza... Background: The origin of outflow tract ventricular tachycardia (OTVT) can be predicted from a surface electrocardiogram: indexes of R-wave amplitudes in leads V1 and V2 are used to differentiate a right origin from a left origin, while the axis of lead I differentiates an anterior origin from a posterior origin. Incorrect electrode placement is clinically common and may alter predictability of OTVTs. Objective: To explore the influence of vertical deviation in leads V1 and V2 and arm lead position on the QRS morphology of OTVTs. Methods: Vertical deviation of leads V1 and V2 was studied in 18 patients with OTVTs. Ventricular premature depolarization beats were recorded in the standard position, superior position, and inferior position. The effect of arm lead position was studied in a separate cohort of 16 patients: ventricular premature depolarizations were recorded with limb leads positioned over the shoulders and over the chest. The origin of tachycardia was determined by using activation mapping and confirmed by successful ablation. Results: Superior displacement of leads V1 and V2 reduced the R-wave amplitude and led to a decreased R/S ratio (0.11 ± 0.09 vs 0.17 ± 0.1; P <.01), while inferior displacement of leads V1 and V2 resulted in an increased R-wave amplitude and led to an increased R/S ratio (0.46 ± 0.35 vs 0.17 ± 0.1; P <.01). Anterior displacement of the arm leads from shoulders to chest resulted in the reduction in the R-wave amplitude in lead I (0.25 ± 0.30 mV vs 0.04 ± 0.43 mV; P <.05). Conclusions: Small changes in electrocardiographic electrode placement markedly alter the QRS morphology of OTVTs and thus alter the predictability of OTVT origin. These deviations are well within the range of clinical application and have the potential to misdirect ablation procedures.
- Predictors of long-term success after catheter ablation o... Background: Electrophysiologic characteristics, mapping strategies, and acute success rates of radiofrequency catheter ablation of atriofascicular accessory pathways are well described. However, data on long-term prognosis and predictors for freedom from arrhythmias are lacking. Objective: To report our 20-year single-center experience on ablation of atriofascicular fibers. Method: Between 1992 and 2010, 34 patients with atriofascicular accessory pathways underwent catheter ablation at our institution because of symptomatic antidromic atrioventricular reentrant tachycardias. Radiofrequency procedures were retrospectively analyzed, and patients were followed for recurrences of tachyarrhythmias. Electrocardiograms (before and after ablation and at follow-up) were analyzed for each patient. Results: Successful catheter ablation of the atriofascicular fiber was achieved in 23 (68%) patients. Mechanical block during mapping occurred in 3 (9%) patients, and in 2 of them ablation was performed at the site of mechanical block. Mere modification of conduction properties of the pathway without complete block was achieved in 5 patients (15%). Fast pathway ablation was performed in 2 (6%) of the patients ablated in the early 1990s. During follow-up of 9.3 ± 5.5 years, 24 patients (71%) remained free of tachyarrhythmias, 7 reported significant improvement, and 3 (9%) had no change in symptoms after ablation. Long-term success was identical between patients from the first (1992–1999) and second (2000–2010) decade (12 of 17 [71%] vs 12 of 17 [71%]). It was 87% in those with complete block of the atriofascicular fiber while all patients with mechanical block during mapping reported recurrences. Fast pathway ablation was complicated by complete atrioventricular block in 1 patient, who required pacemaker implantation 18 years after ablation owing to loss of conduction properties of the atriofascicular fiber over the years. On analyzing patients with preexcitation before ablation (n = 16; 47%), we found that the PR interval after ablation was significantly longer only in those without recurrence (162 ± 21 ms vs 134 ± 21 ms; P = .042). None of the other analyzed electrocardiographic parameters, including PR, QRS duration, and preexcitation, had prognostic impact. Conclusion: Acute success of complete ablation of atriofascicular pathways is associated with excellent long-term success (87%). Mere modification of conduction properties of atriofascicular fibers or ablation at the sites of mechanical block are less promising end points of ablation with high recurrence rates. Technical innovations during decades may not further improve long-term outcome in these patients.
- Contact force–controlled zero-fluoroscopy catheter abla... Background: Conventional catheter ablation of cardiac arrhythmias is associated with radiation risks for patients and laboratory personnel. However, nonfluoroscopic catheter guidance may increase the risk for inadvertent cardiac injury. A novel radiofrequency ablation catheter capable of real-time tissue-tip contact force measurements may compensate for nonfluoroscopic safety issues. Objective: To investigate the feasibility of contact force–controlled zero-fluoroscopy catheter ablation. Methods: In 30 patients (including 12 pediatric patients), zero-fluoroscopy catheter ablation of right-sided (right atrium, n = 20; right ventricle, n = 2) and left atrial (n = 8) arrhythmias was attempted. Inclusion criteria were symptomatic suspected atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal right atrial and ventricular arrhythmias, and lone atrial fibrillation. A novel irrigated-tip catheter with an integrated contact force sensor was used for nonfluoroscopic 3-dimensional electroanatomical mapping and radiofrequency ablation. Transseptal access was gained under transesophageal guidance for ablation of left-sided arrhythmias. Results: Procedural success without fluoroscopy was achieved in 29 of the 30 patients (97%). In 1 patient, endocardial nonfluoroscopic ablation failed because of an epicardial accessory pathway within a coronary sinus aneurysm. Mean total contact force and amplitude of force undulations were kept below 50 g during mapping and below 40 g during ablation to prevent contact force peaks (>100 g). Apart from a transient second-degree type I atrioventricular block, no complications occurred. The mean procedure time was 2.8 ± 0.9 hours. There were no arrhythmia recurrences during a mean follow-up of 6.2 ± 4.2 months. Conclusion: Contact force–controlled zero-fluoroscopy catheter ablation is generally feasible in right-sided and left atrial cardiac arrhythmias.
- Radiation exposure: A silent complication of catheter abl... An underappreciated “silent complication” of catheter ablation procedures is radiation exposure. X-ray exposure results in acute complications related to dose- and time-dependent exposure as well as a cumulative, lifetime risk to not only the patient but also the operator and electrophysiology staff. These risks include acute and subacute dermatologic injury, musculoskeletal injury, cataracts, malignancy, and genetic defects. These risks are heightened for lengthy and multiple ablation procedures (eg, atrial fibrillation) and for vulnerable patients such as pediatric, obese, and pregnant patients.
- Unpredictable battery depletion of St Jude Atlas II and A... Background: Predictable progression to battery depletion is necessary for device management in patients with pacemakers or implantable cardioverter-defibrillators, particularly in patients who either are pacemaker dependent or have required implantable cardioverter-defibrillator therapies. Objective: To determine the incidence and characteristics of unexpected battery depletion in patients implanted with a cardiac resynchronization therapy – defibrillator (CRT-D) device. Methods: All patients with a St Jude Atlas+ HF or Atlas II HF CRT-D device implanted between 2004 and 2007 at the Massachusetts General Hospital and the Nashville VA Medical Center (Vanderbilt University) were studied. All patients with early generator depletion (transition of generator voltage above specified elective replacement indicator [ERI] to end of life [EOL] in less than 90 days) were evaluated further. Results: Eight cases (mean age 69.6 ± 9 years) with abrupt battery depletion were identified among 191 patients (4.2%) implanted with a St Jude Atlas CRT-D device. The longevity of 8 premature depletion devices was 46.4 ± 10 months (median 45 months). The battery voltage in these 8 devices decreased from a mean of 2.48 ± 0.03 V (above ERI) to 2.3 ± 0.08 V (below ERI) over 33.3 ± 23 days (range 1–59 days; median 38.5 days). One device reached EOL status within 1 day of having battery voltage above ERI and another device within 12 days. Conclusion: The incidence of abrupt battery depletion was 4.2% in patients implanted with a St Jude Atlas CRT-D device. No common mechanism has been identified for this failure. Close monitoring of battery voltage and timely generator replacement are required in patients with these devices.
- Expecting the unpredictable The implantable cardioverter-defibrillator (ICD) is the cornerstone for the prevention of sudden cardiac death in high-risk patients. This has been proven time and again in numerous randomized trials and observational studies conducted over the last 20 years. However, its efficacy depends heavily on the predictability of device longevity and integrity. Impaired longevity confers risks to the patient associated with more frequent reoperations (infection, lead damage, etc). In addition, cost-effectiveness calculations are perturbed by significant differences between projected and observed device longevities. Impaired integrity might put the patient at risk for malignant arrhythmias that are not detected, not treated, or neither detected nor treated or at a risk of sudden deterioration of heart failure or syncope due to pacing failure.
- Percutaneous extraction of stented device leads Background: There are limited published data regarding the percutaneous extraction of device leads jailed by a venous stent. Objective: In this study we assessed the feasibility and safety of percutaneous extraction of stented device leads. Methods: We reviewed our experience percutaneously extracting 7 chronically implanted device leads jailed to the wall of the left innominate and/or subclavian veins by a previously placed stent. Results: All leads were successfully extracted by using a percutaneous approach. Both pacing leads and defibrillator leads were extracted. The oldest pacing lead extracted was 14 years old. The oldest defibrillator lead extracted was 6 years old. Three of the leads were extracted with simple manual traction alone. The 4 remaining leads required a more complex, femoral extraction approach for successful removal. Conclusion: In our experience extracting 7 stented device leads, complete percutaneous removal was feasible 100% of the time using a combination of simple manual traction and a femoral approach. No major complications were associated with the extraction procedures.
- Incidence and predictors of short- and long-term complica... Background: Today quantitative information about the type of complications and their incidence during long-term pacemaker (PM) follow-up is scarce. Objective: To assess the incidence and determinants of short- and long-term complications after first pacemaker implantation for bradycardia. Methods: A prospective multicenter cohort study (the FOLLOWPACE study) was conducted among 1517 patients receiving a PM between January 2003 and November 2007. The independent association of patient and implantation-procedure characteristics with the incidence of PM complications was analyzed using multivariable Cox regression analysis. Results: A total of 1517 patients in 23 Dutch PM centers were followed for a mean of 5.8 years (SD 1.1), resulting in 8797 patient-years. Within 2 months, 188 (12.4%) patients developed PM complications. Male gender, age at implantation, body mass index, a history of cerebrovascular accident, congestive heart failure, use of anticoagulant drugs, and passive atrial lead fixation were independent predictors for complications within 2 months, yielding a C-index of 0.62 (95% confidence interval 0.57–0.66). Annual hospital implanting volume did not additionally contribute to the prediction of short-term complications. Thereafter, 140 (9.2%) patients experienced complications, mostly lead-related complications (n = 84). Independent predictors for long-term complications were age, body mass index, hypertension, and a dual-chamber device, yielding a C-index of 0.62 (95% confidence interval 0.57–0.67). The occurrence of a short-term PM complication was not predictive of future PM complications. Conclusions: Complication incidence in modern pacing therapy is still substantial. Most complications occur early after PM implantation. Although various patient- and procedure-related characteristics are independent predictors for early and late complications, their ability to identify the patient at high risk is rather poor. This relatively high incidence of PM complications and their poor prediction underscores the usefulness of current guidelines for regular follow-up of patients with PM.
- Potential mechanisms underlying the effect of gender on r... Background: Recent studies demonstrate that women may respond more favorably to cardiac resynchronization therapy (CRT) than do men. The mechanisms remain unclear. Objectives: To describe the effects of gender on response to CRT and to explore potential mechanisms behind these differences. Methods: Data for 846 patients from the SMART-AV trial were used to evaluate the mechanisms behind the effects of gender on CRT response. Atrioventricular optimization (AVO) was performed via SmartDelay or echocardiography. Baseline and 6-month left ventricular end systolic volume index (LVESVi) were fitted to a linear regression model with gender predicting change in LVESVi and adjusted for baseline covariates significantly differing by gender. The interaction variable for AVO and gender was also assessed for its effect on change in LVESVi. Results: Baseline variables, including age, body mass index, left ventricular ejection fraction, QRS width, and severity of heart failure symptoms, were comparable between men and women. Women had a higher incidence of left bundle branch block conduction and nonischemic cardiomyopathy and exhibited greater reductions in LVESVi even after adjustment for these differences (13.4 mL/m2 vs 8.5 mL/m2; P = .002). In addition, women had greater percentages of biventricular pacing and appeared to derive greater reductions in left ventricular volume with AVO than did men. Conclusions: Women demonstrated greater reductions in LVESVi with CRT than did men. These observations are not explained by differences in baseline characteristics. Greater degrees of biventricular pacing and enhanced response to AVO in women may partly explain the reason for the gender effect on CRT response.
- Riata implantable cardioverter-defibrillator lead failure... Background: The Riata family of implantable cardioverter-defibrillator leads (St Jude Medical, Sylmar, CA) appears prone to a unique failure mechanism whereby the conductor cables wear through the silicone insulation from inside-out and are seen outside the lead body (externalized conductors). Objective: To assess the extent of Riata lead damage associated with inside-out insulation defects and their clinical consequences. Methods: In September 2011, we searched the U.S. Food and Drug Administration's Manufacturers and User Defined Experience medical device database for reports describing Riata lead failures that had been analyzed by the manufacturer. Results: The Manufacturers and User Defined Experience search identified 105 leads that had inside-out insulation defects. Eight-French single-coil Riata leads accounted for a higher-than-expected proportion (25.7%) of the leads with this defect. A total of 226 insulation defects were found in the 105 leads (2.2 defects per lead), including 143 inside-out defects (1.4 defects per lead). The most common location of insulation defects was distal to the proximal coil (n = 108). Twenty-eight leads (26.7%) had inside-out insulation defects underneath the shocking coils. Of 43 leads whose cables were assessed for the integrity of the ethylene-tetrafluoroethylene cable coating, 22 (51.2%) were found to be abraded, exposing the conductor surfaces. On X-ray radiography or fluoroscopy, 7 leads were found to have externalized cables; 2 of these leads had no electrical abnormalities, while 4 exhibited noise or increased impedance. Inappropriate shocks were experienced by 31 of the 105 patients (29.5%). Conclusion: Riata leads that have inside-out insulation defects often have multiple defects, including additional inside-out abrasions along the body of the lead and beneath the shocking coils. Eight-French single-coil Riata models may be more prone to externalized cables than are dual-coil and 7-F designs. Externalized cables are but one manifestation of interior insulation damage. Our findings question the durability of the ethylene-tetrafluoroethylene cable coating on exposed cables.
Heart and Vessels
- Mechanical alternans in human idiopathic dilated cardiomy... Abstract Mechanical alternans (MA) is frequently observed in patients with heart failure, and is a predictor of cardiac events. However, there have been controversies regarding the conditions and mechanisms of MA. To clarify heart rate-dependent contractile properties related to MA, we performed incremental right atrial pacing in 17 idiopathic dilated cardiomyopathy (DCM) patients and in six control patients. The maximal increase in left ventricular dP/dt during pacing-induced tachycardia was assessed as the force gain in the force–frequency relationship (FG-FFR), and the maximal increase in left ventricular dP/dt of the first post-pacing beats was examined as the force gain in poststimulation potentiation (FG-PSP). As a result, MA was induced in 9 DCM patients (DCM MA(+)) but not in the other 8 DCM patients (DCM MA(−)), and not in any of the control patients. DCM MA(+) had significantly lower FG-FFR (34.7 ± 40.9 vs 159.4 ± 103.9 mmHg/s, P = 0.0091) and higher FG-PSP (500.0 ± 96.8 vs 321.9 ± 94.9 mmHg/s, P = 0.0017), and accordingly a wider gap between FG-PSP and FG-FFR (465.3 ± 119.4 vs 162.5 ± 123.6 mmHg/s, P = 0.0001) than DCM MA(−) patients. These characteristics of DCM MA(+) showed clear contrasts to those of the control patients. In conclusion, MA is caused with an impaired force–frequency relationship despite significant poststimulation potentiation, suggesting that MA reflects ineffective utilization of the potentiated intrinsic force during tachycardia. Content Type Journal ArticleCategory Original ArticlePages 1-9DOI 10.1007/s00380-012-0251-8Authors Takeshi Kashimura, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanMakoto Kodama, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanKomei Tanaka, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanKeiko Sonoda, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanSatoru Watanabe, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanYukako Ohno, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanMakoto Tomita, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanHiroaki Obata, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanWataru Mitsuma, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanMasahiro Ito, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanSatoru Hirono, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanHaruo Hanawa, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 JapanYoshifusa Aizawa, Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, 951-8510 Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Utility of measuring C-reactive protein for prediction of... Abstract Controlling blood pressure is essential for prevention of events after acute aortic dissection (AAD). However, in some instances a cardiac event occurs despite controlled blood pressure, and its prediction is difficult. We continuously monitored C-reactive protein (CRP) in patients receiving medical treatment for AAD and retrospectively examined the utility of CRP measurement for prediction of in-hospital events. Five hundred and eight patients were diagnosed as having AAD between 1993 and 2009, 240 of whom underwent antihypertensive medical therapy. These subjects were 156 males and 84 females, average age 67.4 years, with 68 cases of Stanford type A and 172 cases of Stanford type B. C-reactive protein was measured in all patients daily until a peak; subsequently, CRP was measured 2–3 times per week following the peak until discharge. In the event-free group CRP demonstrated a peak on the 4th day after the onset (average 13.7 mg/dl), then gradually decreased to an average of 4.6 mg/dl 4 weeks later, displaying a “gradual decay” pattern. Despite controlled systolic arterial pressure of approximately 120 mmHg, 7 of 68 Stanford A cases (10.3 %) and 8 of 172 Stanford B cases (4.7 %) developed cardiovascular events. The group characterized by events exhibited a CRP pattern distinct from that of the event-free group, i.e., prolonged elevation and/or re-elevation. We demonstrated that the CRP pattern could provide information regarding prediction of cardiovascular events. Prolonged elevation or re-elevation of CRP may indicate the necessity of (1) application of computed tomography or magnetic resonance imaging, (2) more rigorous blood pressure management, or (3) early surgical intervention. Content Type Journal ArticleCategory Original ArticlePages 1-6DOI 10.1007/s00380-012-0257-2Authors Norihito Okina, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanMasanao Ohuchida, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanTomohiro Takeuchi, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanTomoki Fujiyama, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanAkira Satoh, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanTeruo Sakamoto, Kurume University Hospital Advanced Critical Care Center, Kurume, Fukuoka, JapanHisashi Adachi, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, JapanTsutomu Imaizumi, Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011, Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Are high-potency statins in low dose “strong statins”? Are high-potency statins in low dose “strong statins”? Content Type Journal ArticleCategory Letter to the editorPages 1-1DOI 10.1007/s00380-012-0255-4Authors Robert Berent, Center for Cardiovascular Rehabilitation, Rehabilitationszentrum Austria, Bad Schallerbach, AustriaHelmut Sinzinger, Institute for Diagnosis and Treatment of Lipid Disorders and Atherosclerosis (ATHOS), Vienna, Austria Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Left atrial thickness under the catheter ablation lines i... Abstract A detailed understanding of the left atrial (LA) anatomy in patients with atrial fibrillation (AF) would improve the safety and efficacy of the radiofrequency catheter ablation. The objective of this study was to examine the myocardial thickness under the lines of the circumferential pulmonary vein isolation (CPVI) using 64-slice multidetector computed tomography (MDCT). Fifty-four consecutive symptomatic drug-refractory paroxysmal AF patients (45 men, age 61 ± 12 years) who underwent a primary CPVI guided by a three-dimensional electroanatomic mapping system (Carto XP; Biosense-Webster, Diamond Bar, CA, USA) with CT integration (Cartomerge; Biosense-Webster) were enrolled. Using MDCT, we examined the myocardial thickness of the LA and pulmonary vein (PV) regions in all patients. An analysis of the measurements by the MDCT revealed that the LA wall was thickest in the left lateral ridge (LLR; 4.42 ± 1.28 mm) and thinnest in the left inferior pulmonary vein wall (1.68 ± 0.27 mm). On the other hand, the thickness of the posterior wall in the cases with contact between the esophagus and left PV antrum was 1.79 ± 0.22 mm (n = 30). After the primary CPVI, the freedom from AF without any drugs during a 1-year follow-up period was 78 % (n = 42). According to the multivariate analysis, the thickness of the LLR was an independent positive predictor of an AF recurrence (P = 0.041). The structure of the left atrium and PVs exhibited a variety of myocardial thicknesses in the different regions. Of those, only the measurement of the LLR thickness was associated with an AF recurrence. Content Type Journal ArticleCategory Original ArticlePages 1-9DOI 10.1007/s00380-012-0253-6Authors Kazuyoshi Suenari, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanYukiko Nakano, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanYukoh Hirai, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanHiroshi Ogi, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanNoboru Oda, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanYuko Makita, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanShigeyuki Ueda, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanKenta Kajihara, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanTakehito Tokuyama, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanChikaaki Motoda, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanMai Fujiwara, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 JapanKazuaki Chayama, Department of Molecular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, JapanYasuki Kihara, Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Comparison of inflammatory response after implantation of... Abstract Because systemic inflammation after coronary intervention places patients at increased risk of subsequent cardiac events, we aimed to compare clinical outcomes and chronic serum inflammation markers of paclitaxel-eluting stents (PES) and sirolimus-eluting stents (SES) in hemodialysis patients. Paclitaxel-eluting stents and SES were implanted in 36 patients with 46 lesions, and 32 patients with 40 lesions, respectively. In addition to 1-year major adverse cardiac event (MACE) rates, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), neopterin, intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) were also compared before and 9 months after percutaneous coronary intervention (PCI). The incidence of MACE was significantly lower in the PES group than in the SES group (11.1 vs. 25.0 %, respectively, P = 0.042), mainly due to the reduction of target lesion revascularization in the PES group (6.5 vs. 17.5 %, P = 0.003). The logarithm of hs-CRP as well as IL-6 decreased significantly 9 months post-PCI compared with pre-PCI in the PES group (hs-CRP: 3.65 ± 0.35 vs. 2.91 ± 0.48, P = 0.007; IL-6: 6.73 ± 3.66 vs. 2.61 ± 2.29, P = 0.017) but not in the SES group (hs-CRP: 3.33 ± 0.29 vs. 3.42 ± 0.27, P not significant; IL-6: 6.08 ± 4.97 vs. 5.66 ± 4.29, P not significant). However, neopterin, ICAM-1, and VCAM-1 remained unchanged both pre-PCI and 9 months post-PCI in both groups. Moreover, MACE were less frequent in patients with decreased hs-CRP levels 9 months post-PCI compared with patients without decreased hs-CRP levels (P = 0.002) in all patients. Paclitaxel-eluting stents appear to be more effective than SES in reducing MACE rates, especially target lesion revascularization, and may be able to stabilize local inflammatory changes of target lesions specifically in patients on hemodialysis. Thus PES, which inhibit in-stent restenosis and cardiac events in hemodialysis patients, may play an important role in suppression of chronic inflammatory response in target lesions as compared with SES. Chronic continuous inflammation plays an important role after implantation of both types of stent with regard to in-stent restenosis in patients on hemodialysis. Content Type Journal ArticleCategory Original ArticlePages 1-8DOI 10.1007/s00380-012-0250-9Authors Hideki Yano, Department of Hypertension and Cardiorenal Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi 321-0293, JapanShigeo Horinaka, Department of Hypertension and Cardiorenal Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi 321-0293, JapanHiroshi Yagi, Department of Hypertension and Cardiorenal Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi 321-0293, JapanToshihiko Ishimitsu, Department of Hypertension and Cardiorenal Medicine, Dokkyo Medical University Hospital, Mibu, Tochigi 321-0293, Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Metabolic syndrome and risk of progression of chronic kid... Abstract Metabolic syndrome (MetS) is a risk factor for the development of diabetes and cardiovascular disease, and recently was linked to incident chronic kidney disease (CKD). The purpose of this study is to examine whether MetS is associated with CKD progression in Japanese at a single center. Outcome variables were a decrease in estimated glomerular filtration rate (eGFR) of 50 % or 25 ml/min/1.73 m2, end-stage renal disease (ESRD), death, or a composite outcome of all three. There were 213 subjects in the analysis, 40.4 % of whom met the criteria for MetS. The group of subjects with MetS had higher urinary albumin-to-creatinine (UACR) levels. Survival curves stratified by MetS status showed early separation of the curves and a significantly higher survival rate in the group without MetS (P = 0.0086). Comparisons with normoalbuminuria and microalbuminuria showed that macroalbuminuria was equally associated with predicted composite outcome (GFR, ESRD, or death) both in the presence and absence of MetS. Multivariate analyses for all covariates showed that eGFR (hazard ratio (HR) 8.286, 95 % confidence interval (CI) 2.360–28.044, P = 0.0012) and the UACR (HR 2.338, 95 % CI 1.442–3.861, P = 0.0005) at baseline were independently associated with the composite outcomes. The results show that MetS was associated with albuminuria in a cohort of Japanese CKD patients, and both MetS and albuminuria were independently associated with CKD progression. Content Type Journal ArticleCategory Original ArticlePages 1-7DOI 10.1007/s00380-012-0254-5Authors Takako Saito, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanToshio Mochizuki, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanKeiko Uchida, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanKen Tsuchiya, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanKosaku Nitta, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Differences in hemodynamic responses between intravenous ... Abstract While recent guidelines for the treatment of acute heart failure syndromes (AHFS) recommend pharmacotherapy with vasodilators in patients without excessively low blood pressure (BP), few reports have compared the relative efficiency of vasodilators on hemodynamics in AHFS patients. The present study aimed to assess the differences in hemodynamic responses between intravenous carperitide and nicorandil in patients with AHFS. Thirty-eight consecutive patients were assigned to receive 48-h continuous infusion of carperitide (n = 19; 0.0125–0.05 μg/kg/min) or nicorandil (n = 19; 0.05–0.2 mg/kg/h). Hemodynamic parameters were estimated at baseline, and 2, 24, and 48 h after drug administration using echocardiography. After 48 h of infusion, systolic BP was significantly more decreased in the carperitide group compared with that in the nicorandil group (22.1 ± 20.0 % vs 5.3 ± 10.4 %, P = 0.003). While both carperitide and nicorandil significantly improved hemodynamic parameters, improvement of estimated pulmonary capillary wedge pressure was greater in the carperitide group (38.2 ± 14.5 % vs 26.5 ± 18.3 %, P = 0.036), and improvement of estimated cardiac output was superior in the nicorandil group (52.1 ± 33.5 % vs 11.4 ± 36.9 %, P = 0.001). Urine output for 48 h was greater in the carperitide group, but not to a statistically significant degree (4203 ± 1542 vs 3627 ± 1074 ml, P = 0.189). Carperitide and nicorandil were differentially effective in improving hemodynamics in AHFS patients. This knowledge may enable physicians in emergency wards to treat and manage patients with AHFS more effectively and safely. Content Type Journal ArticleCategory Original ArticlePages 1-7DOI 10.1007/s00380-012-0252-7Authors Hidetoshi Hattori, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanYuichiro Minami, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanMasayuki Mizuno, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanDai Yumino, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanHiromi Hoshi, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanHiroyuki Arashi, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanToshiaki Nuki, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanYukiko Sashida, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanMichiaki Higashitani, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanNaoki Serizawa, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanNorihiro Yamada, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanJunichi Yamaguchi, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanFumiaki Mori, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanTsuyoshi Shiga, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 JapanNobuhisa Hagiwara, Department of Cardiology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Persistent coronary artery spasm documented by follow-up ... Abstract For patients with variant angina it is very important to start medical therapy using calcium-channel blockers. However, the decision of physicians regarding whether to decrease the dose of the drug or discontinue it is controversial. We investigated whether the nature of spasm is remissive and whether the termination of medications is safe. The subjects studied were included in the Vasospastic Angina in Catholic Medical Center Registry from March 2001 to December 2009. We analyzed 37 patients (62 lesions) with variant angina, diagnosed using coronary angiography (CAG) and he acetylcholine provocation test, without any organic coronary stenosis, whose symptoms were well controlled after medication. The follow-up CAG with provocation test was performed at a median interval of 44 months. The characteristics of spasm were analyzed on each pair of CAGs. The study group consisted of 23 men (62.2 %) and 14 women (37.8 %) with a mean age of 59 ± 11.1 years. The follow-up CAG with provocation test showed that the characteristics of the spasmodic nature were consistent with the first test in all patients. Although the patients with variant angina had no chest pain after medical treatment, the spasmodic nature of coronary arteries still remained. We may decrease the drug dosage after carefully checking the patient’s symptoms but recommend not discontinuing therapy, even if the patient is asymptomatic. Content Type Journal ArticleCategory Original ArticlePages 1-7DOI 10.1007/s00380-012-0249-2Authors Suk Min Seo, Cardiovascular Center and Cardiology Division, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, KoreaPum Joon Kim, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaDong Il Shin, Cardiovascular Center and Cardiology Division, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, KoreaTae-Hoon Kim, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaChan Jun Kim, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaJin-soo Min, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaYoon Seok Koh, Cardiovascular Center and Cardiology Division, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, KoreaHun Jun Park, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaDong Bin Kim, Cardiovascular Center and Cardiology Division, St. Paul’s Hospital, The Catholic University of Korea, Seoul, KoreaSung-Ho Her, Cardiovascular Center and Cardiology Division, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon, KoreaKi-Yuk Chang, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaSang Hong Baek, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaWook Sung Chung, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 KoreaKi-Bae Seung, Cardiovascular Center and Cardiology Division, Seoul St. Mary’s Hospital, The Catholic University of Korea, #505 Banpo-Dong, Seocho-Ku, Seoul, 137-040 Korea Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Endomyocardial biopsy in a patient with hemorrhagic pheoc... Abstract A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma. Content Type Journal ArticleCategory Case ReportPages 1-9DOI 10.1007/s00380-012-0247-4Authors Kohei Iio, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanShunpei Sakurai, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanTamon Kato, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanShigeki Nishiyama, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanTakeki Hata, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanEiichiro Mawatari, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanChihiro Suzuki, Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanKazuhiro Takekoshi, Department of Laboratory Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, JapanKayoko Higuchi, Department of Pathology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanToru Aizawa, Diabetes Center, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano 390-8510, JapanUichi Ikeda, Department of Cardiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
- Adverse cardiovascular outcomes associated with concurren... Abstract Recent clinical studies reported the drug interaction between proton-pump inhibitors (PPI) and clopidogrel, which remains controversial. The aim of this study was to determine whether the concurrent use of PPI with clopidogrel or ticlopidine is associated with increased risk for adverse cardiovascular outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). In this retrospective cohort study, we assessed the cardiovascular outcomes associated with the concurrent use of PPI and clopidogrel or ticlopidine in the well-characterized 1286 patients with CAD undergoing PCI in the University of Tokyo Hospital. In the Japanese patients with CAD undergoing PCI, the concurrent use of PPI was significantly associated with increased risk for major adverse cardiovascular events in the ticlopidine users (hazard ratio 2.63; 95 % confidence interval 1.65–4.18; P < 0.001), but not in the clopidogrel users. In the clopidogrel users as well as the ticlopidine users, PPI use did not affect the occurrence of target lesion revascularization, but significantly increased the risk for new lesion formation in the coronary arteries, which required subsequent revascularization. The adverse cardiovascular effects of the concurrent use of PPI and ticlopidine were identified in the patients with CAD undergoing PCI. Also, new lesion formation in the coronary arteries was shown to be increased when PPI was coprescribed for the thienopyridine users. Content Type Journal ArticleCategory Original ArticlePages 1-9DOI 10.1007/s00380-012-0248-3Authors Atsuko Nakayama, Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 JapanHiroyuki Morita, Department of Translational Research for Healthcare and Clinical Science, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 JapanJiro Ando, Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 JapanHideo Fujita, Department of Ubiquitous Health Informatics, Graduate School of Medicine, University of Tokyo, Tokyo, JapanHiroshi Ohtsu, Department of Clinical Trial Data Management, Graduate School of Medicine, University of Tokyo, Tokyo, JapanRyozo Nagai, Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan Journal Heart and VesselsOnline ISSN 1615-2573Print ISSN 0910-8327
Clinical Lipidology
- Pitavastatin: a new option for the reduction of cardiovas... Clinical Lipidology , June 2012, Vol. 7, No. 3s, Pages 1-1.
- Pitavastatin: a different pharmacological profile Clinical Lipidology , June 2012, Vol. 7, No. 3s, Pages 3-9.
- Which statin is the ideal statin for polymedicated patients? Clinical Lipidology , June 2012, Vol. 7, No. 3s, Pages 11-16.
- Role of HDL-C as a cardiovascular risk factor: clinical r... Clinical Lipidology , June 2012, Vol. 7, No. 3s, Pages 17-24.
- Pitavastatin: an overview of the LIVES study Clinical Lipidology , June 2012, Vol. 7, No. 3s, Pages 25-31.
Critical Pathways in Cardiology
- Current and Future Alternatives to Warfarin for the Preve... Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice and is associated with a nearly 5-fold increase in the risk of stroke. Warfarin has been the cornerstone of treatment to reduce stroke risk in AF patients for decades. Although effective in preventing thrombosis, warfarin is difficult to manage and is associated with a 1% to 7% yearly risk of major hemorrhage. Until recently, there were no effective oral alternatives to warfarin. Dabigatran etexilate, a direct thrombin inhibitor, was approved in 2010 for the reduction of stroke and systemic embolism in patients with nonvalvular AF, and the factor Xa inhibitor rivaroxaban was approved for a similar indication in 2011. Other late-stage orally administered agents that may be approved for this indication include apixaban and edoxaban; others at earlier stages of development will be discussed in this review as well. Nonpharmacological approaches to stroke prevention include left atrial appendage removal, ligation, or occlusion. This review examines advances in the management of stroke risk in AF patients, focusing on recently marketed and late-stage modalities. The advent of alternatives to warfarin for reducing stroke risk in AF patients may improve physicians’ ability to offer safe and effective stroke prevention in all AF patients.
- A Guidance Pathway for the Selection of Novel Anticoagula... Oral anticoagulation with vitamin K antagonists has served as the primary treatment for the prevention of stroke and systemic embolization in patients with atrial fibrillation (AF) for decades. Over the past several years, multiple novel oral anticoagulants targeting key mediators of coagulation, including thrombin and factor Xa, have been developed. Specifically, agents targeting thrombin (dabigatran) and factor Xa (apixaban and rivaroxaban) have either reached late stages of clinical development (apixaban) or have received approval (dabigatran, rivaroxaban) by the US Food and Drug Administration for use in patients with nonvalvular AF. The promising results derived from large-scale clinical trials with these agents compared to warfarin expand the available therapeutic options for the prevention of stroke and systemic embolization in this rapidly increasing patient population. Here we present a general guidance pathway for the initiation and selection of oral anticoagulants in patients with AF.
- Management of Non–ST-Segment Elevation Acute Coronary S... The American College of Cardiology/American Heart Association and the European Society of Cardiology published updated guidelines in 2011 for the management of patients with non–ST-segment elevation acute coronary syndrome. In this article, we highlight the most important new recommendations, review their supporting data, describe differences between the guidelines, and discuss new literature published since the latest guidelines were released. Key updates include detailed guidance regarding early risk stratification, use of coronary computed tomography angiography, selection of initial management strategy, novel antiplatelet agents, and new measures to enhance performance and quality. Major unique recommendations in the European Society of Cardiology guideline include endorsement of ticagrelor inhibitor or prasugrel (after delineation of coronary anatomy) as the first choice of P2Y12 inhibitors, establishment of protocols to identify patients for percutaneous coronary interventions vs. coronary artery bypass surgery, and use of the CRUSADE bleeding score. Meanwhile, unique recommendations in the American College of Cardiology/American Heart Association guideline include administration of prasugrel in selected patients before coronary angiography and consideration of continued dual antiplatelet therapy beyond 15 months after drug-eluting stent placement. Both guidelines include new recommendations endorsing platelet function and genetic testing in selected patients on clopidogrel, renal protection strategies, and less aggressive in patient’s glycemic control. As these guidelines represent the most evidence-based approach, health care providers should become familiar with these updated recommendations to ensure optimal treatment of their patients with non–ST-segment elevation acute coronary syndrome.
- Utility of Daily Troponin Orders for Identifying Acute My... Background: Previous studies have demonstrated low rates of adherence to American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for acute myocardial infarction (AMI). Quality improvement projects increase compliance with recommended therapies, but identification of AMI patients is a major challenge. Objective: To determine the utility of a daily troponin list in identifying AMI patients for a quality improvement initiative to increase compliance with ACC/AHA-recommended therapies. Design: Quality improvement initiative. Methods and Results: During a 3-month period, the charts of patients with elevated troponin levels were screened for a diagnosis of AMI. For those patients with AMI, a clinical reminder about ACC/AHA-recommended therapies was placed in the chart. Nearly half (46%) of our hospital population had a troponin level measured during their clinical course. Of these, 26% had elevated troponin levels and 5% had AMI. All patients with AMI were identified using the daily troponin list with a sensitivity of 100% and a specificity of 78.4%. The daily troponin list captured more AMI patients than the admitting diagnosis. Use of the daily troponin list and targeted clinical reminders was associated with maintenance of a high (>95%) compliance with recommended therapies. Conclusions: A daily list of inpatients with a positive troponin identified all patients with AMI. Targeted reminders to clinicians regarding ACC/AHA-recommended therapies for AMI were associated with consistent adherence to guideline-recommended therapies.
- Treatment Pathways and Quality Improvement for Patients W... The timely diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI) have become paramount to improving outcomes in this population. Many states, including North Carolina, have established systems to guide regional emergency providers in caring for STEMI. We describe the current pathway for diagnosis and treatment of STEMI for providers referring patients to Duke University Hospital, including a system for expedited patient transport and activation of the cardiac catheterization laboratory from a wide referral base. There is also a structured process for review of cases and quality improvement, which incorporates physicians, administrators, and emergency medical personnel.
- Acute Stroke Initiative Involving an Acute Care Team The Acute Care Team Educational Initiative (ACTEI) was developed as a quality improvement initiative for the recognition and initial management of time-sensitive medical conditions. For our first time-sensitive disease process, we focused on acute stroke [acute stroke initiative (ASI)]. As part of the larger ACTEI, the ASI included creating an ACT that responds to all suspected emergency department stroke patients. In this article, we describe the planning, process, and development of the ACTEI/ASI as well as how we created an acute response team for the diagnosis and management of suspected acute stroke.
- A Novel Pericardial Effusion Scoring Index to Guide Decis... Background: Subacute pericardial tamponade can present without signs of cardiogenic shock. Symptoms and signs lack both sensitivity and specificity. Methods: We conducted a case-control study in consecutive hospitalized patients with moderate-to-large pericardial effusion who had no evidence of hemodynamic compromise upon admission. Patients with pericardial effusion drained for diagnostic and/or therapeutic purposes served as cases, and patients who were not drained served as controls. Demographic, clinical, and laboratory data were obtained by retrospective chart review. Echocardiograms were reviewed by 2 independent observers. Pericardial effusion scoring index was calculated for each patient based on effusion size, echocardiographic assessment of hemodynamics, and clinical factors. Results: A total of 48 patients were included in the study: 27(56%) patients had pericardial effusion drained and 21(44%) had clinical follow-up without drainage. Pericardial effusion drainage was surgical in 60% of the cases with the mean time to drainage of 2.5 days. No significant difference was seen between the groups in terms of clinical hemodynamic parameters such as blood pressure or heart rate upon initial presentation. The mean pericardial effusion scoring index was 6.0 for cases and 3.3 for controls showing a wide separation between the groups (P < 0.01). The area under the curve for receiver operator characteristic was 0.91 (95% confidence interval, 0.82–1.00). Conclusions: The pericardial effusion scoring index obtained at the initial presentation in patients without immediate hemodynamic compromise showed a high accuracy in identifying patients who required pericardial effusion drainage downstream.
- Society of Chest Pain Centers: What Factors Drive Prehos... No abstract available
The American Journal of Geriatric Cardiology
- Progress in Treating Hypertension
- The Utility of the 6-Minute Walk Test as a Measure of Fra... Patients with heart failure (HF) are at increased risk for frailty, and identification is challenging. The authors assessed the distance on the 6-minute walk test (6MWT) as a measure of frailty in 60 older HF patients (ejection fraction ≤40%) compared with frailty phenotype (FP). Scores were dichotomized to frail (F) or nonfrail (NF), and the results of 6MWT were dichotomized to low endurance (LE) or normal endurance (NE). FP and 6MWT results were in moderate agreement (κ=0.57, confidence interval [CI], 0.36–0.79; age-adjusted κ=0.54, 95% CI, 0.33–0.76);25% of participants were classified as F/LE, and 55% were classified as NF/NE. Discordance was asymmetric (McNemar P=.006); 18% of participants were NF/LE. There were no differences between the NF/LE and other groups in age, sex, body mass index, or physical activity level. Results in the NF/LE group differed from those in the NF/NE group by a slower 8-foot walking speed (P=.02), weaker grip strength (P=.056), and worse renal function (P=.01) and from those in the F/LE group by faster 8-foot walking speed (P<.001). The 6MWT may be useful to identify frailty and those in transition to frailty.
- High NT-proBNP Is a Strong Predictor of Outcome in Elderl... All patients older than 65 years (184 men; mean age, 78±0.8 years/181 women; mean age, 82±0.6 years) seeking medical attention at the Lund University Hospital Emergency Clinic during a 2-year period who had an N-terminal prohormone brain natriuretic peptide (NT-proBNP) value >2000 pg/mL were followed up for survival. Mortality in the entire population was 21% after 3 months, 35% after 1 year, and 40% after 2 years. Multivariate analysis indicated that the NT-proBNP level and the New York Heart Association (NYHA) functional class were stronger predictors of mortality than were echocardiographic estimation of left ventricular ejection fraction or chest radiography. Patients who survived the first year were younger, had higher systolic blood pressure, had lower plasma creatinine, had lower inflammatory activity, and were treated with lower doses of furosemide. The results indicate that in this population, NT-proBNP level together with assessment of NYHA class gives the best prognostic information of 1-year mortality.
- Impact of Combination Evidence-Based Medical Therapy on M... Antiplatelet drugs, β-blockers, statins, and angiotensinogen-converting enzyme inhibitors reduce mortality following myocardial infarction (MI). The data on the impact of combination evidence-based medications on mortality following acute MI in elderly patients are limited. In this study, 5529 patients with MI admitted between January 2000 and December 2003 were assessed. Based on discharge use of evidence-based medications, the patients were divided into those using 0, 1, 2, 3, or 4 medications. The impact of medications on 1-year mortality was assessed for patients younger than 75 years and 75 years and older. Mean age of the patients was 63±13 years (71% male). The unadjusted 1-year mortality post-MI was 18.3% and 52.7% for young and elderly patients, respectively. Compared with patients with 0 medications, the adjusted odds ratio for 1-year mortality was lower in patients with 1, 2, 3, and 4 medications in both groups. Use of combination evidence-based medications was independently associated with lower 1-year post-MI mortality irrespective of age.
- Efficacy and Safety of Fixed Combinations of Irbesartan/H... Subgroup analysis of the Irbesartan/Hydrochlorothiazide Blood Pressure Reductions in Diverse Patient Populations (INCLUSIVE) trial evaluated the efficacy and safety of irbesartan/hydrochlorothiazide (HCTZ) fixed combinations in patients aged 65 years or older with uncontrolled systolic blood pressure (SBP) after ≥4 weeks of antihypertensive monotherapy. The INCLUSIVE trial was a prospective, open-label, single-arm trial carried out in 119 sites. Of 844 patients completing placebo treatment, 212 were aged 65 years or older. Participants received treatment with placebo (4–5 weeks), HCTZ 12.5 mg (2 weeks), irbesartan/HCTZ 150/12.5 mg (8 weeks), and then irbesartan/HCTZ 300/25 mg (8 weeks). From baseline to week 18 (n=184, intent-to-treat population), mean change in SBP was −23.0±13.3 mm Hg (P<.001) and diastolic BP (DBP) was −10.9±7.7 mm Hg (P<.001). Mean SBP/DBP at study end was 134.0±14.7/75.1±8.4 mm Hg, and SBP, DBP, and SBP/DBP goal was achieved in 73%, 96%, and 72% of patients, respectively. Irbesartan/HCTZ combination therapy allowed SBP goal attainment in 73% of patients aged 65 years or older whose hypertension was previously uncontrolled with antihypertensive monotherapy.
- The Women's Initiative for Nonsmoking (WINS) XI: Age-Rela... Smoking cessation has immediate health benefits; however, the efficacy of smoking cessation interventions among older adults and women has received limited research attention. The original Women's Initiative for Nonsmoking (WINS) study was a randomized controlled trial that tested the efficacy of a smoking cessation intervention for Bay Area women hospitalized with cardiovascular disease. The current study, which used the WINS dataset, compares participants 62 and older with those younger than 62 years. The sample (n=277) contained 136 older smokers and 141 younger smokers. At the 6-month follow-up, 52.1% of older smokers had quit smoking compared with 40.6% of younger smokers. At the 12-month follow-up, 52.0% of older smokers had quit smoking compared with 38.1% of younger smokers. The difference at 12 months was statistically significant, and a Kaplan-Meier survival analysis further supported these findings. Clinicians should be sure to also include older smokers in smoking assessments and smoking cessation interventions.(Am J Geriatr Cardiol. 2008;17:37–47)
- Ethical Issues in the Management of Geriatric Cardiac Pat... Ethical Issue:Participating physicians failed to properly document that the patient had no reasonable expectation of recovery. This caused a delay in the initiation of discussion concerning end-of-life.
- Morphologic Features of Atherosclerotic Plaque in Occlusi...
- Twiddler's Syndrome: An Unusual Cause of Pacemaker Dysfun...
- Increased Heart Rate: An Emerging Cardiovascular Risk Fac...
Annals of Noninvasive Electrocardiology
- Letter from the New Editor-in-Chief
- Direct His Bundle and Parahisian Cardiac Pacing The success rate of direct His bundle pacing (DHBP) and paraHisian pacing has improved remarkably in the last 3–5 years with the advent of dedicated fixation systems that have reduced procedural duration, dislodgement rate, and fluoroscopy time. The methodology of DBHP remains still more complex than paraHisian pacing and is associated with high-pacing thresholds. Thus, DHBP entails greater battery current drain and reduced device longevity. A shift toward paraHisian pacing (which is fusion pacing of myocardium and His bundle) has occurred because its implementation is easier and the electrical parameters are superior to those of DBHP. Currently, an additional safety lead is inserted at the RV apex or outflow tract to prevent asystole, especially in patients with pure DHBP. It is often possible to avoid a safety lead with paraHisian pacing because ventricular pacing is virtually assured on a long-term basis via myocardial capture. DBHP and paraHisian pacing can be achieved in a substantial proportion of patients with varying grades of narrow QRS AV block or after AV junctional ablation and in some patients with the ECG manifestation of bundle branch block caused by an intraHisian lesion. Preliminary observations suggest that DHBP may be useful in some patients requiring cardiac resynchronization if it produces a narrow QRS complex because the site of an intraHisian lesion responsible for left bundle branch block is above the site of DHBP.
- The Year of 2010 in Electrocardiology
- The Terminal Part of the QT Interval (T peak to T end): A... Background: The terminal part of the QT interval (T peak to T end; Tp-e)—an index for dispersion of cardiac repolarization—is often prolonged in patients experiencing malignant ventricular arrhythmias after acute myocardial infarction (AMI). We wanted to explore whether high Tp-e might predict mortality or fatal arrhythmia post-AMI.Methods: Tp-e was measured prospectively in 1359/1384 (98.2%) consecutive patients with ST elevation (n = 525) or non-ST elevation (n = 859) myocardial infarction (STEMI or NSTEMI) admitted for coronary angiography.Results: Tp-e was significantly correlated with age, heart rate (HR), heart failure, LVEF, creatinine, three-vessel disease, previous AMI and QRS and QT duration. During a mean follow-up of 1.3 years (range 0.4–2.3),109 patients (7.9%) died; 25, 45, and 39 from cardiac arrhythmia, nonarrhythmic cardiac causes and other causes, respectively. Long Tp-e was strongly associated with increased risk of death, and Tp-e remained a significant predictor of death in multivariable Cox analyses (RR 1.5, 95% CI[1.3–1.7]). HR-corrected Tp-e (cTp-e) was the strongest predictor of death (RR 1.6 [1.4–1.9]). Tp-e and cTp-e were particularly strong predictors of fatal cardiac arrhythmia (RR 1.6 [1.2–2.1] and RR 1.8 [1.4–2.4]). Findings were similar in STEMI and NSTEMI. When comparing two methods for measuring Tp-e, one including the tail of the T wave and one not, the former had markedly higher predictive power (P < 0.001).Conclusion: Tp-e, and in particular cTp-e, were strong predictors of mortality during the first year post-AMI, and should be further evaluated as prognostic factors additional to established post-AMI risk factors.
- Behavior of Repolarization Variables during Exercise Test... Background: T peak–T end, QT peak/QT ratio and T peak–T end/QT ratio are markers able to test myocardial repolarization homogeneity, their increase has been related to a higher risk of ventricular tachyarrhythmias. These parameters have not yet been studied in left ventricular hypertrophy due to training. Aim of the research was to test the behavior of these variables in the athlete's heart during exercise.Methods: We examined 70 athletes, all males, divided into two groups according to the absence or the presence of a left ventricular mass index over 49 g/m2.7 and a control group composed of 35 healthy, untrained males. All study participants underwent electrocardiogram at rest, transthoracic echocardiogram, and ergometric test. Repolarization markers (QT, corrected QT, QT dispersion, T peak–T end, QT peak/QT, T peak–T end/QT) were calculated at rest, at peak exercise and during recovery.Results: There was no statistically significant difference among the groups regarding all the parameters studied, except for corrected QT at rest between athletes with left ventricular hypertrophy and control group. The behavior of repolarization markers during exercise was not dissimilar in the three groups.Conclusions: Athlete's heart is not associated to any alteration in ventricular repolarization homogeneity, neither at rest nor during physical activity nor during recovery. Training-induced left ventricular hypertrophy does not affect relationship QT parameters/RR interval.
- Dynamicity of Early and Late Phases of Repolarization in ... Background: Repolarization dynamicity (QT/RR) is supposed to be a prognostic marker in post-MI patients. However, data on the relationships between early and late phases of QT and RR intervals (QT peak/RR and T peak–T end/RR) are insufficient, and which ECG lead should be used for the analysis is unclear. We analyzed repolarization dynamicity in patients after anterior MI with and without VT/VF history using two leads of Holter recordings- modified V5 and V3. The daytime and nighttime periods were also analyzed.Methods: Cohort of 88 patients after anterior MI (>6 months) consisted of 43 patients without VT/VF (33 males; 59 ± 12 years; LVEF: 41 ± 7%; NoVT/VF), and 45 patients with VT/VF history- ICD implanted as secondary prevention (40 males; 64 ± 10 years; LVEF: 32 ± 8%; VT/VF). QT/RR, QT peak/RR and T peak–T end/RR were calculated from 24-hour ECG for the entire recording, daytime and nighttime periods, from V5 and V3 leads, respectively.Results: VT/VF patients had lower LVEF (P = 0.001). There were no differences in age and gender. VT/VF group had steeper QT/RR, QT peak/RR, and T peak–T end/RR in V5: 0.233 ± 0.04 versus 0.150 ± 0.05, P = 0.0001, 0.181 ± 0.04 versus 0.120 ± 0.04, P = 0.0001, 0.052 ± 0.02 versus 0.030 ± 0.02, P = 0.0001, and in V3: 0.201 ± 0.04 versus 0.149 ± 0.05, P = 0.0001, 0.159 ± 0.03 versus 0.118 ± 0.04, P = 0.0001, and 0.042 ± 0.02 versus 0.031 ± 0.02, P = 0.004; respectively. VT/VF patients had higher indices in V5 than in V3 lead (P = 0.001). QT/RR and QT peak/RR were steeper at daytime period in both leads. It was not found for T peak–T end/RR.Conclusions: Patients with VT/VF history are characterized by steeper relationships between repolarization duration and RR intervals. These findings are more evident in modified V5 lead.
- Specificity of Elevated Intercostal Space ECG Recording f... Background: Right precordial (V1–3) elevated electrode placement ECG (EEP-ECG) is often used in the diagnosis of Brugada syndrome (BrS). However, the specificity of this has only been studied in smaller studies in Asian populations. We aimed to study this in a larger European population.Methods: Two different populations consisting of healthy subjects were used. A total of 340 subjects were included, 80% were men, the median age was 43 year (interquartile range: 31–51) and all were of European ethnicity.Results: No type 1 ECG patterns were identified but 16 (4.7%) subjects with a type 2 ECG and 32 (9.4%) subjects with a type 3 ECG were identified in any lead placement. In total 43 (13%) subjects had any BrS ECG pattern in any lead placement. The specificity was 100% (one-sided 97.5% CI: 99%) for the use of EEP-ECG to uncover type 1 pattern. For type 2 pattern the specificity was 95% (95% CI: 92–97%) and for type 3 pattern 91% (95% CI: 88–94%).Conclusions: Elevated electrode placement ECG in the diagnosis of BrS seems to have a very high specificity with regards to the finding of a type 1 ECG pattern in a European population; conversely a finding of a type 2 or 3 pattern is of a significantly lower specificity and should perhaps be disregarded.
- Prevalence of Conduction Abnormalities in a Systolic Hear... Background: There is paucity of data regarding conduction abnormalities in the Hispanic population with systolic heart failure (HF). We aimed to evaluate the prevalence of electrocardiogram (ECG) abnormalities in a systolic HF population, with attention to the Hispanic population.Methods: A cross sectional study of 926 patients enrolled in a systolic HF disease management program. ECGS were obtained in patients with an ejection fraction (EF) ≤ 40% by echocardiography at enrollment. Univariate and multivariate analysis adjusted by ethnicities was performed.Results: White patients exhibited higher prevalence of atrial fibrillation (14.7%) than black patients (8.0%, P = 0.01) whereas Hispanics presented higher prevalence of paced rhythm (14.3% in Hispanics vs. 6.5% in whites and 5.2% in blacks, P<0.01 for both comparisons), higher prevalence of left bundle branch block (LBBB, 14.5% in Hispanics vs. 8.8% in whites and 5.8% in blacks, P = 0.002) and increased frequency of abnormal QT intervals (76.7% in Hispanics) than whites (59.6%) and blacks (69%) patients (P< 0.01 for both comparisons). A QRS interval greater than 120 ms was less prevalent among blacks (15.8% vs. 26.0% in whites and 25.3% in Hispanics, P = 0.01 for both comparisons). Univariate and multivariate analysis disclosed no influence of other characteristics (age, sex, coronary artery disease, hypertension, ejection fraction, medications) in the ECG findings.Conclusions: Hispanics with Systolic HF presented with increased prevalence of paced rhythm, LBBB, and abnormal QT intervals. Attention should be addressed to these ECG variations to recommend additional guidance for therapeutic interventions and provide important prognostic information.
- Global and Regional Ventricular Repolarization Study by B... Background: The controversial effects promoted by cardiac resynchronization therapy (CRT) on the ventricular repolarization (VR) have motivated VR evaluation by body surface potential mapping (BSPM) in CRT patients.Methods: Fifty-two CRT patients, mean age 58.8 ± 12.3 years, 31 male, LVEF 27.5 ± 9.2, NYHA III-IV heart failure with QRS181.5 ± 14.2 ms, underwent 87-lead BSPM in sinus rhythm (BASELINE) and biventricular pacing (BIV). Measurements of mean and corrected QT intervals and dispersion, mean and corrected T peak end intervals and their dispersion, and JT intervals characterized global and regional (RV, Intermediate, and LV regions) ventricular repolarization response.Results: Global QTm (P < 0.001) and QTcm (P < 0.05) were decreased in BIV; QTm was similar across regions in both modes (P = ns); QTcm values were lower in RV/LV than in Intermediate region in BASELINE and BIV (P < 0.001); only RV/Septum showed a significant difference (P < 0.01) in the BIV mode. QTD values both of BASELINE (P < 0.01) and BIV (P < 0.001) were greater in the Intermediate than in the LV region. CRT effect significantly reduced global/regional QTm and QTcm values. QTD was globally decreased in RV/LV (Intermediate: P = ns). BIV mode significantly reduced global T peak end mean and corrected intervals and their dispersion. JT values were not significant.Conclusions: Ventricular repolarization parameters QTm, QTcm, and QTD global/regional values, as assessed by BSPM, were reduced in patients under CRT with severe HF and LBBB. Greater recovery impairment in the Intermediate region was detected by the smaller variation of its dispersion.
- Comparison of Standard versus Orthogonal ECG Leads for T-... T-wave alternans (TWA), an electrophysiologic phenomenon associated with ventricular arrhythmias, is usually detected from selected ECG leads. TWA amplitude measured in the 12-standard and the 3-orthogonal (vectorcardiographic) leads were compared here to identify which lead system yields a more adequate detection of TWA as a noninvasive marker for cardiac vulnerability to ventricular arrhythmias. Our adaptive match filter (AMF) was applied to exercise ECG tracings from 58 patients with an implanted cardiac defibrillator, 29 of which had ventricular tachycardia or fibrillation during follow-up (cases), while the remaining 29 were used as controls. Two kinds of TWA indexes were considered, the single-lead indexes, defined as the mean TWA amplitude over each lead (MTWAA), and lead-system indexes, defined as the mean and the maximum MTWAA values over the standard leads and over the orthogonal leads. Significantly (P < 0.05) higher TWA in the cases versus controls was identified only occasionally by the single-lead indexes (odds ratio: 1.0–9.9, sensitivity: 24–76%, specificity: 76–86%), and consistently by the lead-system indexes (odds ratio: 4.5–8.3, sensitivity: 57–72%, specificity: 76%). The latter indexes also showed a significant correlation (0.65–0.83) between standard and orthogonal leads. Hence, when using the AMF, TWA should be detected in all leads of a system to compute the lead-system indexes, which provide a more reliable TWA identification than single-lead indexes, and a better discrimination of patients at increased risk of cardiac instability. The standard and the orthogonal leads can be considered equivalent for TWA identification, so that TWA analysis can be limited to one-lead system.
Journal of Interventional Cardiac Electrophysiology
- Pacing polarity and left ventricular mechanical activatio... Abstract Objective The aim of this study is to evaluate the relationship between polarity of left ventricular (LV) pacing and the resultant regional, global, and transmural mechanical sequence of contraction. Background Cardiac resynchronization therapy (CRT) is widely utilized in patients with drug refractory congestive heart failure with systolic dysfunction (EF <35 %) and intraventricular conduction delay (QRS duration >120 ms). However, little is known about polarity of pacing stimulation and the resultant differences in LV mechanics. Methods The polarity of pacing was altered sequentially in 20 patients (73 ± 13, 16 males) with preexisting biventricular devices with potential choice of multiple vectors for pacing stimulation. Initial unipolar or extended bipolar configurations were switched to bipolar configuration or vice versa, and echocardiographic images were acquired for off-line analysis. Regional and global LV longitudinal and radial mechanics were assessed selectively from the subendocardial and subepicardial regions with 2D speckle-tracking echocardiography. Left ventricular capture by each vector configuration was confirmed by local lead capture and appropriate QRS alteration. Results Unipolar pacing resulted in increased dispersion of LV regional endocardial strains with a higher base-to-apex gradients of longitudinal shortening strains (P < 0.05). LV longitudinal shortening strain magnitude was higher at LV base with bipolar stimulation in comparison with unipolar stimulation (−10.5 ± 10.5 vs. −4.2 ± 6.3, P = 0.02). Conclusion There is a difference in the mechanical activation sequence of the LV between unipolar vs. bipolar pacing stimulation. This may have important implications for CRT. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9686-1Authors Hyan Suk Yang, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAGiuseppe Caracciolo, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAPartho P. Sengupta, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USARamil Goel, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAKrishnaswamy Chandrasekaran, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USAKomandoor Srivathsan, Division of Cardiovascular Diseases, Mayo Clinic, 5777, E Mayo Boulevard, Phoenix, AZ 85054, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Canine left ventricle electromechanical behavior under di... Abstract Background Cardiac resynchronization therapy may improve survival and quality of life in patients suffering from heart failure with left ventricular (LV) contraction dyssynchrony. While several studies have investigated electrical or mechanical determinants of synchronous contraction, few have focused on activation contraction coupling at a macroscopic level. Objective The objective of the study was to characterize LV electromechanical behavior and response to pacing in a heart failure model. Methods We analyzed data from 3D electroanatomic non-contact mapping and blood pool SPECT for 12 dogs with right ventricular (RV) tachycardia pacing-induced dilated cardiomyopathy. Surfaces generated by the two modalities were registered. Electrical signals were analyzed, and endocardial wall displacement curves were portrayed. Results Rapid pacing decreased the mean LV ejection fraction (LVEF) to 20.9 % and prolonged the QRS duration to 79 ± 10 ms (normal range: 40–50 ms). QRS duration remained unchanged with biventricular pacing (88.5 ms), while single site pacing further prolonged the QRS duration (113.3 ms for RV pacing and 111.6 ms for LV pacing). No trend was observed in LV systolic function. Activation duration time was significantly increased with all pacing modes compared to baseline. Finally, electromechanical delay, as defined by the delay between electrical activation and mechanical response, was increased by single site pacing (172.9 ms for RV pacing and 174.6 ms for LV pacing) but not by biventricular pacing (162.4 ms). Conclusions Combined temporal and spatial coregistration electroanatomic maps and baseline gated blood pool SPECT imaging allowed us to quantify activation duration time, electromechanical delay, and LVEF for different pacing modes. Even if pacing modes did not significantly modify LVEF or activation duration, they produced alterations in electromechanical delay, with biventricular pacing significantly decreasing the electromechanical delay as measured by surface tracings and endocardial non-contact mapping. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-010-9532-2Authors Thanh-Thuy Vo Thang, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaBernard Thibault, Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, CanadaVincent Finnerty, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaMatthieu Pelletier-Galarneau, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaPaul Khairy, Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, CanadaJean Grégoire, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, CanadaFrançois Harel, Department of Nuclear Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Reuse of infected cardiac rhythm management devices in th... Abstract Purpose Infected device explantation is increasingly necessary given the rapid growth in cardiac rhythm management device (CRMD) implantation in China. However, some patients with CRMD infection are unlikely to be capable of paying for a new device. Reassuringly, evidence suggests that reuse of cardiac devices can be safe and feasible. In this study, we evaluated whether explanted cardiac devices, due to infection, can be reimplanted safely within the same individuals. Methods All patients with CRMD infection between 2007 and 2010 were entered into a computer database. From these, patients that had need for CRMD implantation and reimplantation of their infected device were analyzed for safety and complications. Results Sixty patients had CRMD implantation after the infected device removal, and 44 (73.3 %) patients underwent procedures for reimplantation of their infected device. The mean age of the patients was 64.8 ± 16.5 years, and 32 (72.7 %) were male. Indications for device explantation were: pocket infection (86.6 %) and endocarditis (11.4 %). The average follow-up was 20.4 ± 9.0 months. Endocarditis recurred in one (2.3 %) patient with Brugada syndrome at 17 months after reimplantation of a refurbished implantable cardioverter-defibrillator. There were three deaths during the follow-up period secondary to myocardial infarction and cerebral vascular accident. No early battery depletion or device malfunction was identified during follow-up. Conclusions Our data emphasize that reimplantation of explanted CRMDs, due to infection, within the same individual is feasible, safe, and effective. Reuse of explanted CRMDs is an alternative choice for people in developing countries. Content Type Journal ArticlePages 1-6DOI 10.1007/s10840-012-9688-zAuthors Duan Jiangbo, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaLI Xuebin, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaZhang Ping, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaWang Long, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaLi Ding, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaChu Xianming, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, ChinaZe Feng, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaFang Yong, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaYuan Cuizhen, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, ChinaGuo Jihong, Department of Cardiac Electrophysiology, Peking University People’s Hospital, Beijing, China Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Gender differences in accessory connections location: an ... Abstract Background Recent studies have shown that the pathogenesis of accessory connections (AC) formation may have a genetic component. Objective The purpose of the study was to examine whether AC location differs by gender in a large cohort of patients with AC undergoing radiofrequency ablation (RFA) in two Israeli electrophysiology (EP) laboratories. Methods All consecutive patients who underwent RFA of single ACs in Tel Aviv Sourasky Medical Center between 1992 and 2009 (n = 574) as well as the first consecutive 230 patients who underwent RFA in Sheba Medical Center between 1992 and 2001 were included in this study. Results The 804 patients in the two centers included 511 males (63.6 %) and 293 (36.4 %) females, mean age 34 + 16 years old. The AC was located in the left free wall, posteroseptal, right free wall, right anteroseptal, and in other areas in 57.8, 22.8, 9.3, 7 and 3.1 % of patients, respectively. The anatomical AC distribution was similar in the two EP laboratories. A right free wall location was more frequent in females (13 %) than in males (7.2 %; p = 0.008). A right anteroseptal location was more frequent in males (8.4 %) than in females (4.4 %) (p = 0.043). The left free wall and posteroseptal locations were similarly encountered in males (58.1 and 23.1 %, respectively) and in females (57.3 and 22.2 %, respectively). Conclusions In our Israeli population, females more commonly have right free wall ACs and males more commonly have right anteroseptal ACs. These findings support the possible role of a genetic component in the pathogenesis of AC formation. Content Type Journal ArticlePages 1-3DOI 10.1007/s10840-012-9683-4Authors Edo Y. Birati, Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelMichael Eldar, Leviev Heart Center, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelBernard Belhassen, Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Ablation of atrial tachycardia occurring after catheter a... Abstract Objective The purpose of this study is to investigate the mechanism and the effectiveness of ablation of atrial tachycardia (AT) recurring after atrial fibrillation (AF) ablation in patients with rheumatic valvular disease (RVD) and mitral valve prosthesis. Methods Twenty-eight consecutive patients with RVD and mitral valve prosthesis and a 1:2 matched control group (n = 56) without RVD underwent reablation for recurrent AT after catheter ablation of long-standing persistent AF. Results Macro- or localized reentrant ATs were identified in 47 (87 %) of 54 ATs from RVD group and in 65 (78.3 %) of 83 ATs from control. There were more average ATs per patient in the RVD group than in the control (1.9 ± 0.6 vs.1.5 ± 0.6, P = 0.002). The proportion of patients having ≥2 ATs was significantly higher in the RVD group than in the control (78.6 vs.41.1 %, P = 0.001). In the RVD group, ATs were successfully ablated in 44 (81.5 %) of 54 ATs and terminated in 18 (64.3 %) of 28 patients. In the control, ATs were successfully ablated in 72 (86.7 %) of 83 ATs and terminated in 45 (80.4 %) of 56 patients, P = 0.54 and 0.10, respectively. After a mean follow-up of 13 months, 16 patients (57.1 %) from the RVD group and 45 patients (80.4 %) from the control were free of further recurrence, P = 0.02. Conclusions Macro- or localized reentries were the predominant type of recurrent AT after long-standing persistent AF ablation in both the RVD and the control groups. Compared with patients without RVD, patients with RVD had more average number of ATs and had higher probability of further recurrence despite the similar acute effectiveness of reablation. Content Type Journal ArticlePages 1-12DOI 10.1007/s10840-012-9678-1Authors Xin-hua Wang, Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China 430060Cong-xin Huang, Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China 430060Xu Liu, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaHai-feng Shi, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaHong-wei Tan, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaWei-feng Jiang, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, ChinaYuan-long Wang, Department of Cardiology, Shanghai Chest Hospital affiliated with Shanghai Jiaotong University, Shanghai, China Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Post-ablation prolongation of atrioventricular nodal refr... Abstract Purpose A residual slow pathway after successful cryoablation for atrioventricular nodal reentrant tachycardia (AVNRT) is correlated with a higher recurrence rate. We described determinants of recurrence in subjects with a residual jump. Methods We analyzed the data of subjects with acute successful slow pathway cryoablation for AVNRT using a 6-mm-tip cryocatheter. Success was defined as AVNRT non-inducibility. Patients with no baseline elicitable jump, no inducible AVNRT, and transient first atrioventricular (AV) block at the last site were excluded. Results From 371 patients who underwent cryoablation from May 2002 to March 2011, 303 fulfilled the entry criteria (mean age, 41 ± 16; 222 women). Baseline AV nodal effective refractory period (ERP) was 272 ± 57 ms, postprocedural 331 ± 64 (P < 0.001), and the mean of the difference (Δ ERP) 60 ± 41. At the end of the procedure, 64 patients (21 %) had a residual jump, of whom 22 with a single echo. At 12 months follow-up, the actuarial recurrence-free rate was 70.3 % in patients with a residual jump and 86 % in those without (P = 0.01). In patients with a jump, only Δ AV nodal ERP was correlated with recurrence (37 ± 41 vs. 68 ± 47 ms; P < 0.04) while a single echo was not. The actuarial rate of recurrence was 60.8 % in patients with a Δ AV nodal ERP ≤ 30 ms and 18.8 % in those with a Δ AV nodal ERP >30 ms (P < 0.01). Conclusions Suppression of slow pathway conduction is the optimal endpoint for AVNRT cryoablation. A residual jump can be tolerated if AV nodal ERP postcryoablation is prolonged >30 ms. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9680-7Authors Joelci Tonet, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceAntonio De Sisti, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceNatalia Pardo Restrepo, Universidad CES, Calle 10 A No. 22, Medellín, ColombiaDenis Raguin, Rhythmology Unit, Clinique de l’Europe, Amiens, FranceWalid Amara, Cardiology Department, le Raincy-Montfermeil Hospital, Montfermeil, FranceManlio F. Márquez, Departamento de Electrofisiología, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Col. Sección XVI, 14080 Mexico City, MexicoPhilip Aouate, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceXavier Waintraub, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceFaouzi Touil, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, FranceFrancoise Hidden-Lucet, Cardiology Institute, Rhythmology Unit, Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75651 Paris, France Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Nearly uniform failure of atrial flutter ablation and con... Abstract Background Ablation for atrial flutter and continued pharmacologic therapy (hybrid therapy) is a management strategy when treatment with class I antiarrhythmic drugs organize atrial fibrillation (AF) into flutter. Previous studies with 2–3-year follow-up have reported satisfactory control of AF burden. Objective We evaluated the effectiveness of hybrid therapy after a follow-up of 5 years. We hypothesized that longer term follow-up would demonstrate eventual failure of this strategy to control AF. Methods A consecutive, retrospective evaluation of all first time ablations of right atrial flutter at the University of Pennsylvania between August 2003 and August 2005 was performed (n = 179). The study population consisted of 33 patients who had atrial flutter only after treatment of AF with class I antiarrhythmic drugs and was continued on them post-ablation. Follow-up data were obtained by reviewing records from our institution, from referring cardiologists, and from direct patient questionnaires. Results Atrial fibrillation recurrence was noted in 28 of 31 patients (90.3 %) who completed 5 years of follow-up. AF recurrence typically resulted in significant symptoms, although 21 % developed persistent AF and were eventually minimally symptomatic on a rate control strategy. A wide range of time to recurrence was observed (0.2–64.5 months) with 39 % recurring greater than 2 years post-ablation. Conclusion Hybrid therapy is not effective for long-term control of AF. Patients should be counseled about the likelihood of eventual AF recurrence and anticoagulation should be maintained indefinitely when this strategy is used. Content Type Journal ArticlePages 1-5DOI 10.1007/s10840-012-9679-0Authors Nicholas Anastasio, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid S. Frankel, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAMarc W. Deyell, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAErica Zado, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAEdward P. Gerstenfeld, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USASanjay Dixit, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAJoshua Cooper, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid Lin, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USAFrancis E. Marchlinski, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USADavid J. Callans, Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- A novel approach to eliminate intraventricular lead place... Abstract Purpose We describe two patients with congenital heart disease who were referred for implantable cardioverter-defibrillator (ICD) placement. Both patients possessed factors causing the conventional transvenous approach to be undesirable. We therefore devised a technique which circumvented both intravascular ICD lead placement, as well as placement of leads across the tricuspid valve. Methods For both patients, a bipolar pace–sense lead was successfully placed in a branch of the coronary sinus. A shocking coil was then tunneled from the posterolateral margin of the device pocket, being positioned posterior and inferior to the cardiac silhouette. Defibrillation testing was carried out with goal of a 10-J safety margin. Results We were able to successfully achieve ICD implantation in both patients with complex congenital heart disease without requirement for surgical thoracotomy or a lead across the AV valve. R waves in excess of 5 mV were obtained and acceptable defibrillation characteristics were achieved. Both patients are doing well after mid-term follow-up. Conclusion A new implant approach is presented, which involves minimal intravascular hardware and eliminates passage across the atrioventricular valve for patients with congenital heart disease in whom conventional ICD implant techniques may be undesirable or not possible. This procedure is technically straightforward with proper technique and knowledge of the patient specific anatomy. Content Type Journal ArticlePages 1-4DOI 10.1007/s10840-012-9682-5Authors Nikhil Gupta, Los Angeles, CA, USAJeremy P. Moore, Los Angeles, CA, USAKevin Shannon, Los Angeles, CA, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Bifocal right ventricular pacing: an alternative way to a... Abstract Purpose Bifocal pacing in the right ventricle is an option for patients with end-stage heart failure in whom biventricular pacing is not possible, due to failure in left ventricular (LV) lead insertion. The purpose of this prospective study was to document the clinical response of these patients, after bifocal pacing. Methods From the patients referred for cardiac resynchronization therapy (CRT), from 2009 to 2010, 13 cardiac CRT candidates who underwent unsuccessful LV lead implantation were included. The bifocal system’s leads were implanted in the right atrium, the right ventricular (RV) apex, and the RV outflow tract. Initial patient assessment and follow-up evaluation after 6 months included clinical criteria, echocardiographic indices, and biochemical parameters. Results From 13 patients (age 68 ± 9 years, nine male), 10 improved clinically. New York Heart Association classification was reduced by one grade (from 3.6 ± 0.5 to 2.8 ± 0.8, p < 0.005 and respectively), while hospitalizations in 6-month time were reduced from three to one (p < 0.001). Six-minute walk test (in meters) increased from 176 ± 86 to 297 ± 91 (p < 0.001) and quality of life improved (EQ-VAS scale changed from 42 ± 12.5 % to 70.8 ± 20.3 %, p < 0.001). Mean shortening in QRS duration was 31.3 ms (from 165.1 ± 16.3 to 133.8 ± 12.7, p < 0.001) and B-type natriuretic peptide (in picograms per milliliter) dropped from 834 ± 350 to 621 ± 283 (p < 0.001). Ejection fraction (in percent) increased from 27.5 ± 4.6 to 33.3 ± 4.4 (p < 0.001), and mitral regurgitation severity decreased by one grade (from 2.7 ± 0.9 to 1.8 ± 0.7, p < 0.05). Conclusion RV bifocal pacing seems to offer a substantial clinical benefit to heart failure patients with traditional CRT indications and could be an alternative option when LV access is unsuccessful. Content Type Journal ArticlePages 1-7DOI 10.1007/s10840-012-9681-6Authors Skevos Sideris, Cardiology Department, Hippokration Hospital, Athens, GreeceConstantina Aggeli, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceEmmanouil Poulidakis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceKostas Gatzoulis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIoannis Vlaseros, Cardiology Department, Hippokration Hospital, Athens, GreeceKaterina Avgeropoulou, Cardiology Department, Hippokration Hospital, Athens, GreeceIoannis Felekos, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIlias Sotiropoulos, Cardiology Department, Hippokration Hospital, Athens, GreeceChristodoulos Stefanadis, First Cardiology Department, University of Athens, Hippokration Hospital, Athens, GreeceIoannis Kallikazaros, Cardiology Department, Hippokration Hospital, Athens, Greece Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
- Detection of inadvertent catheter movement into the coron... Abstract Objective The objective of this study was to evaluate the use of continuous catheter impedance monitoring prior to ablation to facilitate differentiation of the coronary sinus ostium (CSO) and the middle cardiac vein (MCV) from the right atrial posteroseptal region (RPS). Background Empiric observations have suggested that continuous catheter impedance monitoring could differentiate the CSO and MCV from the RPS region. Radiofrequency ablation in the MCV or coronary sinus has been associated with coronary artery injury. Differentiation of these areas may be difficult with either fluoroscopy or electrogram characteristics. Methods and results Continuous impedance measurements using a 4-mm Navistar (Biosense Webster) ablation catheter were conducted in 17 consecutive patients undergoing ablation for supraventricular tachycardia. The average impedance value was recorded at the right atrial septum (RS) posterior to the bundle of His, the RPS region, within 1 cm inside the CSO and in the MCV. These areas were confirmed and demarcated with 3-D mapping and biplane fluoroscopy. A significant increase in impedance was observed between the CSO (X = 146.6 ± 24.8) and RPS æè - x = 112.0 ± 12.6 öø regions (p < 0.001). Furthermore, a significant rise in impedance was seen between the MCV æè - x = 207.5 ± 45.8 öø and RPS and CSO, respectively (p < 0.001). No significant change in impedance was found between the RS æè - x = 112.9 ± 9.1 öø and RPS regions. Conclusions Continuous impedance measurements during mapping can facilitate differentiation of catheter locations inside the CSO and MCV from extracoronary sinus regions. This may reduce the risk of inadvertent coronary artery damage during the ablation procedure. Content Type Journal ArticlePages 1-5DOI 10.1007/s10840-012-9667-4Authors Scott J. Pollak, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAHeather Seckel, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAJoseph Monir, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAGeorge Ebra, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USAGeorge Monir, Arrhythmia and Ablation Center, Department of Cardiology, Florida Hospital, Orlando, FL, USA Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN 1383-875X
Journal of Interventional Cardiology
- Safety of Transcatheter Patent Ductus Arteriosus Closure ...
- Expanding the Use of 7-Fr Radial Access to Primary Percut... (J Interven Cardiol 2012; 25:1–2)
- Improving Long-Term ACS Management: Is There a Role for t... Acute coronary syndrome (ACS) is a major health burden, resulting in increased hospital admissions and significant morbidity and mortality. Platelet activation, which leads to thrombin generation, is highly implicated in ACS, and antiplatelet agents represent the current standard of care. Established antiplatelet agents include acetylsalicylic acid (ASA), thienopyridines (clopidogrel, ticlopidine), and glycoprotein IIb/IIIa inhibitors. Recently, antiplatelet therapy for ACS has evolved to include more potent inhibitors (e.g., prasugrel, cangrelor, and ticagrelor). During the acute phase of an acute coronary event, both anticoagulation and dual antiplatelet therapy with aspirin and a thienopyridine are guideline recommended as first-line treatment. While anticoagulation is usually limited to the acute in-patient phase, dual antiplatelet therapy is recommended for 12 months. Despite the efficacy of antiplatelet agents in ACS, in many patients the residual risk of death from cardiac events, myocardial infarction, stroke, and refractory ischemia remains high. Dual therapy (i.e., ASA or clopidogrel plus a vitamin K antagonist [VKA]), and triple therapy (two antiplatelets plus a VKA) are associated with increases in bleeding complications. New oral anticoagulants that offer a novel mechanism of action may, when added to the current standard of care, provide a more comprehensive response to thrombin generation. In this review, we examine the pathology of ACS, investigate antiplatelet therapies and describe emerging anticoagulants that may be of benefit when used as combination therapy with antiplatelet agents for secondary prevention in ACS patients.(J Interven Cardiol 2012;**:1–8)
- Comparison Between Radial and Femoral Approach for Percut... Objective:To compare safety and efficacy between the radial and femoral approach for percutaneous coronary intervention (PCI) in patients aged 80 years and older.Method:Two hundred sixty-eight elderly patients (80–97 years old, 176 men) who underwent elective PCI between May 2003 and May 2007 were included in this study: the femoral (hereinafter referred to as the Femoral Approach Group) approach was used on 156 patients and radial (Radial Approach Group) on 112 patients. Clinical and procedural characteristics and the incidence of in-hospital major adverse cardiac events (MACE, including cardiac death, nonfatal myocardial infarction, and target lesion revascularization) were compared between the 2 groups.Results:Procedural success rate was similar and >95% for both approaches. The radial approach was associated with longer cannulation (3.0 ± 2.8 minutes vs. 2.0 ± 1.9 minutes, P < 0.001), fluoroscopy time (23 ± 15 minutes vs. 19 ± 12 minutes, P = 0.03) and higher rate of crossover to an alternative access site (9.8% vs. 3.8%, P = 0.02) compared with the femoral approach, while ambulation time (5 ± 2 hours vs. 20 ± 4 hours, P < 0.001), and rates of access site bleeding (2.7% vs. 9.6%, P = 0.004), hematoma (4.5% vs. 10.9%, P = 0.006), or any vascular complication (7.1% vs. 23.7%, P < 0.001) were significantly reduced with the radial approach as opposed to femoral. Multivariate regression identifies the radial approach (OR = 0.25, CI = 0.09–0.75) as an independent negative predictor of postprocedural vascular complications.Conclusion:When compared to the femoral approach, PCI with the radial approach significantly reduces rates of vascular complications in high-risk populations of patients aged 80 years and older. However, efficacy and procedural success rates were similar for both groups whereas cannulation and fluoroscopy time longer and puncture failure rate higher with the radial approach than femoral.(J Interven Cardiol 2012;**:1–5)
- Thrombus-Aspiration through 5 Fr Guiding Catheter with Tr... Objectives:The purpose of this study was to assess the feasibility and safety of thrombus-aspiration through a 5 Fr guiding catheter with transradial approach in acute coronary syndromes.Background:The use of thrombus-aspirating devices improves myocardial reperfusion but requires at least a 6 Fr guiding catheter. Transradial coronary interventions using a 5 Fr guiding catheter are attractive to reduce bleeding complications.Methods:We retrospectively selected patients presenting acute coronary syndromes with angiographically visible thrombus who underwent thrombus-aspiration through radial access using a 4 Fr multipurpose catheter in a 5 Fr guiding catheter. We described clinical and angiographic characteristics of the cohort, and the procedure's technique, success and complications.Results:Among the 34 included patients, 29 presented ST-segment elevation myocardial infarction. Complete resolution of the ST-segment elevation was effective in 93% of these patients. TIMI flow grade after thrombus-aspiration was significantly improved compared to baseline TIMI flow grade or after passage of the guidewire (P < 0.001 for both). There was no dissection or perforation but we noted distal embolization in 5 cases probably explained by the high grade of intracoronary thrombus in our cohort.Conclusion:Thrombus-aspiration through a 5 Fr guiding catheter with transradial approach seems to be safe and effective in selected patients with acute coronary syndrome. This mini-invasive approach brought the advantages of the transradial access in 5 Fr but also its limitations.(J Interven Cardiol 2012;**:1–7)
- Guthrie Health Off-Label Stent (GHOST) Registry (J Interven Cardiol 2012;00:1–2)
- Devices to Treat Peripheral Chronic Total Occlusions Chronic total occlusions occur in approximately 40% of patients with peripheral vascular disease and are a difficult lesion subset to treat by endovascular approaches. The challenge lies in the difficulty in placing a wire across the site of occlusion and remaining in an intraluminal position. Conventional percutaneous transluminal balloon angioplasty for chronic total occlusions involves advancing a stiff wire through the site of obstruction, has the chance for vessel dissection and perforation, and is associated with high rates of procedural failure. Several mechanical devices have thus been developed to treat peripheral chronic total occlusions. In this article, we provide a review of the currently available devices that may increase the procedural success of treating peripheral chronic total occlusions.(J Interven Cardiol 2012;00:1–9)
- Effects of Sheath Injury and Trimetazidine on Endothelial... Objective:We evaluated the effects of sheath injury and trimetazidine (TMZ) on endothelial dysfunction of the radial artery (RA) after transradial coronary artery angiography (TRCAG) or transradial percutaneous coronary intervention (TRPCI) with flow-mediated dilation (FMD).Methods:One hundred twenty patients who underwent TRCAG or TRPCI with either a long 5Fr or 6Fr sheath were randomly assigned to the TMZ group or the control group. Baseline, postsheath injury ( 50% (ΔFMDbaseline – 10 week > 50%).Conclusion:Repeated sheath injury negatively influences endothelial recovery after long 6Fr sheath injury to the RA, and TMZ lessens endothelial dysfunction of the RA after radial catheterization. (J Interven Cardiol 2012;**:1–7)
- Percutaneous Mitral Valvotomy by S. Harikrishnan
- Regarding Protamine, ACT and Sheath Removal (J Interven Cardiol 2012;00:1–2)
Journal of the CardioMetabolic Syndrome
- Association of Lipid Abnormalities With Measures and Seve... Obesity and lipid abnormalities in children may increase premature cardiovascular disease risk, but the relationship of dyslipidemia with adiposity among obese children is not well defined. The authors performed a cross-sectional analysis of children and adolescents (N=698) in 3 age groups (3–8 years, 9–11 years, and 12–18 years; 53% female, 81% African American, and 16% Hispanic) attending an obesity treatment program. More than 50% of the sample had abnormal levels of triglycerides (TG) or high-density lipoprotein (HDL) cholesterol or both. Only HDL cholesterol and TG were significantly associated with adiposity measures and insulin resistance (measured by homeostasis model assessment [HOMA]) and only in adolescents. All measures of adiposity, adjusted for age and sex, among adolescents were modest predictors of abnormal TG and HDL cholesterol, but these associations were attenuated when adjusting for HOMA. Despite the high prevalence of dyslipidemia in overweight children and adolescents, severity of adiposity appears to be a poor predictor of lipid values except among adolescents. Insulin resistance may in part mediate the relationship of adiposity and dyslipidemia among obese adolescents.
- When the Heart and the Mind Collide: Cardiovascular Risk ...
- Measures of Coronary Artery Calcification and Association... The authors compared the metabolic syndrome status and Framingham 10-year coronary heart disease risk score (FRS) with the coronary artery calcification (CAC) in subclinical atherosclerosis. In all, 356 consecutive patients who underwent coronary artery calcium scanning were studied. Participants’ metabolic syndrome status (by National Cholesterol Education Program Adult Treatment Panel III [NCEP ATP III] guidelines) and FRS were measured. The association between the metabolic syndrome, diabetes mellitus (DM), FRS, and CAC was analyzed by multivariable logistic regression analyses. These analyses were adjusted for demographics, age, sex, and conventional cardiovascular risk factors. The prevalence of significant CAC (CAC score ≥100) in those with DM, the metabolic syndrome, and neither condition was 64%, 43%, and 24%, respectively. The receiver operating characteristic C statistic for the prediction of significant CAC by the NCEP ATP III criteria for FRS, the metabolic syndrome, and DM was 0.61, 0.67, and 0.72, respectively, and increased significantly to 0.78 and 0.90 respectively for the metabolic syndrome and DM when added to the prediction models (P<.0001). This study suggests that the metabolic syndrome and DM are associated with increased risk of subclinical atherosclerosis. In addition, the presence of the metabolic syndrome or DM with increased FRS has incremental value over the FRS, DM, or the metabolic syndrome alone in predicting significant CAC.
- Waist Circumference, Body Mass Index, and Their Associati... Total body fat and adipose tissue distribution are associated with cardiometabolic risk, yet there are conflicting data as to whether waist circumference (WC) or body mass index (BMI) is a better predictor of cardiovascular risk. To determine whether WC or BMI was more strongly associated with cardiometabolic risk, family members of patients with cardiac disease were studied (N=501; mean age, 48 years; 66% female; 36% nonwhite). Height, weight, WC, BMI, blood pressure, high-density lipoprotein cholesterol, triglycerides, glucose, high-sensitivity C-reactive protein, and lipoprotein-associated phospholipase A2 were systematically measured. Global risk was calculated using the Framingham function. Increased WC and BMI were equally strong predictors of cardiometabolic and global risk. The prevalence of cardiometabolic risk factors and their correlation with WC and BMI varied by race/ethnicity. Our data support inclusion of WC and BMI in screening guidelines for diverse populations to identify individuals at increased cardiometabolic risk.
- Drugs Are Not Enough: The Metabolic Syndrome—A Call for... Whether intensive pharmacologic cardiovascular risk factor management reduces metabolic syndrome (MetS) prevalence is unknown. The authors compared the number of secondary prevention medications and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)–defined MetS prevalence in coronary artery disease patients entering cardiac rehabilitation from 1996 to 2001 (period 1, n=516) with those entering from 2002 to 2006 (period 2, n=609). Age, sex, and ethnicity were similar in both periods. From period 1 to period 2, participants took more secondary prevention medications (2.8±1.3 vs 3.5±1.0, P<.001). Prevalence of low high-density lipoprotein cholesterol (66% vs 66%), diabetes (37% vs 38%), and hypertension (81% vs 81%) were unchanged. The prevalence of hypertriglyceridemia decreased (48% vs 36%, P<.001), but the proportion meeting criteria for elevated waist circumference increased (51% vs 58%, P<.05), resulting in no change in overall MetS prevalence (60% vs 59%, P=NS). More emphasis on therapeutic lifestyle change in addition to intensive pharmacologic therapy is needed to reduce MetS prevalence in patients with coronary artery disease.
- Comparison Between Turkish Cardiovascular Risk Platform a... The Turkish Cardiovascular Risk Platform (TCRP) calls for the diagnosis of the metabolic syndrome (MS) if insulin resistance, impaired fasting glucose, impaired glucose tolerance, or diabetes mellitus and ≥2 other established criteria are present. TCRP defines insulin resistance as a homeostasis model assessment >2.7. The aim of this cross-sectional study was to compare TCRP guidelines with the United States National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition of MS in Turkish adults (N=1690). The age- and sex-adjusted prevalence of MS was 25% with the TCRP and 40% for the NCEP definition. Patients with MS identified by the NCEP definition but not by the TCRP definition had lower body mass index and less insulin resistance, but had a similarly adverse cardiovascular risk factor profile to those with TCRP-identified MS, with high blood pressure, waist circumference, triglycerides, and total cholesterol/high-density lipoprotein cholesterol ratio. Other national health organizations should avoid using homeostasis model assessment as a prerequisite for diagnosing MS. Modification of the NCEP definition would be more appropriate for ethnic groups with different body sizes.
- Coronary Artery Calcification and Inflammation According ... A number of metabolic syndrome (MS) definitions exist, and one’s cardiovascular disease risk may depend on the definition used. The authors compared the association of subclinical atherosclerosis (coronary artery calcification [CAC] score >0] and inflammation (white blood cell [WBC] count greater than or equal to the highest quartile) with 3 definitions of MS (those of the National Cholesterol Education Program Adult Treatment Panel III [NCEP ATP III], the American Heart Association/National Heart, Lung and Blood Institute [AHA/NHLBI], and the International Diabetes Federation [IDF]) in 458 asymptomatic men (mean age, 46±7 years). MS was present in 28%, 29%, and 34% according to NCEP ATP III, AHA/NHLBI, and IDF criteria, respectively. CAC was observed in 40% and high WBC count in 24%. After adjustment for age, smoking, and low-density lipoprotein cholesterol, the odds ratios for CAC scores >0 with MS by NCEP ATP III, AHA/NHLBI, and IDF definitions were 1.67 (95% confidence interval [CI], 1.02–2.72), 1.67 (95% CI, 1.03–2.70), and 1.63 (95% CI, 1.03–2.57), respectively. The multivariate odds ratios for high WBC count with MS by NCEP ATP III, AHA/NHLBI, and IDF definitions were 1.69 (95% CI, 1.04–2.73), 1.84 (95% CI, 1.14–2.95), and 1.66 (95% CI, 1.05–2.62), respectively. MS is associated with increased subclinical atherosclerosis and inflammation irrespective of various definitions.
- Insulin Resistance and the Cardiometabolic Syndrome in HI... Highly active antiretroviral therapy (HAART) has dramatically improved the prognosis of HIV-positive patients. However, long-term adverse effects of this therapy include dyslipidemia, insulin resistance (IR), changes in body fat distribution (lipodystrophy), and cardiometabolic syndrome (CMS). IR in HIV-positive patients does not seem to represent a significant independent risk factor for the development of cardiovascular disease; nevertheless, the association with other metabolic complications (dyslipidemia, fat redistribution) and CMS may increase the risk of type 2 diabetes and cardiovascular disease. The use of nucleoside analogue reverse transcriptase inhibitors is associated with the development of upper trunk and visceral fat accumulation and may cause IR. The progression of IR toward diabetes may be impeded with the choice of HAART regimens with less IR effects and encouraging patients to adhere to a healthy lifestyle. For patients with marked IR but relatively preserved fat, the use of metformin may consent the improvement of CMS and lipodystrophy, especially when combined with an appropriate exercise program. Therapy with rosiglitazone is not indicated in these patients.
- The Role of Adiponectin in Obesity, Diabetes, and Cardiov... Nearly 1 in 4 adults in the United States is obese. The connection between obesity and insulin resistance, type 2 diabetes, and cardiovascular disease is a well researched one. The increasing prevalence of each of these diseases has become a growing concern for the medical community. Adiponectin is a collagen-like plasma protein secreted by adipocytes that has been suggested to play a causal role in the development of insulin resistance and cardiovascular disease. The protein has been found to be decreased in cases of insulin resistance, diabetes, atherosclerosis, and coronary artery disease. Up-regulation of adiponectin and its receptor, through the use of thiazolidinediones, has been found to be partially related to insulin sensitization and thus antidiabetic effects. In this review, we discuss adiponectin’s antiatherogenic effects, its association with insulin resistance and obesity, and the possibility of using adiponectin and its receptor as a therapeutic target.
- Prevalence and Significance of Cardiometabolic Risk Facto... Type 1 diabetes (T1D) is a common disease of childhood with a current prevalence of almost 2 cases per 1000 adolescents, according to the third National Health and Nutrition Examination Survey. Modern insulin treatment has resulted in improved quality of life for children with this chronic disorder. However, T1D continues to carry a long-term burden of increased microvascular and macrovascular complications and mortality risk. Compared to the nondiabetic population, patients with T1D are more likely to have ≥1 cardiovascular risk factor and often at an earlier age. Since the prevalence of cardiovascular risk factors increases with age in young persons with T1D, there is a clear need for early screening and counseling to prevent their occurrence and manage long-term health ramifications. The purpose of this review is to describe how traditional risk factors for cardiovascular disease such as an abnormal lipid profile, hypertension, obesity, and insulin resistance contribute to the accelerated atherosclerosis seen in young persons with T1D. A summary is given of the guidelines and recommendations published for clinical care for these patients.
Journal of Cardiovascular Electrophysiology
- A novel missense mutation causing a G487R substitution in... Introduction: Mutations of human ether-à-go-go-related gene (hERG), which encodes a cardiac K+ channel responsible for the acceleration of the repolarizing phase of an action potential and the prevention of premature action potential regeneration, often cause severe arrhythmic disorders. We found a novel missense mutation of hERG that results in a G487R substitution in the S2-S3 loop of the channel subunit [hERG(G487R)] from a family and determined whether this mutant gene could induce an abnormality in channel function. Methods and Results: We made whole-cell voltage-clamp recordings from HEK-293T cells transfected with wild-type hERG [hERG(WT)], hERG(G487R), or both. We measured hERG channel-mediated current as the “tail” of a depolarization-elicited current. The current density of the tail current and its voltage- and time-dependences were not different among all the cell groups. The time-courses of deactivation, inactivation, and recovery from inactivation and their voltage-dependences were not different among all the cell groups. Furthermore, we performed immunocytochemical analysis using an anti-hERG subunit antibody. The ratio of the immunoreactivity of the plasma membrane to that of the cytoplasm was not different between cells transfected with hERG(WT), hERG(G487R), or both. Conclusion: hERG(G487R) can produce functional channels with normal gating kinetics and cell-surface expression efficiency with or without the aid of hERG(WT). Therefore, neither the heterozygous nor homozygous inheritance of hERG(G487R) is thought to cause severe cardiac disorders. hERG(G487R) would be a candidate for a rare variant or polymorphism of hERG with an amino acid substitution in the unusual region of the channel subunit.
- Clinical Significance of Induced Atrial Tachycardia after... Introduction: The utility of inducibility test of atrial tachycardia (AT) in patients with longstanding persistent atrial fibrillation (AF) (LPAF) is unclear. This study aimed to evaluate the significance of induced AT and the impact of their ablation on the clinical outcome.Methods: In 194 patients with LPAF (> 1 year) who underwent catheter ablation (pulmonary vein isolation with substrate ablation), an inducibility test was performed after AF termination.Results: AT was induced in 108 (56%) patients (induced AT group); neither AT nor AF was inducible in 37 (19%, non-induction group). During 39 ± 21 months, AT recurred in 30 patients (28%), AF in 19 (17%), and no arrhythmia in 56 (52%) among induced AT group, while there was a recurrence of AT in 9 (24%), AF in 6 (16%), and no arrhythmia in 22 (60%) among non-induction group (p = NS). Ten patients with repeated ablation in induced AT group revealed eight different and two similar recurrent ATs compared to the induced ATs at first session. The mean cycle length of induced AT that terminated by ablation (271 ± 64ms) was longer than that without (249 ± 58 ms, p < 0.05). In induced AT group, AT recurrence rate in patients who achieved AT termination by ablation was lower than those without termination (5% vs 36%, p < 0.05).Conclusions: ATs that are inducible after LPAF termination do not necessarily become clinical AT. However, patients who achieved non-inducibility of AT by ablating slower cycle length of AT had better outcomes.
- Mitral Isthmus Ablation Using Steerable Sheath and High A... Background: Mitral isthmus ablation is challenging. The use of steerable sheath and high ablation power may improve success rate.Methods: This single-center, prospective study enrolled 200 patients who underwent ablation for atrial fibrillation, including mitral isthmus ablation. Mitral isthmus ablation was performed using an irrigated ablation catheter via a steerable sheath (Endocardium: max power: 40/50W limited to annular end, max temp: 48˚C; Coronary Sinus (CS): max power: 25/30W, max temp: 48˚C). Endpoint was bidirectional mitral isthmus block.Results: Mitral isthmus block was acutely achieved in 182/200 patients (91%). 69% of patients required CS ablation. Mean total ablation time was 13±6 min. There was one case of acute circumflex artery occlusion. Mean LA diameter was significantly bigger in patients with unsuccessful mitral isthmus ablation (49±4 mm vs 43±6 mm, p = 0.0007). In redo procedures, the incidence of re-conduction at the mitral isthmus, roof and cavotricuspid isthmus was 44%, 37% and 29%, respectively. Overall incidence of perimitral flutter was 9%. Prior CFAE ablation was a predictor for microreentrant atrial tachycardia while gaps in linear lesions predicted macroreentrant flutters. After a mean follow-up of 20±9 months, 73% of patients remained free from AF or AT.Conclusion: We reported on a series of mitral isthmus ablation using steerable sheath and high ablation power (50W). Larger LA diameter was a predictor of failure to achieve mitral isthmus block. The mitral isthmus had a moderately high incidence of re-conduction but was only associated with a relatively low incidence of perimitral flutter.
- A Prospective, Randomized Comparison of Modified Pulmonar... Introduction: Pulmonary vein isolation (PVI) is the primary ablation therapy in patients with atrial fibrillation (AF). We hypothesized that high dominant frequency sites (AF nests during sinus rhythm, SR) adjacent to the PV ostia are associated with the atrial substrate that maintains AF, and PVI incorporating the high frequency AF nests may have a higher efficacy.Methods and Results: In a prospective and randomized comparison, 126 symptomatic paroxysmal AF patients that underwent PVI were enrolled. We compared the efficacy of a modified PVI (ablation line: 1.0–1.5 cm from the PV ostium with encircling the AF nests 〔spectral analysis with DF> 70Hz during SR, Group II〕) versus the anatomy-guided conventional PVI (Group I). In Group II, the DF value along the PV ostium was lower than 70 Hz after the PVI. The primary endpoint was the freedom from symptomatic atrial arrhythmias after a single procedure. We also followed the autonomic function by a time-domain analysis of the heart rate variability. In both groups, AF nests were observed and electric isolation was successfully obtained in all patients. With a mean duration of 16±6.1 months of follow-up, Group II had a higher single procedure efficacy without drugs (78.7% vs. 66.1%, log-rank test: P = 0.02), and fewer repeat procedures (6.6% vs. 23%, P = 0.04), as compared to Group I.Conclusion: Pulmonary vein isolation incorporating the high frequency AF nests adjacent to the PV ostia had a better single procedure efficacy.
- Prevalence and Predictors of Cable Extrusion and Loss of ... Introduction: Recently, a medical advisory was issued regarding the Riata and Riata ST silicone endocardial defibrillator leads (St. Jude Medical, Sylmar, CA, USA) addressing the issue of conductor cables extruding in an “inside-out” fashion from the main body of the lead. However, little data exist to guide our management of patients with these leads.Methods and Results: A retrospective analysis was performed of 84 patients with a Riata lead who underwent cine-fluoroscopy and electrical evaluation as part of a screening program to assess for cable extrusion. All leads screened were dual-coil except for one single-coil lead. Of 84 patients, 23 patients (27.4%) had fluoroscopic evidence of cable extrusion. Multivariate analysis showed that the duration of time since lead implant and the presence of multiple right ventricular leads were significantly associated with cable extrusion. All 23 patients had normal electrical parameters on routine device interrogation. Fifteen of these 23 patients (65%) with extruded cables had high voltage shocks within 12 months of lead screening; only one patient demonstrated post-shock electrical abnormalities.Conclusions: The prevalence of cable extrusion in dual-coil Riata leads is significantly higher than previously reported at 27.4%. The duration of time since implantation and the presence of multiple right ventricular leads are associated with cable extrusion. High-energy shocks did not reveal electrical abnormalities in most patients with cable extrusion.
- Long-term Outcome after Catheter Ablation for Left Poster... Background: Catheter ablation of left posterior fascicular (LPF) ventricular tachycardia (VT) is commonly performed during tachycardia. The current study reports on the long-term outcome of patients undergoing ablation of LPF VT targeting the earliest retrograde activation within the posterior Purkinje fiber network during sinus rhythm (SR).Methods: This study retrospectively analyzed 24 consecutive patients (8 female; mean age 26 ± 11 years) referred for catheter ablation of electrocardiographically documented LPF VT. Programmed stimulation was performed to induce tachycardia, while mapping and ablation was aided by use of a 3-D electroanatomical mapping system. Catheter ablation targeted the earliest potential suggestive of retrograde activation within the posterior Purkinje fiber network (retro-PP) recorded along the posterior midseptal left ventricle during SR if LPF VT was noninducible.Results: Overall, 21/24 (87.5%) patients underwent successful catheter ablation in SR targeting the earliest retro-PP, while 3/24 (12.5%) patients were successfully ablated during tachycardia. In none of the patients, ablation resulted in LPF block. No procedure-related complications occurred. After a median follow-up period of 8.9 (4.8–10.9) years, 22/24 (92%) patients were free from recurrent VT.Conclusion: In patients presenting with LPF VT, ablation of the earliest retro-PP along the posterior midseptal LV during SR results in excellent longterm outcome during a median follow-up period of almost 9 years.
- Reverse electrical remodeling by cardiac resynchronizatio... Background: Cardiac resynchronization Therapy (CRT) improves left ventricular ejection fraction (LVEF) in patients with congestive heart failure, LV systolic dysfunction and a wide QRS complex. Previous reports suggest that CRT may also induce electrical remodeling but the impact on clinical outcome remains unknown.Objective: We sought to determine 1) if chronic CRT induces a relevant shortening of the intrinsic QRS (iQRS), 2) whether changes in the native conduction system correlate with clinical or echocardiographic response to CRT, and 3) to identify predictors of iQRS width shortening.Methods: We prospectively included 85 consecutive patients with left bundle branch block who received a CRT device in 3 French centers. NYHA class, iQRS duration, LVEF and left ventricular volumes were assessed before and one year after CRT implantation. Clinical and echocardiographic CRT responders were defined respectively as NYHA class improvement >1 class without heart failure hospitalization and an increase of LVEF by ≥10% and/or a decrease in LVESV by ≥15%. Electrocardiographic responders were defined as a decrease in iQRS duration by ≥20msec.Results: Baseline and 1-year follow-up mean iQRS durations were respectively 168.0 ± 19.7 ms and 149.6 ± 31.6 ms (p<0.0001). Electrocardiographic response, observed in 43/85 patients (51%), was associated with a greater rate of clinical (p = 0.035) and echocardiographic (p = 0.023) response. Younger age, male gender and longer baseline QRS width were independent predictors of electrocardiographic response.Conclusion: CRT decreases iQRS duration. A reduction of at least 20 ms in iQRS duration is associated with better clinical and echocardiographic response.
- Implantation Feasibility, Procedure-Related Adverse Event... Introduction: Aim of this substudy was to assess implantation feasibility and long-term safety of triple-site resynchronization therapy (CRT) in a series of consecutive patients included in a randomized trial.Methods and results: One hundred consecutive patients enrolled into Triple-Site Versus Standard Cardiac Resynchronization Therapy Randomized Trial were analyzed. Eligibility criteria included NYHA class III-IV, sinus rhythm, QRS≥120msec, left ventricular ejection fraction ≤35%, and significant mechanical dyssynchrony. Patients were randomized in a 1:1 ratio to conventional or triple-site CRT with defibrillator-cardioverter. After 12 months of resynchronization 30% of patients with conventional resynchronization and 12.5% with triple-site CRT were in NYHA functional class III or IV (P<0.05). Implantation of triple-site systems was significantly longer (median 125 vs.96min; P<0.001), with higher fluoroscopic exposure, especially in patients with very enlarged left ventricle or pulmonary hypertension. Implantation success-rate was similar in the triple-site and conventional group (94 vs.98%; P = NS); however, additional techniques had to be used in a greater proportion of the triple-site patients (33.3 vs.16%; P<0.05). Long-term lead performance tests revealed significantly higher pacing threshold and lower impedance in the triple-site group. The 1-year incidence of serious, CRT-related adverse events was similar in triple-site and conventional group (20.8 vs.30%; P = NS).Conclusions: Triple-site CRT is associated with more pronounced functional improvement than standard resynchronization. This form of pacing is equally safe and feasible as the conventional CRT. However, triple-site procedure is more time-consuming, associated with higher radiation exposure and the need to use additional techniques. Triple-site resynchronization is associated with less favorable electrical lead characteristics.
- Idiopathic Ventricular Fibrillation Originating from the ... We report a case of a 59-year-old man with idiopathic ventricular fibrillation storm. Ventricular fibrillation was pause-dependent and triggered by an early-coupled right ventricular premature complex. The characteristic premature beat was mapped and successfully ablated from Purkinje fibers of the moderator band.
- Interventional Electrophysiology at the Crossroads: Cardi...
Congenital Heart Disease
- Longevity of Neonatal Ductal Stenting for Congenital Hear... Introduction. Ductal stent (DS) in duct-dependent pulmonary circulation is less morbid than neonatal Blalock–Taussig shunt. However, there is concern if DS provides an adequately long palliation before definitive repair.Methods. This is a retrospective review of clinical follow-up of all consecutive infants after successful DS performed by a single operator. They were divided into three anatomic groups. Group A neonates had balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum, who needed DS patency until the right ventricle was adequate to provide antegrade pulmonary flows. Group B patients with tetralogy of Fallot and pulmonary atresia suited for later biventricular repair needed ductal patency until conduit surgery was completed. Group C patients with functionally univentricular hearts needed DS patency until bidirectional Glenn shunt completion.Results. Among 22 infants, four Group A patients followed for 26–54 months after balloon pulmonary valvotomy had adequate oxygen saturation and needed only short-term DS patency. In six out of nine Group B patients, corrective biventricular repair using conduits was performed after 5–14 months at a body weight of 5–7.5 kg. Bidirectional Glenn shunt and confluence repair were performed in seven of nine Group C patients weighing 6–8.5 kg after 8–15 months. The hilar pulmonary artery growth in B and C groups was adequate for surgical repair. No patient needed stent redilatations or additional shunts on follow-up for hypoxia. Four patients had sudden death.Conclusions. The short-term patency of DS was adequate after balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum. Duration of palliation by DS was also sufficient in univentricular hearts to allow adequate somatic growth before Glenn surgery. In patients with biventricular anatomy treated by DS, conduit repair had to be performed at a relatively early age. Interstage mortality was 18%.
- Vascular and Autonomic Function in Preschool-aged Childre... Objective. To compare indices of vascular health and heart rate variability in preschool-aged children with repaired congenital heart disease (CHD) including tetralogy of Fallot (n = 6) and coarctation of the aorta (n = 6).Design. A cross-sectional study design was used. All measures were noninvasive and collected over a single testing session under the supervision of a parent/guardian.Setting. Data collection took place in a quiet, temperature-controlled room (23°± 1°C) with the participant in a supine position.Patients. Twelve (six females, six males) preschool-aged children with repaired CHD (CHD: 4 ± 1 years) and 12 age- and gender-matched healthy controls (CON: 5 ± 1 years) participated in the study.Outcome Measures. Supine, resting measures of heart rate variability (time, frequency, and nonlinear domains), whole-body pulse wave velocity (ventricular depolarization to dorsalis pedis artery), brachial blood pressures, and carotid artery distensibility, lumen diameter, intima-media thickness, and wall/lumen ratio were collected in both groups.Results. The groups were similar in age, height, and weight; however, CON had significantly higher body mass index values (CON: 16.9 ± 2.2, CHD: 15.1 ± 1.0, P .05). Carotid artery pulse pressures (CHD: 38 ± 6 mm Hg, CON: 31 ± 6 mm Hg, P < .05) and wall/lumen ratios (CHD: 0.091 ± 0.007, CON: 0.085 ± 0.006, P < .01) were significantly higher in the CHD group.Conclusions. These results may indicate that preschool-aged children with repaired CHD display early signs of vascular remodeling, but not autonomic or vascular dysfunction. The effects of larger wall/lumen ratios on cardiovascular disease risk require further investigation.
- Spontaneous Termination of Ventricular Fibrillation in a ... Sudden death is common in patients with congenital coronary artery anomalies mainly when the left main coronary artery originates from the right coronary sinus. Ventricular fibrillation in these patients is irreversible unless defibrillation can be rapidly performed.We describe a 57-year-old male with an anomalous origin of circumflex and the left anterior descending coronary arteries from the right coronary sinus. He developed two episodes of ventricular fibrillation that terminated spontaneously, 10 hours after percutaneous revascularization of the circumflex coronary artery.Computed tomography angiography, in addition to confirming the anomalous origin of the coronary arteries, showed a muscle bridge over the midportion of the left anterior descending coronary artery. This is the first report of spontaneous termination of ventricular fibrillation in a patient with congenital anomaly of the coronary arteries.
- Urinary Interleukin-18 and Urinary Neutrophil Gelatinase-... Background. It is becoming increasingly recognized that manifestations of congenital heart disease (CHD) extend beyond the cardiovascular system. The factors contributing to renal dysfunction in patients with CHD are multifactorial, with acute kidney injury (AKI) at time of cardiac surgery playing a major role. AKI is often diagnosed based on changes in serum creatinine and estimated glomerular filtration rate (eGFR). Such measurements are often late and imprecise. Recent data indicate that urinary biomarkers interleukin-18 (IL-18) and neutrophil gelatinase-associated lipocalin (NGAL) are earlier markers of AKI. We sought to determine the efficacy of urinary IL-18 and NGAL for detecting early AKI in patients undergoing surgical pulmonary valve replacement (PVR).Methods. Twenty patients presenting for surgical PVR with a history of previous repair of a conotruncal anomaly were enrolled. Preoperative clinical data were measured and urine samples and serum creatinine were collected at 6, 12, 24, and 72 hours post bypass. Urine was evaluated for NGAL and IL-18. AKI was determined using the Risk, Injury, Failure, Loss and End Stage Renal Disease (RIFLE) classification system.Results. Using the RIFLE classification system, seven patients (35%) were found to have AKI defined as a drop in the eGFR or an increase in serum creatinine. All seven patients with AKI had marked increase from preoperative baseline in urine IL-18 (sixfold) and NGAL (26-fold). Using NGAL and IL-18, AKI was detected at 6 hours postoperatively, resulting in AKI being identified 12–36 hours prior to detection by conventional methods. No preoperative predictors for AKI were identified.Conclusion. Both NGAL and IL-18 are early predictive biomarkers of AKI, and both increase in tandem after surgical PVR. Importantly, both rise before an increase in creatinine or a decrease in eGFR is present. Monitoring both biomarkers may allow for earlier detection and subsequent interventions to prevent AKI at time of surgery for CHD.
- Congenital Quadricuspid Pulmonary Valve in an Adult Patie... The quadricuspid pulmonary valve (QPV) is a rare congenital anomaly reported in the general population. There are less than 300 reported cases in the literature to date. It has been found in one in 400 to one in 2000 autopsies. We describe here the case of a 47-year-old patient who presents with a QPV with double valvular lesions (stenosis and insufficiency), causing a poststenotic dilatation of the trunk and the left branch of the pulmonary artery (PA).The diagnosis was made by transesophageal echocardiography (TEE) and confirmed by tomographic angiography (computed tomography). The English as well as the Spanish literature were reviewed.To the best of our knowledge, this is the first case of: (1) congenital QPV with double valvular lesions (stenosis and insufficiency), complicated with (2) aneurysmatic dilatation of the PA trunk as well as left branch, and (3) diagnosed by a TEE.
- Neonatal Myocardial Infarction: Case Report and Review of... Myocardial infarction in a neonate is rare. We describe the case of a full-term male who presented with respiratory distress. A chest radiograph demonstrated cardiomegaly. An electrocardiogram revealed ST segment changes suggestive of ischemia. Cardiac enzymes were elevated and an echocardiogram revealed a regional wall motion abnormality. Cardiac catheterization was performed demonstrating occlusion of the ramus intermedius branch of the left main coronary artery. The patient decompensated, requiring extracorporeal membrane oxygenation (ECMO). The infant was able to be decannulated from ECMO support in 5 days and was ultimately discharged on hospital day 25. We review this case as well as the literature on neonatal myocardial infarction.
- The Potential to Avoid Heart Transplantation in Children:... Pediatric mechanical circulatory support has evolved considerably in the past decade. Improvements in device design and availability have led to increased short-, medium-, and long-term support options for pediatric patients with heart failure. Most pediatric mechanical circulatory support is utilized as a bridge to transplant and as a bridge to recovery in patients with temporary etiologies of heart failure (i.e., myocarditis). Described herein is our recovery program, and we report our experience as an independent pediatric ventricular assist device program with an intracorporeal continuous-flow device employed as an out-of-hospital bridge to recovery for a child with end-stage chronic heart failure.
- Electrophysiology Procedures in Adults with Congenital He... Background. In adult congenital heart disease (CHD), arrhythmias contribute significantly to morbidity and mortality. Often, these adult patients are treated at a freestanding pediatric facility. Limited data exist looking at this cohort.Methods. A retrospective review was performed of all electrophysiology (EP) procedures performed in adults at our institution during a 5-year period from January 1, 2006 through December 31, 2010.Results. There were 99 cases performed in a total of 87 adults with CHD during this time period. The mean patient age was 27.1 years (18–51 years). The most common congenital cardiac diagnoses were: 27% with D-transposition of the great arteries (n = 27)—of which 85% (n = 23) have had a previous atrial switch procedure, 20% with tetralogy of Fallot (n = 20), and 16% with previous Rastelli repair (n = 16). Overall, 37 EP studies were performed, with the majority done in patients with complex CHD. There were 74 additional cases. These procedures consisted of: 38 pacemakers (51%), 26 implantable cardiac defibrillators (36%), six laser lead extractions (8%), two loop recorders (3%), and two pocket revisions (3%). During this 5-year period, there was one major complication (1%) and seven minor complications (7%).Conclusions. The complex care of adults with CHD requiring EP procedures can be safely and effectively accomplished in a freestanding pediatric hospital with low complications, provided institutional support of an adult CHD program.
- The Presentation and Diagnosis of Coronary Allograft Vasc... One of the most important causes for long-term graft failure in pediatric heart transplant recipients is coronary allograft vasculopathy (CAV). Graft survival is approximately 50% at 5 years postdiagnosis of CAV. CAV can be difficult to detect largely because of its variability in presentation and in the definition of CAV. Making the diagnosis of CAV can be challenging, and to date, the current gold standard test is angiography, which is an expensive and invasive procedure. A number of studies in the pediatric and adult heart transplant literature exist for noninvasive methods of diagnosing CAV, ranging from biochemical markers and echocardiographic techniques to computed tomography and magnetic resonance imaging. In addition, there is evidence to show that hemodynamic and function evaluation of the coronary arteries in transplanted patients may provide diagnostic clues to the potential development of CAV. These methodologies add to the armamentarium that can compliment angiography for the purposes of diagnosis. Clinical suspicion for CAV should be heightened in patients who have had recurrent rejection, new onset arrhythmias, unexplained recurrent chest or abdominal pain, and/or the development of systolic or diastolic dysfunction in the absence of rejection. This review strives to highlight the current literature with respect to the investigations available for the diagnosis of CAV, recognizing that our understanding of this disease process is still currently in evolution.
- Finding the “PR-fect” Solution: What Is the Best Tool... In the absence of structural heart disease, the great majority of cases with complete congenital heart block will be associated with the maternal autoantibodies directed to components of the SSA/Ro—SSB/La ribonucleoprotein complex. Usually presenting in fetal life before 26 weeks' gestation, once third-degree (complete) heart block develops, it is irreversible. Therefore, investigators over the past several years have attempted to predict which fetuses will be at risk for advanced conduction abnormalities by identifying a biomarker for less severe or incomplete disease, in this case, PR interval prolongation or first-degree atrioventricular block. In this state-of-the-art review, we critically analyze the various approaches to defining PR interval prolongation in the fetus, and then analyze several clinical trials that have attempted to address the question of whether complete heart block can be predicted and/or prevented. We find that, first and foremost, definitions of first-degree atrioventricular block vary but that the techniques themselves are all similarly valid and reliable. Nevertheless, the task of predicting those fetuses at risk, and who are therefore candidates for treatment, remains challenging. Of concern, despite anecdotal evidence, there is currently no conclusive proof that a prolonged PR interval predicts complete heart block.
Congestive Heart Failure
- Exercise Training Improves Heart Rate Variability in Olde... Congest Heart Fail. ****;**:**–**. ©2012 Wiley Periodicals, Inc.Reduced heart rate variability (HRV) in older patients with heart failure (HF) is common and indicates poor prognosis. Exercise training (ET) has been shown to improve HRV in younger patients with HF. However, the effect of ET on HRV in older patients with HF is not known. Sixty-six participants (36% men), aged 69±5 years, with HF and both preserved ejection fraction (HFPEF) and reduced ejection fraction (HFREF), were randomly assigned to 16 weeks of supervised ET (ET group) vs attention-control (AC group). Two HRV parameters (the standard deviation of all normal RR intervals [SDNN] and the root mean square of successive differences in normal RR intervals [RMSSD]) were measured at baseline and after completion of the study. When compared with the AC group, the ET group had a significantly greater increase in both SDNN (15.46±5.02 ms in ET vs 2.37±2.13 ms in AC, P=.016) and RMSSD (17.53±7.83 ms in ET vs 1.69±2.63 ms in AC, P=.003). This increase was seen in both sexes and HF categories. ET improved HRV in older patients with both HFREF and HFPEF.
- Clinical Picture and Social Characteristics of Super-Elde... The number of super-elderly patients older than 80 years with chronic heart failure (HF) is dramatically increased in Japan; however, therapeutic strategies for patients 80 years or older remains to be established. The present investigation was undertaken to clarify the clinical picture and socioeconomic characteristics of super-elderly HF patients. A total of 380 consecutive patients with acute HF or acutely worsening chronic HF were divided into three groups according to age: patients younger than 60 years, those 60 to 80 years, and those 80 years or older (super-elderly group). HF patients in the super-elderly group initially presented with more atypical symptoms at admission compared with those in the younger age group. The prevalence of HF with preserved ejection fraction was more pronounced compared with the patients in the younger age group. Furthermore, the social background was quite different for the 3 groups in several respects: recurrent hospitalization, the prevalence of dementia, and the number of patients living alone all increased with age. The lack of social support in patients with HF is a problem that needs to be resolved in the “super-graying” societies such as Japan.©2012 Wiley Periodicals inc.
- Prognostic Value of Capnography During Rest and Exercise ... New variables obtained from cardiopulmonary exercise testing (CPX) have received attention in recent years, in particular the partial pressure of end-tidal carbon dioxide (PETCO2). The purpose of this study was to therefore comprehensively assess the ability of resting and exercise PETCO2 to predict major cardiac events in a heart failure (HF) cohort referred for CPX. A total of 963 patients with systolic HF undergoing symptom-limited CPX were included in the analysis. Resting and exercise PETCO2 along with other CPX variables were determined, and patients were followed for major adverse events. With regard to resting measures, multivariate analysis revealed that left ventricular ejection fraction was the most robust prognostic marker (P<.001) while resting PETCO2 added significant predictive value and was retained in the regression (P<.001). When exercise data were considered, the multivariate analysis revealed that the PETCO2 apex during exercise added predictive value and was retained (P<.05). In what is the largest evaluation of PETCO2 in the assessment of systolic HF patients to date, the authors substantiate prior (smaller) studies showing prognostic utility of PETCO2, both as a resting measure (an important potential screening tool) and during exercise. These data add to the rationale to incorporate PETCO2 as a routine monitoring component in HF management. 00:00–00. ©2012 Wiley Periodicals, Inc.
- Exercise Training in Heart Failure With Preserved Systoli... Exercise training improves functional capacity in patients with exercise limitation attributed to systolic dysfunction (SD), but exercise training effects in patients with diastolic dysfunction is unclear. The authors determined the functional capacity, quality of life, and echocardiography responses of heart failure with preserved ejection fraction (HFpEF) patients to 16 weeks exercise training. Thirty patients with HFpEF were randomized to an exercise training or non-exercising control group. The patients had a baseline mean age of 64±8 years, left ventricular ejection fraction 57%±10%, and peak oxygen consumption (peak VO2) of 13.3±3.8 mL O2/kg/min. Minnesota Living With Heart Failure and Hare-Davis scores and echocardiographic measures (ejection fraction, systolic and diastolic tissue velocity and filling pressure [E/E′]) were performed at baseline and after 16 weeks of exercise training. The exercise training and non-exercising control groups showed similar baseline VO2 (12.2±3.6 mL/kg/min vs 14.1±4.1 mL/kg/min), ejection fraction (58%±13% vs 57%±8%), and systolic and diastolic function. After exercise training the increment in peak VO2 in the exercise training group was (24.6%, P=.02), and the non-exercising control group (5.1%, P=.19). VE/VCO2 slope was reduced by 12.7% in the exercise training group (P=.02) but was unchanged in the non-exercising control group (P=.03). No significant changes in diastolic or systolic function were noted in either group. Quality-of-life and depression scores were unchanged with exercise training. Changes in peak VO2 and VE/VCO2 slope were unrelated to measures of diastolic and systolic function. In patients with exercise limitation attributed to HFpEF, the improvement in peak VO2 with exercise training was not clearly related to changes in cardiac function. Congest Heart Fail. 2012;00:00–00. ©2012 Wiley Periodicals, Inc.
- Left Ventricular Assist Device as Bridge to Recovery for ... Anthracycline treatments are hampered by dose-related cardiotoxicity, frequently leading to heart failure (HF) with a very poor prognosis. The authors report a case of a 19-year-old man developing HF after anthracycline treatment for Ewing sarcoma. Despite medical treatment, his condition deteriorated to terminal HF, leading to implantation of a mechanical left ventricular assist device (LVAD). His heart function recovered, allowing explantation of the device 14 months after implantation. Heart transplantation is often contraindicated in the first years after treatment for cancers, and LVAD as “bridge to recovery” may be warranted in similar patients.
- Independent and Incremental Value of Severely Enlarged Le... Congest Heart Fail. ****;**:**–**. ©2012 Wiley Periodicals, Inc.The authors sought to assess the impact on survival of demographic, clinical, and echo-Doppler parameters in patients with chronic heart failure due to left ventricular systolic dysfunction divided according to age groups. This study included 734 patients (age 69±11 years) who were classified into tertiles of age: I (22–66 years), II (67–76 years), and III (77–94 years). Severely enlarged left atrial size was defined as ≥52 mm in men and ≥47 mm in women. Multivariable analysis identified male sex (P=.018) and severely enlarged left atrium (P=.024) as significant correlates of all-cause mortality in the very elderly cohort, while restrictive filling pattern (RFP) (P=.004) and New York Heart Association class III or IV (P=.005) among patients of the first tertile and RFP (P=.028) among patients in the second tertile were independently associated with mortality after 30±21 months of follow-up. At the interactive stepwise model in the very elderly population, a severely enlarged left atrium, added to the model after clinical parameters and ejection fraction, moved the chi-square value from 20.7 to 25.8 (P=.048). RFP emerged as the single best predictor of all-cause mortality in the younger and intermediate ranges, whereas severely enlarged left atrium was the best predictor in the very elderly.
- Prognostic Implications of Left Ventricular Dilation in P... Congest Heart Fail. ****;**:**–**. ©2012 Wiley Periodicals, Inc.The aim of this study was to evaluate whether small left ventricular (LV) volumes increase the negative prognostic impact of a restrictive filling pattern (RFP) and that of mitral regurgitation (MR) in patients with nonischemic heart failure (HF). The Meta-analysis Research Group in Echocardiography (MeRGE) is a meta-analysis that collated individual patient data from several prospective echocardiography outcome studies. This analysis was restricted to 10 studies and 601 patients with nonischemic HF. The role of MR was tested in a subgroup of 252 patients. A total of 106 deaths occurred during a median follow-up of 32 months. At multivariate analysis, RFP (hazard ratio [HR], 4.16; 95% confidence interval [CI], 1.54–11.23; P=.005) and New York Heart Association class III or IV (HR, 2.15; 95% CI, 1.33–3.47; P=.001) were the independent predictors of poor prognosis, and there was no statistically significant interaction between LV dilation and RFP. Moderate/severe MR was associated with poorer outcome in the group of patients with normal volumes, whereas it was not a significant predictor of mortality in patients with any degree of LV dilation. In patients with nonischemic HF, RFP is the most important indicator of poor prognosis, irrespective of the degree of LV dilation. Normal LV volumes increase the negative prognostic impact of moderate to severe MR.
- The Etiology-Filling Pattern-Pulmonary Artery Pressure Sc... ©2012 Wiley Periodicals, Inc.Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, “restrictive” LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ≥50 mm Hg (P=.027), and peak oxygen uptake (VO2) <15.9 mL/kg/min (P=.046) resulted independent predictors of the outcome. A simple risk score was then obtained using these significant independent variables, excluding peak VO2 because of only borderline significance. Patients with ischemic etiology, restrictive LV filling pattern, and PASP ≥50 mm Hg have a very high risk of death (odds ratio, 33.77; 95% confidence interval, 5.74–198.8; P<.001, compared with patients with no risk factors). In this high-risk group, evaluation of peak VO2 could be superfluous. A very simple clinical echocardiographic model based on etiology-LV filling and pulmonary pressure is a powerful tool for risk stratification of systolic HF in ambulatory patients.
- Phosphodiesterase Inhibitors, Congestive Heart Failure, a... ©2012 Wiley Periodicals, Inc.A 42-year-old diabetic man was admitted with systolic heart failure and pulmonary hypertension being treated with sildenafil for the previous year. With an increase in creatinine, he experienced 3 episodes of ventricular tachycardia and ventricular fibrillation. Withdrawal of the phosphodiesterase (PDE) inhibitor resulted in no further episodes of dysrhythmias. The basic pharmacology of PDE inhibitors is presented and the use of PDE-3 inhibitors for the treatment of heart failure causing an increase in sudden death is also reviewed. There have been several cases of sudden death associated with sildenafil use and with its increasing use in patients with severe pulmonary hypertension and decompensated heart failure. The authors also reviewed the electrophysiologic effects of PDE-5 inhibitors associated with their use. The crossover between PDE-3 and PDE-5 inhibitors is also discussed and caution is urged when contemplating the use of PDE-5 inhibitors in patients with systolic heart failure and pulmonary hypertension.
- Effect of Age on Outcome on Patients Hospitalized With He... ©2012 Wiley Periodicals, Inc.The association between age, risk factors, and outcome of non-Caucasian patients hospitalized with heart failure (HF) is not clear. A total of 7066 consecutive patients hospitalized with HF at Hamad General Hospital, Doha, Qatar, from 1991 through 2010 were studied. Patients were divided into 3 groups according to age: group 1, 50 years and younger; group 2, older than 50 and up to 70 years; and group 3, older than 70 years. The prevalence of hypertension, chronic renal impairment, and atrial fibrillation increased with increased age. On admission, the older the age of the HF patient, the less likely they were to receive β-blockers and vasodilators. In-hospital mortality rate was higher in older patients when compared with the younger groups (10.6% group 3 vs 7% group 1 and 7.2% group 2; P=.001). During the study period, the relative reduction in mortality rates was higher in the younger when compared with the older patients (55%, 49%, and 41%, respectively). The clinical characteristics of Middle-Eastern HF patients vary considerably according to age. Over time, an overall marked improvement in hospital survival for HF was observed, which was associated with progressively increased treatment with evidence-based therapies. This survival improvement over time appears to be less pronounced in the elderly.
Current Atherosclerosis Reports
- The Pathophysiology and Clinical Presentation of Cerebral... Abstract Cerebral amyloid angiopathy (CAA) is defined as the deposition of amyloid ß peptide within leptomeningial and cortical vessels, likely reflecting an imbalance between Aβ production and clearance. Amyloid buildup triggers a series of destructive alterations in the cerebral vascular architecture, leading to a spectrum of neurological events including lobar intracerebral hemorrhage, brain ischemia and cognitive decline. Although traditionally diagnosed pathologically, neuroimaging has taken a central role in defining CAA. This review will discuss the pathological, clinical and radiological aspects of CAA. Content Type Journal ArticleCategory Cardiovascular Disease and Stroke (M Fink and J Safdieh, Section Editors)Pages 1-8DOI 10.1007/s11883-012-0254-zAuthors Eitan Auriel, J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 175 Cambridge st, Suite 300, Boston, MA 02114, USASteven Mark Greenberg, J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 175 Cambridge st, Suite 300, Boston, MA 02114, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804
- Etiologies of Intracerebral Hematomas Abstract Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage. Content Type Journal ArticleCategory Cardiovascular Disease and Stroke (M Fink and J Safdieh, Section Editors)Pages 1-8DOI 10.1007/s11883-012-0253-0Authors Qingliang T. Wang, Departments of Neurology, Mount Sinai Medical Center, Annenberg 2-230, One Gustave L. Levy Place, New York, NY 10029, USAStanley Tuhrim, Departments of Neurology, Mount Sinai Medical Center, Annenberg 2-230, One Gustave L. Levy Place, New York, NY 10029, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804
- Approaching the Asymptote: Obstacles and Opportunities fo... Abstract Over the past decades, tremendous advances have been made in the understanding, diagnosis, and treatment of cardiovascular disease. However, we now face new challenges, including an aging population and increases in metabolic risk factors, that threaten to slow and even reverse these gains. To overcome these new challenges, fundamental insights from the life sciences must be integrated with advances from the physical sciences to develop novel molecular tools to better diagnose, monitor, and treat this complex disease. Nanotechnology has emerged from the intersection of several disciplines and, if combined with our evolving molecular understanding of atherogenesis, has the potential to revolutionize our management of patients at risk for or with existing cardiovascular disease. However, to realize this potential, we must understand the principles governing the interactions between nanomaterials and biological systems. This review explores nanoparticle attributes and how they can be leveraged to develop novel molecular tools for the diagnosis and treatment of cardiovascular disease. Content Type Journal ArticleCategory Vascular Biology (RS Rosenson, Section Editor)Pages 247-253DOI 10.1007/s11883-012-0249-9Authors Sascha N. Goonewardena, Michigan Nanotechnology Institute for Medicine and Biological Sciences, Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
- International Epidemiology of Intracerebral Hemorrhage Abstract Intracerebral hemorrhage is the second most common subtype of stroke. In recent decades our understanding of intracerebral hemorrhage has improved. New risk factors have been identified; more knowledge has been obtained on previously known risk factors; and new imaging techniques allow for in vivo assessment of preclinical markers of intracerebral hemorrhage. In this review the latest developments in research on intracerebral hemorrhage are highlighted from an epidemiologic point of view. Special focus is on frequency, etiologic factors and pre-clinical markers of intracerebral hemorrhage. Content Type Journal ArticleCategory Cardiovascular Disease and Stroke (M Fink and J Safdieh, Section Editors)Pages 1-7DOI 10.1007/s11883-012-0252-1Authors M. Arfan Ikram, Department of Neurology, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The NetherlandsRenske G. Wieberdink, Department of Epidemiology, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The NetherlandsPeter J. Koudstaal, Department of Neurology, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804
- Sortilin as a Regulator of Lipoprotein Metabolism Abstract Elevated low-density lipoprotein cholesterol (LDL-C) is associated with increased risk of atherosclerotic cardiovascular disease (ASCVD) and myocardial infarction (MI). Much of the insight into LDL metabolism has been gained through the study of Mendelian disorders of lipid metabolism. Genome-wide associations studies (GWAS) are now being used to identify novel genes and loci that contribute to variations in LDL-C levels, and they have identified the SORT1 gene as an important modulator of LDL-C levels and ASCVD risk. Mechanistic studies in mice and cell culture also suggest that the SORT1 gene is an important regulator of lipoprotein metabolism; however, these studies disagree on the directionality of the effect of Sort1 expression on plasma lipids and the mechanism for the lipid changes. Here we review the identification of the SORT1 locus as a modulator of LDL-C levels and ASCVD risk and the first mechanistic studies that explore the role of Sortilin in lipid metabolism. Content Type Journal ArticleCategory Genetics (AJ Marian, Section Editor)Pages 211-218DOI 10.1007/s11883-012-0248-xAuthors Alanna Strong, Perelman School of Medicine at the University of Pennsylvania, 11-166 Translational Research Center, 3400 Civic Center Blvd, Building 421, Philadelphia, PA 19104-5158, USADaniel J. Rader, Perelman School of Medicine at the University of Pennsylvania, 11-125 Translational Research Center, 3400 Civic Center Blvd, Building 421, Philadelphia, PA 19104-5158, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
- Clinical Syndromes and Management of Intracerebral Hemorr... Abstract Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with high morbidity and mortality. Acutely, ICH is associated with a sudden surge in intracranial pressure (ICP), as the volume of hematoma increases the pressure in the closed head, leading to non-specific symptoms of ICP: headache, nausea, vomiting, and alterations in consciousness. In the early phase, damage to the brain tissues surrounding the hematoma causes progression of neurologic symptoms. Expansion of supratentorial ICHs may result in transtentorial herniation, causing mental status deterioration and loss of pupillary light reflex. Compared to ischemic stroke, seizure is more common in ICH. Content Type Journal ArticleCategory Cardiovascular Disease and Stroke (M Fink and J Safdieh, Section Editors)Pages 1-7DOI 10.1007/s11883-012-0251-2Authors Sang-Bae Ko, Department of Neurology, Seoul National University Hospital, Seoul, KoreaH. Alex Choi, Division of Critical care neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USAKiwon Lee, Division of Critical care neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804
- Genetics of Cholesterol Efflux Abstract Plasma levels of high-density lipoprotein cholesterol (HDL-C) show an inverse association with coronary heart disease (CHD). As a biological trait, HDL-C is strongly genetically determined, with a heritability index ranging from 40 % to 60 %. HDL represents an appealing therapeutic target due to its beneficial pleiotropic effects in preventing CHD. This review focuses on the genetic basis of cellular cholesterol efflux, the rate-limiting step in HDL biogenesis. There are several monogenic disorders (e.g., Tangier disease, caused by mutations within ABCA1) affecting HDL biogenesis. Importantly, many disorders of cellular cholesterol homeostasis cause a reduced HDL-C. We integrate information from family studies and linkage analyses with that derived from genome-wide association studies (GWAS) and review the recent identification of micro-RNAs (miRNA) involved in cellular cholesterol metabolism. The identification of genomic pathways related to HDL may help pave the way for novel therapeutic approaches to promote cellular cholesterol efflux as a therapeutic modality to prevent atherosclerosis. Content Type Journal ArticleCategory Genetics (AJ Marian, Section Editor)Pages 235-246DOI 10.1007/s11883-012-0247-yAuthors Iulia Iatan, Cardiovascular Research Laboratories, Division of Cardiology, Department of Biochemistry, Faculty of Medicine, McGill University and McGill University Health Center / Royal Victoria Hospital, 687 Pine Avenue West, Montreal, QC H3A 1A1, CanadaAurélien Palmyre, Magistère Européen de Génétique, Université Paris Diderot - Paris 7, 5 Thomas Mann street, 775013 Paris, FranceSarah Alrasheed, Cardiovascular Research Laboratories, Division of Cardiology, Department of Human Genetics, Faculty of Medicine, McGill University and McGill University Health Center / Royal Victoria Hospital, 687 Pine Avenue West, Montreal, QC H3A 1A1, CanadaIsabelle Ruel, Cardiovascular Research Laboratories, Division of Cardiology, McGill University Health Centre / Royal Victoria Hospital, 687 Pine Avenue West, Montreal, QC H3A 1A1, CanadaJacques Genest, Faculty of Medicine, Novartis Chair in Medicine, Cardiovascular Research Laboratories, Division of Cardiology, McGill University and McGill University Health Center / Royal Victoria Hospital, 687 Pine Avenue West, Montreal, QC H3A 1A1, Canada Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
- Intracranial Hemorrhage in Patients with Cancer Abstract Intracranial hemorrhage (ICH) is a common neurological emergency in patients with cancer, typically occurring late in the disease course, although it occasionally heralds the cancer diagnosis. ICH in these patients often occurs from unique mechanisms, especially intratumoral hemorrhage or coagulopathy, whereas hypertensive hemorrhage is rare. Lung, melanoma, breast, and glioblastoma multiforme are the most commonly associated solid tumors, partly because of their ubiquity and frequent brain involvement, whereas leukemia is the most commonly associated hematological cancer. Patients typically present with focal neurological deficits, headache, and encephalopathy, and their initial diagnostic evaluation and management should follow standard guidelines, although steroids and/or surgical resection should be strongly considered in those with intratumoral hemorrhage. Short-term outcomes are comparable to ICH in the community, whereas long-term outcomes are generally poor, corresponding to the prognosis of the underlying cancer. This review focuses on the recent advances and special considerations in cancer-related intracranial hemorrhage. Content Type Journal ArticleCategory Cardiovascular Disease and Stroke (M Fink and J Safdieh, Section Editors)Pages 1-9DOI 10.1007/s11883-012-0250-3Authors Alan J. Velander, Division of Stroke and Critical Care, Department of Neurology and Neuroscience, New York-Presbyterian Hospital/Columbia and Cornell Medical Centers, 525 East 68th Street, F610, New York, NY 10065, USALisa M. DeAngelis, Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USABabak B. Navi, Division of Stroke and Critical Care, Department of Neurology and Neuroscience, Weill Cornell Medical College, 525 East 68th Street, F610, New York, NY 10065, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804
- The Complex Genetic Basis of Plasma Triglycerides Abstract Demonstration of a direct relationship between plasma triglyceride (TG) concentration and atherosclerosis has proven difficult due to confounding variables that accompany elevated plasma TG, such as other dyslipidemias, obesity, and type 2 diabetes. However, human genetic studies have provided evidence suggesting a causal link between plasma TG and cardiovascular risk. Analyses in human patients with hypertriglyceridemia (HTG) also provides insight into the relationship between genetic variation, predisposition to elevated plasma TG, and risk of subsequent cardiovascular disease. Here, we review recent key studies that have contributed to our understanding of the genetic determinants of plasma TG concentration, including HTG susceptibility and phenotypic heterogeneity, and discuss our maturing model of the allelic and phenotypic spectrum of plasma TG. Content Type Journal ArticleCategory Genetics (AJ Marian, Section Editor)Pages 227-234DOI 10.1007/s11883-012-0243-2Authors Christopher T. Johansen, Departments of Medicine and Biochemistry, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, ON N6A 5K8, CanadaRobert A. Hegele, Departments of Medicine and Biochemistry, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, ON N6A 5K8, Canada Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
- Atherosclerosis, Inflammation, Genetics, and Stem Cells: ... Abstract Atherosclerosis is a peculiar form of inflammation triggered by cholesterol-rich lipoproteins and other noxious factors such as cigarette smoke, diabetes mellitus, and hypertension. Genetics also play an important role in the disease, accounting for about 40% of the risk. Of surprise in recent years of post-human genome sequencing, atherosclerosis-relevant genes discovered by non-biased techniques (ie, genome-wide association studies), did not rehash previously suspected pathways of lipid metabolism, diabetes, or hypertension. Instead these studies highlighted genes relevant to mechanisms of inflammation and stem cell biology. Only a minority of implicated genes were linked to lipid and other cardiac risk factor genes. Although such findings do not contradict the fact that atherosclerosis is triggered and exacerbated by elevated lipids, atherosclerosis “new genes” suggest that the mechanism responsible for the development of arterial lesions is more complex than a simple response to injury, where injury is necessary, but perhaps not sufficient, for disease progression. Content Type Journal ArticleCategory Genetics (AJ Marian, Section Editor)Pages 201-210DOI 10.1007/s11883-012-0244-1Authors Pascal J. Goldschmidt-Clermont, Cardiology Division, Department of Medicine, Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, 1600 NW 10th Avenue, Miami, FL 33136, USAChunming Dong, Division of Clinical Pharmacology, Department of Medicine, Interdisciplinary Stem Cell Institute, Leonard M. Miller School of Medicine, University of Miami, 1501 NW 10th Avenue, Miami, FL 33136, USADavid M. Seo, Hussman Institute for Human Genomics, Interdisciplinary Stem Cell Institute, Leonard M. Miller School of Medicine, University of Miami, 1501 NW 10th Avenue, Miami, FL 33136, USAOmaida C. Velazquez, Division of Vascular and Endovascular Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1611 NW 12th Avenue, Miami, FL 33136, USA Journal Current Atherosclerosis ReportsOnline ISSN 1534-6242Print ISSN 1523-3804 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
Journal of Cardiovascular Electrophysiology
- A novel missense mutation causing a G487R substitution in... Introduction: Mutations of human ether-à-go-go-related gene (hERG), which encodes a cardiac K+ channel responsible for the acceleration of the repolarizing phase of an action potential and the prevention of premature action potential regeneration, often cause severe arrhythmic disorders. We found a novel missense mutation of hERG that results in a G487R substitution in the S2-S3 loop of the channel subunit [hERG(G487R)] from a family and determined whether this mutant gene could induce an abnormality in channel function. Methods and Results: We made whole-cell voltage-clamp recordings from HEK-293T cells transfected with wild-type hERG [hERG(WT)], hERG(G487R), or both. We measured hERG channel-mediated current as the “tail” of a depolarization-elicited current. The current density of the tail current and its voltage- and time-dependences were not different among all the cell groups. The time-courses of deactivation, inactivation, and recovery from inactivation and their voltage-dependences were not different among all the cell groups. Furthermore, we performed immunocytochemical analysis using an anti-hERG subunit antibody. The ratio of the immunoreactivity of the plasma membrane to that of the cytoplasm was not different between cells transfected with hERG(WT), hERG(G487R), or both. Conclusion: hERG(G487R) can produce functional channels with normal gating kinetics and cell-surface expression efficiency with or without the aid of hERG(WT). Therefore, neither the heterozygous nor homozygous inheritance of hERG(G487R) is thought to cause severe cardiac disorders. hERG(G487R) would be a candidate for a rare variant or polymorphism of hERG with an amino acid substitution in the unusual region of the channel subunit.
- Clinical Significance of Induced Atrial Tachycardia after... Introduction: The utility of inducibility test of atrial tachycardia (AT) in patients with longstanding persistent atrial fibrillation (AF) (LPAF) is unclear. This study aimed to evaluate the significance of induced AT and the impact of their ablation on the clinical outcome.Methods: In 194 patients with LPAF (> 1 year) who underwent catheter ablation (pulmonary vein isolation with substrate ablation), an inducibility test was performed after AF termination.Results: AT was induced in 108 (56%) patients (induced AT group); neither AT nor AF was inducible in 37 (19%, non-induction group). During 39 ± 21 months, AT recurred in 30 patients (28%), AF in 19 (17%), and no arrhythmia in 56 (52%) among induced AT group, while there was a recurrence of AT in 9 (24%), AF in 6 (16%), and no arrhythmia in 22 (60%) among non-induction group (p = NS). Ten patients with repeated ablation in induced AT group revealed eight different and two similar recurrent ATs compared to the induced ATs at first session. The mean cycle length of induced AT that terminated by ablation (271 ± 64ms) was longer than that without (249 ± 58 ms, p < 0.05). In induced AT group, AT recurrence rate in patients who achieved AT termination by ablation was lower than those without termination (5% vs 36%, p < 0.05).Conclusions: ATs that are inducible after LPAF termination do not necessarily become clinical AT. However, patients who achieved non-inducibility of AT by ablating slower cycle length of AT had better outcomes.
- Mitral Isthmus Ablation Using Steerable Sheath and High A... Background: Mitral isthmus ablation is challenging. The use of steerable sheath and high ablation power may improve success rate.Methods: This single-center, prospective study enrolled 200 patients who underwent ablation for atrial fibrillation, including mitral isthmus ablation. Mitral isthmus ablation was performed using an irrigated ablation catheter via a steerable sheath (Endocardium: max power: 40/50W limited to annular end, max temp: 48˚C; Coronary Sinus (CS): max power: 25/30W, max temp: 48˚C). Endpoint was bidirectional mitral isthmus block.Results: Mitral isthmus block was acutely achieved in 182/200 patients (91%). 69% of patients required CS ablation. Mean total ablation time was 13±6 min. There was one case of acute circumflex artery occlusion. Mean LA diameter was significantly bigger in patients with unsuccessful mitral isthmus ablation (49±4 mm vs 43±6 mm, p = 0.0007). In redo procedures, the incidence of re-conduction at the mitral isthmus, roof and cavotricuspid isthmus was 44%, 37% and 29%, respectively. Overall incidence of perimitral flutter was 9%. Prior CFAE ablation was a predictor for microreentrant atrial tachycardia while gaps in linear lesions predicted macroreentrant flutters. After a mean follow-up of 20±9 months, 73% of patients remained free from AF or AT.Conclusion: We reported on a series of mitral isthmus ablation using steerable sheath and high ablation power (50W). Larger LA diameter was a predictor of failure to achieve mitral isthmus block. The mitral isthmus had a moderately high incidence of re-conduction but was only associated with a relatively low incidence of perimitral flutter.
- A Prospective, Randomized Comparison of Modified Pulmonar... Introduction: Pulmonary vein isolation (PVI) is the primary ablation therapy in patients with atrial fibrillation (AF). We hypothesized that high dominant frequency sites (AF nests during sinus rhythm, SR) adjacent to the PV ostia are associated with the atrial substrate that maintains AF, and PVI incorporating the high frequency AF nests may have a higher efficacy.Methods and Results: In a prospective and randomized comparison, 126 symptomatic paroxysmal AF patients that underwent PVI were enrolled. We compared the efficacy of a modified PVI (ablation line: 1.0–1.5 cm from the PV ostium with encircling the AF nests 〔spectral analysis with DF> 70Hz during SR, Group II〕) versus the anatomy-guided conventional PVI (Group I). In Group II, the DF value along the PV ostium was lower than 70 Hz after the PVI. The primary endpoint was the freedom from symptomatic atrial arrhythmias after a single procedure. We also followed the autonomic function by a time-domain analysis of the heart rate variability. In both groups, AF nests were observed and electric isolation was successfully obtained in all patients. With a mean duration of 16±6.1 months of follow-up, Group II had a higher single procedure efficacy without drugs (78.7% vs. 66.1%, log-rank test: P = 0.02), and fewer repeat procedures (6.6% vs. 23%, P = 0.04), as compared to Group I.Conclusion: Pulmonary vein isolation incorporating the high frequency AF nests adjacent to the PV ostia had a better single procedure efficacy.
- Prevalence and Predictors of Cable Extrusion and Loss of ... Introduction: Recently, a medical advisory was issued regarding the Riata and Riata ST silicone endocardial defibrillator leads (St. Jude Medical, Sylmar, CA, USA) addressing the issue of conductor cables extruding in an “inside-out” fashion from the main body of the lead. However, little data exist to guide our management of patients with these leads.Methods and Results: A retrospective analysis was performed of 84 patients with a Riata lead who underwent cine-fluoroscopy and electrical evaluation as part of a screening program to assess for cable extrusion. All leads screened were dual-coil except for one single-coil lead. Of 84 patients, 23 patients (27.4%) had fluoroscopic evidence of cable extrusion. Multivariate analysis showed that the duration of time since lead implant and the presence of multiple right ventricular leads were significantly associated with cable extrusion. All 23 patients had normal electrical parameters on routine device interrogation. Fifteen of these 23 patients (65%) with extruded cables had high voltage shocks within 12 months of lead screening; only one patient demonstrated post-shock electrical abnormalities.Conclusions: The prevalence of cable extrusion in dual-coil Riata leads is significantly higher than previously reported at 27.4%. The duration of time since implantation and the presence of multiple right ventricular leads are associated with cable extrusion. High-energy shocks did not reveal electrical abnormalities in most patients with cable extrusion.
- Long-term Outcome after Catheter Ablation for Left Poster... Background: Catheter ablation of left posterior fascicular (LPF) ventricular tachycardia (VT) is commonly performed during tachycardia. The current study reports on the long-term outcome of patients undergoing ablation of LPF VT targeting the earliest retrograde activation within the posterior Purkinje fiber network during sinus rhythm (SR).Methods: This study retrospectively analyzed 24 consecutive patients (8 female; mean age 26 ± 11 years) referred for catheter ablation of electrocardiographically documented LPF VT. Programmed stimulation was performed to induce tachycardia, while mapping and ablation was aided by use of a 3-D electroanatomical mapping system. Catheter ablation targeted the earliest potential suggestive of retrograde activation within the posterior Purkinje fiber network (retro-PP) recorded along the posterior midseptal left ventricle during SR if LPF VT was noninducible.Results: Overall, 21/24 (87.5%) patients underwent successful catheter ablation in SR targeting the earliest retro-PP, while 3/24 (12.5%) patients were successfully ablated during tachycardia. In none of the patients, ablation resulted in LPF block. No procedure-related complications occurred. After a median follow-up period of 8.9 (4.8–10.9) years, 22/24 (92%) patients were free from recurrent VT.Conclusion: In patients presenting with LPF VT, ablation of the earliest retro-PP along the posterior midseptal LV during SR results in excellent longterm outcome during a median follow-up period of almost 9 years.
- Reverse electrical remodeling by cardiac resynchronizatio... Background: Cardiac resynchronization Therapy (CRT) improves left ventricular ejection fraction (LVEF) in patients with congestive heart failure, LV systolic dysfunction and a wide QRS complex. Previous reports suggest that CRT may also induce electrical remodeling but the impact on clinical outcome remains unknown.Objective: We sought to determine 1) if chronic CRT induces a relevant shortening of the intrinsic QRS (iQRS), 2) whether changes in the native conduction system correlate with clinical or echocardiographic response to CRT, and 3) to identify predictors of iQRS width shortening.Methods: We prospectively included 85 consecutive patients with left bundle branch block who received a CRT device in 3 French centers. NYHA class, iQRS duration, LVEF and left ventricular volumes were assessed before and one year after CRT implantation. Clinical and echocardiographic CRT responders were defined respectively as NYHA class improvement >1 class without heart failure hospitalization and an increase of LVEF by ≥10% and/or a decrease in LVESV by ≥15%. Electrocardiographic responders were defined as a decrease in iQRS duration by ≥20msec.Results: Baseline and 1-year follow-up mean iQRS durations were respectively 168.0 ± 19.7 ms and 149.6 ± 31.6 ms (p<0.0001). Electrocardiographic response, observed in 43/85 patients (51%), was associated with a greater rate of clinical (p = 0.035) and echocardiographic (p = 0.023) response. Younger age, male gender and longer baseline QRS width were independent predictors of electrocardiographic response.Conclusion: CRT decreases iQRS duration. A reduction of at least 20 ms in iQRS duration is associated with better clinical and echocardiographic response.
- Implantation Feasibility, Procedure-Related Adverse Event... Introduction: Aim of this substudy was to assess implantation feasibility and long-term safety of triple-site resynchronization therapy (CRT) in a series of consecutive patients included in a randomized trial.Methods and results: One hundred consecutive patients enrolled into Triple-Site Versus Standard Cardiac Resynchronization Therapy Randomized Trial were analyzed. Eligibility criteria included NYHA class III-IV, sinus rhythm, QRS≥120msec, left ventricular ejection fraction ≤35%, and significant mechanical dyssynchrony. Patients were randomized in a 1:1 ratio to conventional or triple-site CRT with defibrillator-cardioverter. After 12 months of resynchronization 30% of patients with conventional resynchronization and 12.5% with triple-site CRT were in NYHA functional class III or IV (P<0.05). Implantation of triple-site systems was significantly longer (median 125 vs.96min; P<0.001), with higher fluoroscopic exposure, especially in patients with very enlarged left ventricle or pulmonary hypertension. Implantation success-rate was similar in the triple-site and conventional group (94 vs.98%; P = NS); however, additional techniques had to be used in a greater proportion of the triple-site patients (33.3 vs.16%; P<0.05). Long-term lead performance tests revealed significantly higher pacing threshold and lower impedance in the triple-site group. The 1-year incidence of serious, CRT-related adverse events was similar in triple-site and conventional group (20.8 vs.30%; P = NS).Conclusions: Triple-site CRT is associated with more pronounced functional improvement than standard resynchronization. This form of pacing is equally safe and feasible as the conventional CRT. However, triple-site procedure is more time-consuming, associated with higher radiation exposure and the need to use additional techniques. Triple-site resynchronization is associated with less favorable electrical lead characteristics.
- Idiopathic Ventricular Fibrillation Originating from the ... We report a case of a 59-year-old man with idiopathic ventricular fibrillation storm. Ventricular fibrillation was pause-dependent and triggered by an early-coupled right ventricular premature complex. The characteristic premature beat was mapped and successfully ablated from Purkinje fibers of the moderator band.
- Interventional Electrophysiology at the Crossroads: Cardi...
Current Cardiology Reports
- Coronary Stent Choice in Patients with Acute Myocardial I... Abstract A prompt reperfusion with primary percutaneous coronary intervention represents the current gold standard treatment for patients with acute myocardial infarction. In this setting, coronary stents have been shown to improve outcomes compared to plain angioplasty and are routinely used. However, the stent selection among patients with acute myocardial infarction is still a matter of some debate. An increased risk of very late (>1-year) stent thrombosis has been associated with the use of early-generation drug-eluting stents (DES), leading to concerns regarding the long-term safety of these devices. Newer-generation DES were developed with the aim of addressing this safety issue, and were recently investigated in a few randomized studies in patients with acute myocardial infarction. The objective of the present review is to summarize the accumulated evidence, to guide the stent selection in patients with acute myocardial infarction. Content Type Journal ArticleCategory Management of Acute Coronary Syndromes (R Mehran, Section Editor)Pages 1-9DOI 10.1007/s11886-012-0281-yAuthors Giulio G. Stefanini, Department of Cardiology, Bern University Hospital, 3010 Bern, SwitzerlandStephan Windecker, Department of Cardiology, Bern University Hospital, 3010 Bern, Switzerland Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Risk Stratification and Timing of Revascularization: Whic... Abstract In acute coronary syndromes, risk stratification is essential, particularly in patients without ST elevation, and is based upon clinical, electrocardiogram (ECG), and biological markers. Among them, recent and repeated attacks of angina, ST-segment deviation from baseline on the admission ECG as well as elevated markers of myonecrosis (particularly increased troponin levels), myocardial dysfunction (B-type natriuretic peptide [BNP]; N-terminal prohormone of BNP[NT-proBNP]), and inflammation (high-sensitivity C-reactive protein) are predictors of an adverse outcome. These variables can be incorporated into broader risk predictive scores, among which the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores are the most widely used. Two general therapeutic strategies (routine invasive vs conservative or selective invasive) are employed in the treatment of non-ST-segment elevation acute coronary syndrome (NSTEACS). Evidence-based analysis and the current American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions clinical practice guidelines recommend an early invasive treatment strategy (8–24 h) for intermediate or high clinical risk patients with NSTEACS. Content Type Journal ArticleCategory Management of Acute Coronary Syndromes (R Mehran, Section Editor)Pages 1-11DOI 10.1007/s11886-012-0279-5Authors Ian J. Sarembock, The Christ Hospital Heart and Vascular Center and The Lindner Research Center at The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USADean J. Kereiakes, The Christ Hospital Heart and Vascular Center and The Lindner Research Center at The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Letter to the Editor: Interobserver Variability of Heart-... Letter to the Editor: Interobserver Variability of Heart-to-Mediastinum Ratio in I-123 MIBG Sympathetic Imaging Content Type Journal ArticleCategory Letter to the EditorPages 1-2DOI 10.1007/s11886-012-0276-8Authors Ben F. Bulten, Department of Nuclear Medicine (757), Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsRoel L. F. van der Palen, Department of Pediatric Hematology and Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsHanneke W. M. van Laarhoven, Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsLivia Kapusta, Department of Pediatric Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsAnnelies M. C. Mavinkurve-Groothuis, Department of Pediatric Hematology and Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsLioe-Fee de Geus-Oei, Department of Nuclear Medicine (757), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Effect of Angiotensin-Converting Enzyme Inhibitors and An... Abstract Atherosclerosis is a highly complex biological process that has become the scourge of modern civilization. Endothelial dysfunction is the first step in the development of atherosclerosis. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the development of endothelial dysfunction and atherosclerosis. Several studies have shown that in vitro blockade of the RAAS is associated with improvement in markers of endothelial dysfunction and inflammation. Many clinical trials have demonstrated a clear benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) manifested by a reduction of cardiovascular events. These findings suggest that ACEIs and ARBs can play an important role in prevention of atherosclerosis and in the delay of its progression. In this review we focus on the importance of RAAS blockade to prevent or delay progression of atherosclerosis and its impact on reduction of cardiovascular events. Content Type Journal ArticleCategory Ischemic Heart Disease (S Brener, Section Editor)Pages 1-10DOI 10.1007/s11886-012-0275-9Authors Maria M. Patarroyo Aponte, Division of Cardiovascular Medicine, Lillehei Heart Institute, University of Minnesota Medical Center, 420 Delaware Street SE MMC 508, Minneapolis, MN 55455, USAGary S. Francis, Division of Cardiovascular Medicine, Lillehei Heart Institute, University of Minnesota Medical Center, 420 Delaware Street SE MMC 508, Minneapolis, MN 55455, USA Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Platelet Function and Inhibition in Ischemic Heart Disease Abstract Platelets play an important role in the pathogenesis of thrombosis, the most common cause for the development of acute coronary syndromes such as complications occurring during percutaneous coronary intervention. Platelets act with a multiple step mechanism, in which different surface molecules are involved representing important therapeutic targets of antiplatelet agents. Despite clopidogrel efficacy which has been demonstrated in several studies, recurrent ischemic events remain considerably high in patients on treatment due to low clopidogrel responsiveness, a phenomenon influenced by environmental, clinical, and genetic factors. New P2Y12 blockers such as prasugrel and ticagrelor have been successfully introduced in clinical practice, whereas cangrelor, with a rapid offset and reversible platelet inhibition, may represent a useful bridging therapy in patients undergoing surgery. Moreover, the simultaneous inhibition of thrombin platelet aggregation by protease-activated receptor inhibitors may be an adjunctive approach in patients with coronary artery disease. Content Type Journal ArticleCategory Ischemic Heart Disease (S Brener, Section Editor)Pages 1-11DOI 10.1007/s11886-012-0280-zAuthors Annunziata Nusca, Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, ItalyGiuseppe Patti, Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Reply to the letter by Ben F. Bulten et al. regarding “... Reply to the letter by Ben F. Bulten et al. regarding “Interobserver Variability of Heart-to-Mediastinum Ratio in I-123 MIBG Sympathetic Imaging” Content Type Journal ArticleCategory Letter to the EditorPages 1-1DOI 10.1007/s11886-012-0277-7Authors Wengen Chen, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201, USAQi Cao, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201, USAVasken Dilsizian, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201, USA Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Initial Strategy of Revascularization Versus Optimal Medi... Abstract Defining optimal management of patients with stable coronary artery disease continues to be a central area of debate. While it has been established that all patients with coronary artery disease should at least be managed with optimal medical therapy, many patients with stable coronary artery disease continue to be treated with revascularization, whether by percutaneous coronary intervention or coronary artery bypass grafting. What remains unclear is whether revascularization further improves outcomes when added to medical therapy. We start by reviewing trials that define optimal medical therapy. We then review results of randomized trials comparing both revascularization strategies with optimal medical therapy and assess the strengths and limitations of each. Next, we briefly describe the ongoing ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, which will seek to determine optimal management for patients with stable ischemic heart disease in a population of patients at a uniformly higher risk prior to diagnostic cardiac catheterization. We conclude that revascularization and medical therapy should be used as complementary strategies. Available data have shown some benefits of revascularization in addition to medical therapy, but further trials are needed to better define the optimal population and magnitude and cost effectiveness of adding revascularization to optimal medical therapy. Content Type Journal ArticleCategory Ischemic Heart Disease (S Brener, Section Editor)Pages 1-11DOI 10.1007/s11886-012-0278-6Authors A. Vincent Songco, Division of Cardiology, New York Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USASorin J. Brener, Cardiac Catheterization Laboratory – New York Methodist Hospital, 506 6th Street KP-2, Brooklyn, NY 11215, USA Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Diastolic Stress Test for the Evaluation of Exertional Dy... Abstract Recent studies have highlighted that dyspneic patients comprise a high-risk subgroup of patients referred for cardiac stress testing. Even after adjusting for the presence and degree of coronary artery disease the risk of cardiac and all-cause mortality is at least three- to fivefold higher in dyspneic patients compared to asymptomatic or those with chest pain. Stress echocardiography is uniquely positioned to characterize all potential cardiovascular etiologies of dyspnea from global and regional systolic dysfunction, myocardial ischemia to valvular heart disease, pulmonary hypertension and diastolic dysfunction. Various data point to diastolic dysfunction and associated heart failure as the major potential etiology for dyspnea as well as the likely cause of the heightened mortality risk. Doppler echocardiography at rest and with stress can now characterize the hemodynamics of diastolic dysfunction and close the loop on the comprehensive assessment of the patient who has exertional shortness of breath. This review discusses the role of the Doppler echocardiographic diastolic stress test in the evaluation of patients with cardiac dyspnea. Content Type Journal ArticleCategory Echocardiography (RM Lang, Section Editor)Pages 359-365DOI 10.1007/s11886-012-0269-7Authors Garvan C. Kane, Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USAJae K. Oh, Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782 Journal Volume Volume 14 Journal Issue Volume 14, Number 3
- Which Antiplatelet Agent for Whom? Which Patient Populati... Abstract Antiplatelet treatment is a cornerstone for patients with acute coronary syndromes treated invasively or conservatively to reduce the risk of early and late occurring ischemic complications and to improve survival. Compared to clopidogrel, the novel antiplatelet agents prasugrel and ticagrelor provide faster and more consistent inhibition of platelet aggregation and result in substantially improved clinical outcome in patients with acute coronary syndromes but also an increased bleeding risk. Therefore, balancing the rope between safety and efficacy of treatment is crucial for optimizing outcome. An understanding of the similarities but also differences in pharmacological effect, clinical trial design, and outcome is crucial for understanding which patient populations benefit the most from novel antiplatelet treatments. This review provides recommendations for their optimal use. Content Type Journal ArticleCategory Management of Acute Coronary Syndromes (R Mehran, Section Editor)Pages 1-7DOI 10.1007/s11886-012-0273-yAuthors Christoph Varenhorst, Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, SwedenStefan James, Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
- Multivessel Versus Culprit-Only Revascularization: One Ti... Abstract Multivessel coronary artery disease is a frequent finding in patients with acute myocardial infarction. The proper management of nonculprit lesions in the setting of acute coronary syndromes has historically been a topic of major debate. Despite current guidelines that clearly recommend treatment only of the culprit lesion in this setting, unless there is hemodynamic instability, there is still no consensus about the best treatment strategy for these patients. This article summarizes international experience and authors’ opinion about this controversial topic. Content Type Journal ArticleCategory Management of Acute Coronary Syndromes (R Mehran, Section Editor)Pages 1-9DOI 10.1007/s11886-012-0272-zAuthors Pablo Codner, Department of Cardiology, Institute of Interventional Cardiology, Rabin Medical Center, Petach Tikva and Tel Aviv University, Petah Tikva, 49100 IsraelRan Kornowski, Department of Cardiology, Institute of Interventional Cardiology, Rabin Medical Center, Petach Tikva and Tel Aviv University, Petah Tikva, 49100 Israel Journal Current Cardiology ReportsOnline ISSN 1534-3170Print ISSN 1523-3782
Current Hypertension Reports
- Oxidative Stress in the Cardiorenal Metabolic Syndrome Abstract Excess visceral adiposity contributes to inappropriate activation of the renin-angiotensin-aldosterone system despite a state of volume expansion and of salt retention that contributes to subclinical elevations of pro-oxidant mechanisms. These adverse effects are mediated by excess generation of reactive oxygen species (ROS) and diminished antioxidant defense mechanisms. Excess tissue (i.e., skeletal muscle, liver, heart) free oxygen radicals contribute to impairments in the insulin-dependent metabolic signaling pathways that regulate glucose utilization/disposal and systemic insulin sensitivity. The generation of ROS is required for normal cell signaling and physiological responses. It is a loss of redox homeostasis that results in a proinflammatory/profibrotic milieu that promotes impairments in insulin metabolic signaling, reduced endothelial-mediated vasorelaxation, and associated cardiovascular and renal structural and functional abnormalities. These maladaptive processes are increasingly recognized as important in the progression of hypertension in the cardiorenal metabolic phenotype. There is increasing evidence to support a critical role for Ang II signaling through the AT1R and aldosterone actions through the MR in conjunction with an altered redox-mediating impaired endothelial, cardiac and renal function in this metabolic phenotype. There are emerging clinical data that indicate that therapies that target the renin angiotensin-aldosterone system (RAAS) also attenuate oxidative stress, and improve endothelial, cardiac and renal functions, which collectively contribute to reductions in hypertension. Content Type Journal ArticleCategory THE Therapeutic Trials (G Mancia and TD Giles, Section Editors)Pages 1-6DOI 10.1007/s11906-012-0279-2Authors Adam Whaley-Connell, Diabetes and Cardiovascular Center, Harry S Truman VA Medical Center and the University of Missouri-Columbia School of Medicine, Columbia, MO, USAJames R. Sowers, Diabetes and Cardiovascular Center, Harry S Truman VA Medical Center and the University of Missouri-Columbia School of Medicine, Columbia, MO, USA Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Antihypertensive Treatment and Sexual Dysfunction Abstract Sexual dysfunction is frequently encountered in hypertensive patients. Available data indicates that sexual dysfunction is more frequent in treated than in untreated patients, generating the hypothesis that antihypertensive therapy might be associated with sexual dysfunction. Several lines of evidence suggest that differences between antihypertensive drugs exist regarding their effects on sexual function. Older antihypertensive drugs (diuretics, beta blockers) exert detrimental effects on erectile function whereas newer drugs (nebivolol, angiotensin receptor blockers) have neutral or even beneficial effects. Phosphodiesterase (PDE)-5 inhibitors are effective in hypertensive patients and can be safely administered even when multidrug regimes are used. Precautions need to be taken with alpha blockers or patients with uncontrolled high-risk hypertension, while co-administration with nitrates is contraindicated. Content Type Journal ArticleCategory Antihypertensive Agents: Mechanisms of Drug Action (HM Siragy and B Waeber, Section Editors)Pages 1-8DOI 10.1007/s11906-012-0276-5Authors Athanasios Manolis, Cardiology Department, Asclepeion General Hospital, 41, Thassou Street, 16672 Athens, GreeceMichael Doumas, Second Prop Dpt of Internal Medicine, Aristotle University of Thessaloniki, Greece, Hippokration Hospital, 49, Konstantinoupoleos Street, 54645 Thessaloniki, Greece Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Recent Clinical Trials in Atrial Fibrillation in Hyperten... Abstract Atrial Fibrillation (AF) is the most common clinically significant sustained cardiac arrhythmia, and Hypertension (HTN) is the most common cardiovascular disorder. AF is a major risk factor for strokes whether it is symptomatic or silent. Recent publications have shed light on the role of antihypertensive regiments in prevention of AF, while others have provided data on the efficacy and safety of novel antiarrhythmic drugs such as dronedarone and vernakalant. The older CHADS2 score and its more refined modern counterparts are well validated to determine stroke risk and guide antithrombotic therapy, but haemorrhagic risk has to be respected as well, and scores such as HAS-BLED should be widely used. Novel classes of anticoagulants that overcome many of the drawbacks of warfarin have been introduced with promising results and pose new questions that need to be answered in the near future. Content Type Journal ArticleCategory The Therapeutic Trials (G Mancia and TD Giles, Section Editors)Pages 1-10DOI 10.1007/s11906-012-0268-5Authors Athanasios J. Manolis, Department of Cardiology, Asklepeion General Hospital, 1, Vassileos Pavlou St, Voula, Athens, 16673 GreeceManolis S. Kallistratos, Department of Cardiology, Asklepeion General Hospital, 1, Vassileos Pavlou St, Voula, Athens, 16673 GreeceLeonidas E. Poulimenos, Department of Cardiology, Asklepeion General Hospital, 1, Vassileos Pavlou St, Voula, Athens, 16673 Greece Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Microalbuminuria as Surrogate Endpoint in Therapeutic Trials Abstract A surrogate endpoint is a measure of the effect of a certain treatment that may correlate with a real clinical endpoint but does not necessarily have a guaranteed relationship. The concept is particularly useful in cardiovascular and renal disease. We review evidence regarding microalbuminuria as one potential surrogate endpoint. In diabetes, hypertension and high cardiovascular risk, recent studies have demonstrated the prognostic value of significant changes in urinary albumin excretion for cardiovascular and renal outcomes. The most appropriate timing with which to repeat microalbuminuria and whether or not changes should be targeted during the antihypertensive treatment remain unanswered. Content Type Journal ArticleCategory The Therapeutic Trials (G Mancia and TD Giles, Section Editors)Pages 1-5DOI 10.1007/s11906-012-0270-yAuthors Josep Redon, Hypertension Clinic, Hospital Clinico of Valencia and Research Institute INCLIVA, University of Valencia and CIBERObn, Instituto de Salud Carlos III, Madrid, SpainFernando Martinez, Hypertension Clinic, Hospital Clinico of Valencia and Research Institute INCLIVA, University of Valencia and CIBERObn, Instituto de Salud Carlos III, Madrid, Spain Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Neurogenic Hypertension and Elevated Vertebrobasilar Arte... Abstract There is evidence of sympathetic overdrive in a significant proportion of patients with essential hypertension and an animal model of the condition, the spontaneously hypertensive rat (SHR). The reasons for this remain elusive. However, there is also evidence of narrowing of the arteries supplying the brainstem in the SHR and hypertensive humans. In this review, we discuss the possible role of brainstem hypoperfusion in driving increased sympathetic activity and hypertension. Content Type Journal ArticleCategory SECONDARY HYPERTENSION: ADRENAL AND NERVOUS SYSTEM MECHANISMS (S OPARIL AND KH BERECEK, SECTION EDITORS)Pages 1-9DOI 10.1007/s11906-012-0267-6Authors Matthew J. Cates, Torbay Hospital, Lawes Bridge, Torquay, TQ2 7AA UKC. John Dickinson, Wolfson Institute of Preventative Medicine, Barts and The London School of Medicine and Dentistry Charterhouse Square, London, England EC1M 6BQ, UKEmma C. J. Hart, School of Physiology and Pharmacology, Bristol Heart Institute, Medical Sciences Building, University of Bristol, Bristol, England BS8 1TD, UKJulian F. R. Paton, School of Physiology and Pharmacology, Bristol Heart Institute, Medical Sciences Building, University of Bristol, Bristol, England BS8 1TD, UK Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Pulse Pressure, Arterial Stiffness, and End-Organ Damage Abstract Whereas larger arteries participate in the dampening of blood pressure (BP) oscillations resulting from intermittent ventricular ejection, smaller arteries steadily deliver an adequate supply of blood from the heart to the peripheral organs. Numerous active mechanisms are involved in this process. Cyclic stress acts differently from steady stress, inducing stronger and stiffer material of the vessel wall than under static conditions. Cyclic strain participates in the phenotypic plasticity of smooth muscle cells, initiates transduction mechanisms and induces the transcriptional profile of mechanically induced genes. Finally, the autoregulatory mechanism protecting the brain, heart and kidney from cardiovascular (CV) damage differ markedly according to their localization. Whereas the heart is dependent on pulsatile forces, owing to the diastolic perfusion of coronary arteries, the brain and the kidney are rather influenced by steady mechanical forces. For the kidney, the transmission of pulsatile pressure may greatly contribute to glomerular sclerosis in the elderly. Content Type Journal ArticleCategory The Therapeutic Trials (G Mancia and TD Giles, Section Editors)Pages 1-6DOI 10.1007/s11906-012-0272-9Authors Michel E Safar, Paris Descartes University; AP-HP; Diagnosis and Therapeutic Center, Hôtel-Dieu, 1, place du Parvis Notre-Dame, 75181 Paris Cedex 04, FrancePeter M Nilsson, Department of Clinical Sciences, Lund University, University Hospital, Entrance 33, 205 02 Malmö, SwedenJacques Blacher, Paris Descartes University; AP-HP; Diagnosis and Therapeutic Center, Hôtel-Dieu, 1, place du Parvis Notre-Dame, 75181 Paris Cedex 04, FranceAlbert Mimran, Department of Internal Medicine, Centre Hospitalier Universitaire, Hopital Lapeyronie, 34295 Montpellier Cedex 5, France Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Total Cardiovascular Risk, Blood Pressure Variability and... Abstract In hypertensive patients the risk of developing cardiovascular events and complications depends not only on the magnitude of the blood pressure elevation, but also, and to a consistent extent, on the presence of associated cardiovascular risk factors, concomitant disease and target organ damage. Recent findings suggest that also sympathetic overdrive and alterations in blood pressure variability (which are detected in hypertension) may participate at the increased cardiovascular risk of the patients with high blood pressure. This review will discuss the evidence collected over the past few years on the relationships between sympathetic activation and blood pressure variability and their impact on cardiovascular risk profile. Content Type Journal ArticleCategory The Therapeutic Trials (G Mancia and TD Giles, Section Editors)Pages 1-6DOI 10.1007/s11906-012-0273-8Authors Guido Grassi, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, ItalyMichele Bombelli, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, ItalyGianmaria Brambilla, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, ItalyFosca Quarti Trevano, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, ItalyRaffaella Dell’Oro, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, ItalyGiuseppe Mancia, Clinica Medica, Ospedale San Gerardo dei Tintori Monza, University of Milano-Bicocca, Milan, Italy Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Nocturnal Blood Pressure, Morning Blood Pressure Surge, a... Abstract Cerebrovascular disease is a common cause of death and major cause of disability worldwide. Even in silent cases (e.g., silent cerebral infarction, white matter lesion), cerebrovascular disease can lead to physical and cognitive impairment, thereby substantially reducing the activities of daily living. Accordingly, the earliest possible action to prevent not only symptomatic but also silent cerebrovascular disease has become a major public health challenge. Hypertension is a potent risk factor for both symptomatic and silent cerebrovascular disease. Twenty-four–hour blood pressure (BP) rather than office BP is closely associated with cerebrovascular disease and/or poor physical and cognitive function. In particular, nocturnal BP and morning BP surge have attracted much attention as risk factors for cerebrovascular diseases independently of 24-h BP level. This review is an attempt to summarize some of the evidence on nocturnal BP level or nocturnal BP dipping status, and morning BP surge as potent risk factors for cerebrovascular disease. Content Type Journal ArticleCategory CARDIOVASCULAR RISK AND HYPERTENSION (PW DE LEEUW AND AH GRADMAN, SECTION EDITORS)Pages 1-9DOI 10.1007/s11906-012-0261-zAuthors Yuichiro Yano, Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, JapanKazuomi Kario, Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Vascular Calcification: Pathophysiology and Risk Factors Abstract Vascular calcification can occur in nearly all arterial beds and in both the medial and intimal layers. The initiating factors and clinical consequences depend on the underlying disease state and location of the calcification. The best studied manifestation is coronary artery calcification, in part because of the obvious clinical consequences, but also because of CT-based imaging modalities. In the general population, the presence of coronary artery calcification increases cardiovascular risk above that predicted by traditional Framingham risk factors, suggesting the presence of nontraditional risk factors. In patients with chronic kidney disease (CKD), coronary artery calcification is more prevalent and markedly more severe than in the general population. In these CKD patients, nontraditional risk factors such as oxidative stress, advanced glycation end products, and disordered mineral metabolism are also more prevalent and more severe and offer mechanistic insight into the pathogenesis of vascular calcification. Content Type Journal ArticleCategory CARDIOVASCULAR RISK AND HYPERTENSION (PW de LEEUW AND AH GRADMAN, SECTION EDITORS)Pages 1-10DOI 10.1007/s11906-012-0265-8Authors Neal X. Chen, Division of Nephrology, Department of Medicine, Indiana University School of Medicine, 950 West Walnut Street, R2-Room 219, Indianapolis, IN 46202, USASharon M. Moe, Division of Nephrology, Department of Medicine, Indiana University School of Medicine, 950 West Walnut Street, R2-Room E202C; Roudebush Veterans Affairs Medical Center, 1481 West 10th Street, Indianapolis, IN 46202, USA Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
- Angiotensin Receptor Blockers and Tumorigenesis: Somethin... Abstract The possibility of carcinogenic side effects of antihypertensive therapies due to their chronic administration has been raised multiple times in the past. Recently, the issue has again drawn attention, this time in relation to angiotensin receptor blockers (ARBs). This, among others, caused both American and European drug regulation authorities to review the underlying evidence concerning the relationship between this class of medications and potential adverse carcinogenic outcome. A plethora of both basic science and preclinical evidence has been generated, and three meta-analyses and one nationwide cohort have focused on this specific question. The current review aims to summarize the contemporary multidisciplinary evidence on whether ARBs may be associated with an increased risk of tumorigenesis. Content Type Journal ArticleCategory CARDIOVASCULAR RISK AND HYPERTENSION (PW de LEEUW and AH GRADMAN, SECTION EDITORS)Pages 1-10DOI 10.1007/s11906-012-0263-xAuthors Vadim Tchaikovski, Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital Birmingham, Birmingham, B18 7QH England, UKGregory Y. H. Lip, Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital Birmingham, Birmingham, B18 7QH England, UK Journal Current Hypertension ReportsOnline ISSN 1534-3111Print ISSN 1522-6417
Journal of Cardiovascular Medicine
- Cardiac remodeling and heart failure after a first anteri... Aims: The mechanisms underlying the higher risk of heart failure after myocardial infarction (MI) in diabetic patients remain incompletely understood. Our aim was to investigate cardiac remodeling after MI according to diabetic status. Methods: Data from 512 patients with a first anterior MI included in two prospective cohorts on left-ventricular remodeling were analyzed. Echocardiographic studies were performed before discharge, at 3 months and at 1 year. Clinical follow-up was performed after 3 years. Results: There were 60 (23%) diabetic patients in cohort 1 and 51 (21%) in cohort 2. Therapeutic strategies, infarct size and residual left-ventricular ejection fraction did not differ between diabetic and nondiabetic patients. In both cohorts, there was a significant increase in left-ventricular volumes and a recovery in left-ventricular systolic function from baseline to 1 year; these parameters did not differ according to diabetic status at any of the three time points. Diastolic function was analyzed in cohort 2: the E/Ea ratio was higher in diabetic patients at baseline and during follow-up. Diabetes mellitus was an independent predictor of cardiovascular death or rehospitalization for heart failure in cohort 1 [relative risk (RR) 2.62 (1.35–5.11)] and in cohort 2 [RR 4.99 (2.06–12.21)]. Conclusions: In patients with a modern treatment of MI, diabetes mellitus remains a major and independent predictor of subsequent heart failure. This higher risk is not associated with a decreased left-ventricular systolic function or with increased left-ventricular remodeling. The evidence of higher left-ventricular filling pressures suggests left-ventricular diastolic dysfunction as a potential mechanism.
- B-type natriuretic peptide assessment in ambulatory heart... Background: B-type natriuretic peptide (BNP) levels provide diagnostic and prognostic information in heart failure. This study determined the frequency of BNP assessment and analyzed demographic characteristics, clinical variables and the utilization of guideline-recommended heart failure therapies by BNP level in outpatients with reduced left ventricular ejection fraction (LVEF). Methods and results: The IMPROVE HF registry (The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting) is a prospective cohort study of patients at least 18 years of age with a LVEF 35% or less and chronic heart failure or previous myocardial infarction (MI) presenting to cardiology and multispecialty practices. The medical records of 15 381 patients were reviewed. BNP was measured in 4213 (27.4%) patients and the median plasma BNP level was 384 pg/ml (interquartile range 158–877 pg/ml). Patients were stratified by plasma BNP measurements into the following tertiles: 219 pg/ml or less, more than 219 to 649 pg/ml, and more than 649 pg/ml. Jugular venous distension, pedal edema, rales and systolic murmur on physical examination and elevated renal function parameters were associated with higher BNP levels. BNP assessment and elevated BNP levels were not associated with greater use of any of the quality of care measures. However, patients with a BNP in the top tertile were less likely to be treated with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or aldosterone antagonists compared with patients with a BNP in the bottom tertile. Conclusion: Among practices participating in IMPROVE HF, BNP was not measured in most outpatients with reduced LVEF and chronic heart failure or previous MI. BNP assessment or the BNP level in patients with recorded measurements, with few exceptions, did not impact the utilization of guideline-recommended therapies.
- Changing of SYNTAX score performing fractional flow reser... Objectives: To investigate the relationship between classic SYNTAX and functional SYNTAX score guided by fractional flow reserve (FFR). Background: SYNTAX score predicts clinical outcome after percutaneous coronary intervention in patients with multivessel coronary artery disease (CAD), based on data from angiography alone. However, in the clinical setting, decision-making on myocardial revascularization should be guided by reliable demonstration of inducible ischemia, as detected by FFR. Methods: FFR was collected in all 50–90% angiographic stenoses of 39 consecutive patients with stable multivessel CAD. SYNTAX score was calculated as usually described in SYNTAX group's reports. A functional SYNTAX (F-SYNTAX) score was determined by only considering ischemia-producing lesions (FFR ≤ 0.80). The two scores were compared with correlation, Bland–Altman and agreement tests. Results: FFR was measured in 97 lesions, with a median value of 0.82 ± 0.10. In the 50–70% and 70–90% category stenoses, FFR was greater than 0.80 in 68 and 16% of cases, respectively. F-SYNTAX was systematically inferior to SYNTAX score, with a median difference of 8.4 ± 7.4 (P < 0.05). The correlation between the two methods was globally weak (r = 0.621, rho = 0.563; P < 0.001). After determining F-SYNTAX score, more than 30% of the patients moved to a lower-risk tertile group (P = 0.003). No clinical and angiographic differences were found between patients whether or not reclassified in lower-risk tertiles with F-SYNTAX score. Conclusions: In patients with multivessel CAD, implementation of SYNTAX score with FFR seems to be a more rational approach for revascularization. F-SYNTAX score reclassifies a significant proportion of patients to a lower-risk profile, thus leading to a possible change of therapeutic strategy.
- Association of sleep apnea with coronary slow-flow phenom... Background: Both obstructive sleep apnea (OSA) and coronary slow-flow phenomenon (CSFP) are known to share similar etiopathogenic mechanisms, such as chronic sympathetic activation, upregulation of inflammatory pathways, oxidative stress and, finally, endothelial dysfunction. Objective: We evaluated whether there is an association between OSA and coronary flow rates. Method: We retrospectively reviewed medical records of all patients who underwent diagnostic nocturnal polysomnography for suspected OSA. Those who had coronary angiography performed within the same year of polysomnography were divided into two main groups: those with (group 1) and without (group 2) OSA; also, angiographic coronary TIMI (thrombolysis in myocardial infarction) frame counts (TFC) were compared between the groups. Patients with coronary arterial stenosis and angiograms with inadequate filling of the coronary arteries or visualization of the distal landmarks for frame counting were excluded from the study. Results: There was a statistically significant difference between the groups regarding TFCs. We found a significant positive correlation between mean TFC and apnea-hypopnea index (r = 0.611, P < 0.001). Conclusion: The current study demonstrated that sleep apnea impairs coronary flow rates and is associated with CSFP.
- Does long-lasting sports practice increase the risk of at... Background: Some authors have suggested that sports activity can increase the risk of atrial fibrillation in healthy middle-aged men. Therefore, sport activity, although it prevents coronary artery disease, might be the cause of a potentially dangerous arrhythmia. Methods: To verify this assumption, we critically analyzed the current literature including original articles, reviews and meta-analyses. Results and conclusions: All published articles showed several limitations. The data provided by published studies support the following conclusions: the incidence of atrial fibrillation in sporting middle-aged men is rare (<0.5% per year); a possible facilitating effect on atrial fibrillation is limited to vigorous endurance exercise, not to less vigorous sports; there are no convincing data to demonstrate that sport itself may be the cause of atrial fibrillation in healthy middle-aged men; and a facilitating effect of long-lasting sport cannot be excluded in middle-aged individuals with cardiovascular disorders. Nevertheless, the beneficial effects of exercise should offset this supposed risk, which, albeit increased, remains low.
- Conflicts of interest policies and disclosure requirement... Disclosure of potential conflicts of interest (COI) is used by biomedical journals to guarantee credibility and transparency of the scientific process. COI disclosure, however, is neither systematically nor consistently dealt with by journals. Recent joint editorial efforts paved the way towards the implementation of uniform vehicles for COI disclosure. This article provides a comprehensive editorial perspective on classical COI-related issues. New insights into current COI policies and practices among European Society of Cardiology national cardiovascular journals, as derived from a cross-sectional survey using a standardized questionnaire, are discussed.
- Isolated bicuspid pulmonary valve in adult diagnosed by t... Isolated bicuspid pulmonary valve is a rare arterial valve anomaly with very few reports in the literature, which regard overall cases of postmortem diagnosis. However, the true incidence of bicuspid pulmonary valve could be underestimated because of the difficulty in imaging pulmonary valve morphology with conventional two-dimensional transthoracic echocardiography (TTE). We report a case of isolated bicuspid pulmonary valve in an adult diagnosed by three-dimensional TTE. Off line multidimensional analysis of full-volume 3D allowed to obtain a short axis view of pulmonary valve showing a bicuspid valve characterized by an anterior and a posterior cups, normally thickened and with preserved systolic opening.
- Percutaneous valve replacement in a young adult for radia... A 46-year-old woman known with relapsing Hodgkin's lymphoma diagnosed at age 5, treated with repeated cycles of radiotherapy and chemotherapy, presented with severe symptomatic radiation-induced aortic stenosis. She also had other late sequelae of radiotherapy including thyroid cancer, mediastinal fribrosis and left pulmonary fibrosis with severe restrictive lung disease and a newly diagnosed renal carcinoma. Due to the prohibitively high surgical risk and need for urgent treatment, she underwent successful transcatheter aortic valve replacement with transfemoral implantation of a 23 mm Edwards SAPIEN-XT prosthesis, which was performed without valvuloplasty of the noncalcified fibrotic valve. The final result was excellent with reduction of the transaortic gradient and no residual aortic regurgitation.
- An unusual cause of heart failure Pelvic arteriovenous malformations (AVMs) are uncommon entities that can present with symptoms resulting from compression of adjacent structures, ischemia due to ‘steal phenomenon’ or, rarely, heart failure. We present a case of heart failure in a patient who presented to our facilities for heart transplant and a prior diagnosis of idiopathic dilated cardiomyopathy; further evaluation revealed a massive pelvic AVM as causative for the heart failure. This case emphasizes the importance of a thorough physical examination to guide appropriate diagnostic testing.
- Acute coronary syndrome and Behçet's disease No abstract available
Heart Failure Reviews
- Current management and future directions for the treatmen... Abstract Although patients hospitalized with heart failure have relatively low in-hospital mortality, the post-discharge rehospitalization and mortality rates remain high despite advances in treatment. Most patients admitted for heart failure have normal or high blood pressure, but 15–25 % have low systolic blood pressure with or without signs and/or symptoms of hypoperfusion. All pharmacological agents known to improve the prognosis of patients with heart failure also reduce blood pressure, and this limits their use in patients with heart failure and low blood pressure (HF-LBP). However, patients with HF-LBP have much higher in-hospital and post-discharge mortality. In these patients, a conceptually important therapeutic target is to improve cardiac output in order to alleviate signs of hypoperfusion. Accordingly, the majority of these patients will require an inotrope as cardiac dysfunction is the cause of their low cardiac output. However, the short-term use of currently available inotropes has been associated with further decreases in blood pressure and increases in heart rate, myocardial oxygen consumption and arrhythmias. Agents that improve cardiac contractility without this undesirable effects should be developed. To the best of our knowledge, the epidemiology, pathophysiology and therapy of patients with HF-LBP have not been addressed thoroughly. In June 2010, a workshop that included scientists and clinicians was held in Rome, Italy. The objectives of this meeting were to (1) develop a working definition for HF-LBP, (2) describe its clinical characteristics and pathophysiology, (3) review current therapies and their limitations, (4) discuss novel agents in development and (5) create a framework for the design and conduct of future clinical trials. Content Type Journal ArticlePages 1-16DOI 10.1007/s10741-012-9315-1Authors Mihai Gheorghiade, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAMuthiah Vaduganathan, Department of Medicine, Massachusetts General Hospital, Boston, MA, USAAndrew Ambrosy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USAMichael Böhm, Department of Internal Medicine III, University Hospital of Saarland, Homburg/Saar, GermanyUmberto Campia, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAJohn G. F. Cleland, Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston-upon-Hull, UKFrancesco Fedele, Department of Cardiovascular, Respiratory and Morphological Sciences, Sapienza University, Rome, ItalyGregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USAAldo P. Maggioni, ANMCO Research Center, Florence, ItalyAlexandre Mebazaa, Department of Anesthesia and Intensive Care, Lariboisiere Hospital, University of Paris, Paris, FranceMandeep Mehra, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAMarco Metra, Cardiology, Department of Experimental and Applied Medicine, University and Civil Hospital of Brescia, Brescia, ItalySavina Nodari, Cardiology, Department of Experimental and Applied Medicine, University and Civil Hospital of Brescia, Brescia, ItalyPeter S. Pang, Center of Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave, Suite 1006, Chicago, IL 60611, USAPiotr Ponikowski, Department of Cardiology, Wroclaw Medical University, Wroclaw, PolandHani N. Sabbah, Department of Medicine, Henry Ford Hospital, Detroit, MI, USAMichel Komajda, Assistance Publique Hopitaux de Paris, University Pierre et Marie Curie Paris, Paris, FranceJaved Butler, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Prognostic implications of renal dysfunction in patients ... Abstract Numerous studies over the last decade have demonstrated that renal dysfunction and worsening renal function (WRF) are common in patients hospitalized for heart failure (HHF) and appear to be associated with poor in-hospital and post-discharge outcomes. Unfortunately, its etiology has not been completely understood, and its prediction during hospitalization remains challenging. The evaluation of renal impairment during hospitalization should take into consideration the underlying renal substrate (e.g., predisposing clinical comorbidities such as diabetes and hypertension), initiating mechanisms (e.g., in-hospital therapies such as diuretics), and amplifying factors (neurohormonal and hemodynamic profile changes). Various patterns of WRF may have different prognostic implications and may require different therapeutic approaches. WRF may be initially classified by duration (transient vs. persistent) and by etiology (elevated venous pressures vs. arterial underfilling). Other critical contributing factors during hospitalization include progressive left ventricular dysfunction, neurohormonal activation, and medications. Transient WRF as a result of aggressive therapy targeting congestion may not be associated with poor outcomes. Persistent WRF seen in patients with severe hemodynamic derangements may be associated with poor post-discharge prognosis. Future investigations must clarify the pathophysiological correlates of various patterns of WRF. To date, there is an unmet clinical need to achieve adequate control over congestion while preserving renal function in HHF patients. Thus, the aim of this review is to provide an in-depth and critical interpretation of the available data on the prognostic importance of RD and WRF during hospitalization in an effort to improve HF management. Content Type Journal ArticlePages 1-10DOI 10.1007/s10741-012-9317-zAuthors Filippo Brandimarte, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyMuthiah Vaduganathan, Department of Medicine, Massachusetts General Hospital, Boston, MA, USAGian Francesco Mureddu, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyGiuseppe Cacciatore, Department of Cardiovascular Disease, San Giovanni—Addolorata Community Hospital, Rome, ItalyHani N. Sabbah, Department of Medicine, Henry Ford Hospital, Detroit, MI, USAGregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USASteven R. Goldsmith, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USAJaved Butler, Heart Failure Research, Emory Clinical Cardiovascular Research Institute, Atlanta, GA, USAFrancesco Fedele, Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Diseases, Sapienza University, Rome, ItalyMihai Gheorghiade, Center for Cardiovascular Innovation, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Incretins as a novel therapeutic strategy in patients wit... Abstract Heart failure (HF) and diabetes mellitus (DM) commonly co-exist, with a prevalence of DM of up to 40 % in HF patients. Treatment of DM in patients with HF is challenging since many of the contemporary therapies used for the treatment of DM are either contraindicated in HF or are limited in their use due to the high prevalence of co-morbidities such as significant renal dysfunction. This article presents an overview of the physiology of the incretin system and how it can be targeted therapeutically, highlighting implications for the management of patients with DM and HF. Receptors for the incretin glucagon-like peptide-1 (GLP-1) are expressed throughout the cardiovascular system and the myocardium and are up-regulated in HF. GLP-1 therapy improves cardiac function in animal models of HF through augmented glucose uptake in the myocardium mediated through a p38 MAP kinase pathway. Small clinical studies have shown that GLP-1 improves ejection fraction, reduces BNP levels and enhances functional capacity in patients with chronic HF. A number of randomized controlled trials are currently underway to define the utility of targeting the incretin system in HF patients with DM. Incretin-based therapy may represent a novel therapeutic strategy in the treatment of HF patients with diabetes, in particular for their cardioprotective effects independent of those attributable to tight glycemic control. Content Type Journal ArticlePages 1-8DOI 10.1007/s10741-012-9318-yAuthors M. A. Khan, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKC. Deaton, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKM. K. Rutter, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKL. Neyses, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UKM. A. Mamas, Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Heart failure among South Asians: a narrative review of r... Abstract Individuals of South Asian descent have a high prevalence of comorbidities that are risk factors for the development of heart failure (HF), including diabetes mellitus and metabolic syndrome. However, little is known about the prevalence of HF, its management and prognosis for this population compared to Caucasians. Therefore, a literature review relating to the nature, outcome and treatment of HF in South Asian patients compared to Caucasians was conducted. It was anticipated that collating existing studies in this manner would be useful for guiding professionals in managing HF within this ethnic group, given that to achieve optimal care, regimens need to take into account cultural differences that may impact on adherence. Reviewed literature showed that South Asians with HF were more likely to be younger and have diabetes and hypertension. These papers also implied that outcomes for South Asians with HF were similar or even better than for Caucasians. The review highlighted the under-representation of South Asians in HF trials, meaning that evidence-based recommendations tailored to this specific population are limited. This is an important consideration because ethnic differences in response to medication have been reported; it cannot be assumed that treatments shown to work for Caucasians will be efficacious for those from minority ethnic groups. Content Type Journal ArticlePages 1-10DOI 10.1007/s10741-012-9319-xAuthors Stephanie Tierney, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UKChristi Deaton, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UKMamas Mamas, School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester, M13 9PL UK Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Patient selection for mechanical circulatory support Abstract Heart failure continues to be associated with high morbidity and mortality. Over the past decade, left ventricular assist devices have been shown to improve the survival and quality of life. However, it is quite clear that very sick patients do not do as well, and it is therefore imperative to select patients at the proper time. In this article, we review both the indications for considering left ventricular assist device therapy as well as discuss the considerations and therapy that should be done pre-operatively to possibly improve post-insertion outcomes. Content Type Journal ArticlePages 1-8DOI 10.1007/s10741-012-9316-0Authors Nisha A. Gilotra, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 568, Baltimore, MD 21287, USAStuart D. Russell, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 568, Baltimore, MD 21287, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Diastolic ventricular support with cardiac support device... Abstract Heart failure is a global epidemic with limited therapy. Abnormal left ventricular wall stress in the diseased myocardium results in a biochemical positive feedback loop that results in global ventricular remodeling and further deterioration of myocardial function. Mechanical myocardial restraints such as the Acorn CorCap and Paracor HeartNet ventricular restraints have attempted to minimize diastolic ventricular wall stress and limit adverse ventricular remodeling. Unfortunately, these therapies have not yielded viable clinical therapies for heart failure. Cellular and novel biopolymer-based therapies aimed at stabilizing pathologic myocardium hold promise for translation to clinical therapy in the future. Content Type Journal ArticlePages 1-9DOI 10.1007/s10741-012-9312-4Authors Pavan Atluri, Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St., Philadelphia, PA 19104, USAMichael A. Acker, Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St., Philadelphia, PA 19104, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Diabetic cardiomyopathy: pathophysiology and clinical fea... Abstract Since diabetic cardiomyopathy was first reported four decades ago, substantial information on its pathogenesis and clinical features has accumulated. In the heart, diabetes enhances fatty acid metabolism, suppresses glucose oxidation, and modifies intracellular signaling, leading to impairments in multiple steps of excitation–contraction coupling, inefficient energy production, and increased susceptibility to ischemia/reperfusion injury. Loss of normal microvessels and remodeling of the extracellular matrix are also involved in contractile dysfunction of diabetic hearts. Use of sensitive echocardiographic techniques (tissue Doppler imaging and strain rate imaging) and magnetic resonance spectroscopy enables detection of diabetic cardiomyopathy at an early stage, and a combination of the modalities allows differentiation of this type of cardiomyopathy from other organic heart diseases. Circumstantial evidence to date indicates that diabetic cardiomyopathy is a common but frequently unrecognized pathological process in asymptomatic diabetic patients. However, a strategy for prevention or treatment of diabetic cardiomyopathy to improve its prognosis has not yet been established. Here, we review both basic and clinical studies on diabetic cardiomyopathy and summarize problems remaining to be solved for improving management of this type of cardiomyopathy. Content Type Journal ArticlePages 1-18DOI 10.1007/s10741-012-9313-3Authors Takayuki Miki, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanSatoshi Yuda, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanHidemichi Kouzu, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 JapanTetsuji Miura, Division of Cardiology, Second Department of Internal Medicine, School of Medicine, Sapporo Medical University, South-1 West-16, Chuo-ku, Sapporo, 060-8543 Japan Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Rodent models of heart failure: an updated review Abstract Heart failure (HF) is one of the major health and economic burdens worldwide, and its prevalence is continuously increasing. The study of HF requires reliable animal models to study the chronic changes and pharmacologic interventions in myocardial structure and function and to follow its progression toward HF. Indeed, during the past 40 years, basic and translational scientists have used small animal models to understand the pathophysiology of HF and find more efficient ways of preventing and managing patients suffering from congestive HF (CHF). Each species and each animal model has advantages and disadvantages, and the choice of one model over another should take them into account for a good experimental design. The aim of this review is to describe and highlight the advantages and drawbacks of some commonly used HF rodents models, including both non-genetically and genetically engineered models, with a specific subchapter concerning diastolic HF models. Content Type Journal ArticlePages 1-31DOI 10.1007/s10741-012-9305-3Authors A. C. Gomes, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalI. Falcão-Pires, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalA. L. Pires, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalC. Brás-Silva, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, PortugalA. F. Leite-Moreira, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- MR, CT, and PET imaging in pericardial disease Abstract Although echocardiography remains the standard diagnostic tool for identifying pericardial diseases, procedures with better delineation of morphology and heart function are often required. The pericardium consists of an inner visceral (epicardium) and outer parietal layer (pericardium), which constitute for the pericardial cavity. Pericardial effusion can occur as transudate, exudate, pyopneumopericardium, or hemopericardium. Potential causes are inflammatory processes, that is, pericarditis due to autoimmune or infective reasons, neoplasms, irradiation, or systemic disorders, chronic renal failure, endocrine, or metabolic diseases. Pericardial fat can mimic pericardial effusion. Using various image-acquisition sequences, MRI allows identifying and separating fluid and solid structures. Fast spin-echo T1-weighted sequences with black-blood preparation are favourably used for morphological evaluation. Fast spin-echo T2-weighted sequences, particularly with fat saturation, and short-tau inversion-recovery sequences are useful to visualize oedema and inflammation. For further tissue characterization, delayed inversion-recovery imaging is used. Therefore, image acquisition is performed at 5–20 min subsequent to contrast agent administration, the so-called technique of late gadolinium enhancement. Ventricular volumes and myocardial mass can be assessed accurately by steady-state free-precession sequences, which is required to measure cardiac function and ventricular wall stress. Constrictive pericarditis usually results from chronic inflammatory processes leading to increased stiffness, which impedes the slippage of both pericardial layers and thereby the normal cardiac filling. CT imaging can favourably assess pericardial calcification. Thus, MR and CT imaging allow a comprehensive delineation of the pericardium. Superior to echocardiography, both methods provide a larger field of view and depiction of the complete chest including abnormalities of the surrounding mediastinum and lungs. PET provides unique information on the in vivo metabolism of 18-fluorodeoxyglucose that can be superimposed on CT findings and is useful for identifying inflammatory processes or masses, for example neoplasms. These imaging techniques provide advanced information of anatomy and cardiac function to optimize the pericardial access, for example by the AttachLifter system, for diagnosis and treatment. Content Type Journal ArticlePages 1-18DOI 10.1007/s10741-012-9309-zAuthors Peter Alter, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyJens H. Figiel, Department of Radiology, Philipps University, Marburg, GermanyThomas P. Rupp, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyGeorg F. Bachmann, Department of Radiology, Kerckhoff Heart Center, Bad Nauheim, GermanyBernhard Maisch, Internal Medicine—Cardiology, Philipps University, Baldingerstrasse, 35033 Marburg, GermanyMarga B. Rominger, Department of Radiology, Philipps University, Marburg, Germany Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
- Assessment and management of aortic valve disease in pati... Abstract The onset of symptoms or left ventricular systolic dysfunction heralds a poor prognosis for patients with either aortic stenosis or aortic regurgitation. Echocardiography is the primary imaging modality for assessment of aortic valvular lesions. Cardiac catheterization is indicated to determine the severity of the aortic valve lesion when there is a discrepancy between the clinical findings and the results of echocardiography in patients with either symptoms or left ventricular dysfunction. For patients with low-gradient, low-output aortic stenosis, dobutamine provocation should be used to differentiate truly severe aortic stenosis from patients with a primary cardiomyopathy and low aortic valve area due to low forward flow. Aortic valve surgery improves myocardial performance by relief of ventricular afterload in both patients with severe stenosis and those with severe regurgitation. Surgery should be pursued in both patients with severe aortic stenosis and those with severe regurgitation regardless of the degree of left ventricular dysfunction. Content Type Journal ArticlePages 1-14DOI 10.1007/s10741-012-9311-5Authors Mackram F. Eleid, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USASunil Mankad, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USAPaul Sorajja, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USA Journal Heart Failure ReviewsOnline ISSN 1573-7322Print ISSN 1382-4147
Heart Insight
- Heart Disease: An Equal Opportunity Threat HEART INSIGHT'S Editorial Board Chair, Kathleen Grady, Ph.D, A.P.N., F.A.H.A., F.A.A.N., fills you in on this month's issue.
- Heart of the matter New Jersey mom of five recounts her heart attack during pregnancy
- Let's talk about sex: After a heart attack The AHA has released new guidelines for patients concerned about intimacy after a cardiac event
- Modest Lifestyle and Behavioral Changes That Can Improve ... No abstract available
- Good Medicine Too many medicines have you confused? Here are some practical ways to manage them and prevent mistakes
- Cranberry-Glazed Pork Tenderloin Believe it or not, comfort food can be heart healthy! Mix and match these flavorful recipes to create a hearty dinner.
- Green Beans with Mushrooms and Onions No abstract available
- Turkey Cutlets with Country Gravy No abstract available
- Lemon-Thyme Roasted Potatoes No abstract available
- Bunless Beef-and-Bean Burgers No abstract available
Cardiovascular Drugs and Therapy
- New Challenges Ahead for the Newer Oral Thrombin Inhibito... New Challenges Ahead for the Newer Oral Thrombin Inhibitors that Aim at Replacing Warfarin in Clinical Practice—Any Role for Scientific Societies in the Debate? Content Type Journal ArticleCategory ISCP PRESIDENT'S LETTERPages 1-2DOI 10.1007/s10557-012-6393-1Authors Juan-Carlos Kaski, St. George’s Hospital, University of London, Cranmer Terrace, London, SW17 0RE UK Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Obesity: a new risk factor for cardiac syndrome X? Obesity: a new risk factor for cardiac syndrome X? Content Type Journal ArticleCategory EditorialPages 1-2DOI 10.1007/s10557-012-6390-4Authors Priscilla Lamendola, Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Roma, ItalyGaetano Antonio Lanza, Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Roma, Italy Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Statins Counter the Effects of Hyperlipidemia on iNKT Cells Statins Counter the Effects of Hyperlipidemia on iNKT Cells Content Type Journal ArticleCategory EDITORIALPages 1-3DOI 10.1007/s10557-012-6391-3Authors Joel Linden, Division of Inflammation Biology, La Jolla Institute for Allergy and Immunology, La Jolla, CA, USA Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- ARB and Cardioprotection Abstract A growing body of evidence has suggested that the use of angiotensin II (Ang II) type 1 (AT1) receptor blockers (ARBs) leads to a significant decrease in mortality and morbidity in patients with congestive heart failure. The AT1 receptor is a seven-transmembrane G protein-coupled receptor, and is involved in regulating the physiological and pathological process of the cardiovascular system. Systemically and locally generated Ang II has agonistic action on AT1 receptor. However, recent in vitro studies have demonstrated that AT1 receptor is structurally flexible and instable, and has significant and varying levels of spontaneous activity in an Ang II-independent manner. Furthermore, mechanical stress activates AT1 receptor by inducing conformational switch without the involvement of Ang II. Experimental studies have demonstrated that Ang II-independent activation of AT1 receptor is profoundly relevant to the pathogenesis of cardiac remodeling in vivo, and that these agonist-independent activities of AT1 receptor can be inhibited by inverse agonists, but not by neutral antagonists. Therefore, inverse agonist activity emerges as an important pharmacological parameter that contributes to cardioprotective effects of ARBs through inhibiting both Ang II-dependent and -independent activation of AT1 receptor. Content Type Journal ArticlePages 1-6DOI 10.1007/s10557-012-6392-2Authors Hiroshi Akazawa, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 JapanChizuru Yabumoto, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 JapanMasamichi Yano, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 JapanYoko Kudo-Sakamoto, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 JapanIssei Komuro, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- H2 Mediates Cardioprotection Via Involvements of KATP Cha... Abstract Purpose Inhalation of hydrogen (H2) gas has been shown to limit infarct size following ischemia-reperfusion injury in rat hearts. However, H2 gas-induced cardioprotection has not been tested in large animals and the precise cellular mechanism of protection has not been elucidated. We investigated whether opening of mitochondrial ATP-sensitive K+ channels (mKATP) and subsequent inhibition of mitochondrial permeability transition pores (mPTP) mediates the infarct size-limiting effect of H2 gas in canine hearts. Methods The left anterior descending coronary artery of beagle dogs was occluded for 90 min followed by reperfusion for 6 h. Either 1.3% H2 or control gas was inhaled from 10 min prior to start of reperfusion until 1 h of reperfusion, in the presence or absence of either 5-hydroxydecanoate (5-HD; a selective mKATP blocker), or atractyloside (Atr; a mPTP opener). Results Systemic hemodynamic parameters did not differ among the groups. Nevertheless, H2 gas inhalation reduced infarct size normalized by risk area (20.6 ± 2.8% vs. control gas 44.0 ± 2.0%; p < 0.001), and administration of either 5-HD or Atr abolished the infarct size-limiting effect of H2 gas (42.0 ± 2.2% with 5-HD and 45.1 ± 2.7% with Atr; both p < 0.001 vs. H2 group). Neither Atr nor 5-HD affected infarct size per se. Among all groups, NAD content and the number of apoptotic and 8-OHdG positive cells was not significantly different, indicating that the cardioprotection afforded by H2 was not due to anti-oxidative actions or effects on the NADH dehydrogenase pathway. Conclusions Inhalation of H2 gas reduces infarct size in canine hearts via opening of mitochondrial KATP channels followed by inhibition of mPTP. H2 gas may provide an effective adjunct strategy in patients with acute myocardial infarction receiving reperfusion therapy. Content Type Journal ArticlePages 1-10DOI 10.1007/s10557-012-6381-5Authors Akemi Yoshida, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita 565-8565, Osaka, JapanHiroshi Asanuma, Department of Cardiovascular Science and Technology, Kyoto Prefectural University of Medicine, Suita 565-8565, Osaka, JapanHideyuki Sasaki, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita 565-8565, Osaka, JapanShoji Sanada, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, JapanSatoru Yamazaki, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita 565-8565, Osaka, JapanYoshihiro Asano, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, JapanYoshiro Shinozaki, Department of Physiological Science, Tokai University Graduate School of Medicine, Isehara, JapanHidezo Mori, Department of Physiological Science, Tokai University Graduate School of Medicine, Isehara, JapanAkito Shimouchi, Department of Cardiac Physiology, National Cerebral and Cardiovascular Research Center, Suita, JapanMotoaki Sano, Department of Cardiology, Keio University School of Medicine, Tokyo, JapanMasanori Asakura, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita 565-8565, Osaka, JapanTetsuo Minamino, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, JapanSeiji Takashima, Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, JapanMasaru Sugimachi, Department of Cardiovascular Dynamics, Research Institute, National Cerebral and Cardiovascular Center, Suita, JapanNaoki Mochizuki, Department of Structural Analysis, National Cerebral and Cardiovascular Research Center, Suita, JapanMasafumi Kitakaze, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita 565-8565, Osaka, Japan Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Impact of Statins on the Coagulation Status of Type 2 Dia... Abstract Purpose Dyslipidemia is common in type 2 diabetes (T2D) and contributes to cardiovascular disease (CVD) by exacerbating atherosclerosis and hypercoagulability. Statins can stabilize atherosclerotic plaque and reduce prothrombotic status. In the present study we aimed to evaluate the coagulation activity and the effect of statins on procoagulant state of T2D patients using a novel activated protein C (APC)-dependent thrombin-generation assay. Methods Procoagulant status (by HemosIL ThromboPath (ThP) assay) and in vivo platelet activation (by plasma soluble (s)CD40L levels) were analyzed in a retrospective, cross-sectional study of 198 patients with long-standing T2D and 198 controls. Results Procoagulant status of T2D patients was enhanced when compared to control subjects (p < 0.0001). Similarly, sCD40L levels were increased in T2D (p < 0.0001). When testing ThP as the dependent variable in a multivariate regression model, sCD40L (p < 0.0001) and statin treatment (p = 0.019) were independent predictors of the procoagulant state of T2D patients. Subgroup analysis showed a significant improvement of coagulability in T2D patients on statins (p = 0.012). Conclusions The use of a standardized, easy-to-run, and commercially available APC-dependent thrombin-generation assay detected the presence of a procoagulant status in a large series of patients with long-standing T2D and demonstrated a significant impact of statins in the coagulation status of patients with T2D. Content Type Journal ArticlePages 1-9DOI 10.1007/s10557-012-6388-yAuthors P. Ferroni, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, ItalyD. Della-Morte, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, ItalyA. Pileggi, Diabetes Research Institute, University of Miami, Miami, FL, USAM. G. Valente, InterInstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele, Rome, ItalyF. Martini, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, ItalyF. La Farina, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, ItalyR. Palmirotta, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, ItalyL. F. Meneghini, Diabetes Research Institute, University of Miami, Miami, FL, USAT. Rundek, Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USAC. Ricordi, Diabetes Research Institute, University of Miami, Miami, FL, USAF. Guadagni, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, Italy Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Recombinant Human Interleukin-1 Receptor Antagonist Provi... Abstract Purpose Acute myocardial infarction (AMI) drives an intense inflammatory response that contributes to infarct healing and cardiac remodeling. Recently, different studies have identified a role of interleukin-1 (IL-1) in the development of adverse cardiac remodeling. However, in animal models of AMI IL-1 has been shown to be cardioprotective in preconditioning, raising the question of clinical safety of therapeutic IL-1 blockade for autoinflammatory diseases or for the prevention or the treatment of AMI. In this study we proposed to evaluate the effects of pretreatment with recombinant human interleukin-1 receptor antagonist (rhIL-1Ra) on ischemia reperfusion (I/R) injury to the heart. Methods RhIL-1Ra was given 4 h or 30 min before the surgical induction of I/R. Left ventricular ejection fraction(LVEF) and infarct size were assessed to determine the effects of the drug pretreatment compared to vehicle treated mice. Results RhIL-1Ra, given 4 h or 30 min before the onset of the ischemia, showed marked cardioprotection though preservation of the LVEF (no change vs sham operated mice) and the reduction of the infarct size (−40 % vs vehicle-treated mice). No differences were observed between the two groups of rhIL-1Ra treatment. Conclusions IL-1 blockade therapies using rhIL-1Ra prior the onset of AMI protects the myocardium and preserves cardiac function. Content Type Journal ArticlePages 1-4DOI 10.1007/s10557-012-6389-xAuthors Stefano Toldo, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAAaron M. Schatz, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAEleonora Mezzaroma, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USARaveen Chawla, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAThomas W. Stallard, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAWilliam C. Stallard, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAArehzo Jahangiri, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USABenjamin W. Van Tassell, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USAAntonio Abbate, VCU Pauley Heart Center, Virginia Commonwealth University, 1200 E. Broad St. 10th floor, Richmond, VA 23298, USA Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Thiazolidinedione Drugs Promote Onset, Alter Characterist... Abstract Purpose Despite favorable metabolic and vascular effects, thiazolidinedione (TZD) drugs have not convincingly reduced cardiovascular mortality in clinical trials, raising the possibility of countervailing, off-target effects. We previously showed that TZDs block cardiac ATP-sensitive potassium (KATP) channels in pigs. In this study, we investigated whether TZDs affect onset, spectral characteristics, and mortality of ischemic ventricular fibrillation (VF) and whether such effects are recapitulated by a non-selective KATP blocker (glyburide) or a mitochondrial KATP blocker (5-hydroxydecanoate). Methods A total of 121 anesthetized pigs were pre-treated with TZD (pioglitazone or rosiglitazone, 1 mg/kg IV, resulting in clinically relevant plasma concentrations), glyburide (1 mg/kg IV), 5-hydroxydecanoate (5 mg/kg IV) or inert vehicle. Ischemia was produced by occlusion of the left anterior descending coronary artery. In a subset of pigs treated with rosiglitazone or vehicle, ischemic preconditioning was performed. Results VF developed in all but 6 pigs. In non-preconditioned pigs, onset of VF occurred sooner with pioglitazone (11 ± 3 min, p < 0.05) or rosiglitazone (14 ± 3 min, p = 0.06) than with vehicle (20 ± 2 min). Defibrillation of VF was successful in 44 % of pigs treated with vehicle, compared with 0 % with pioglitazone (p = 0.057) and 33 % with rosiglitazone (NS). After ischemic preconditioning, defibrillation was successful in 62 % of pigs treated with vehicle, compared with 26% treated with rosiglitazone (p = 0.03). TZDs attenuated slowing of conduction due to ischemia and shifted ECG power spectra during VF toward higher frequencies. All effects of TZDs were recapitulated by glyburide, but not by 5-hydroxydecanoate, supporting an interaction of TZDs with the sarcolemmal KATP channel. Conclusion In a porcine model, TZDs promote onset and increase mortality of ischemic VF, associated with alterations of conduction and VF spectral characteristics. Similar effects in a clinical setting might adversely impact cardiovascular mortality. Content Type Journal ArticlePages 1-10DOI 10.1007/s10557-012-6384-2Authors Mohammad Sarraf, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USALi Lu, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USAShuyu Ye, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USAMichael J. Reiter, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USAClifford R. Greyson, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USAGregory G. Schwartz, Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USA Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Statin-Induced Immunomodulation Alters Peripheral Invaria... Abstract Purpose To assess the difference in the prevalence of invariant Natural Killer T (iNKT) lymphocytes between hyperlipidemic and control individuals and to evaluate changes in iNKT cell levels after 6 months lipid lowering therapy. Methods A total of 77 hyperlipidemic individuals (54 ± 5 years) were assigned to simvastatin 40 mg or ezetimibe 10 mg daily for 6 months. Fifty individuals with normal cholesterol levels were used as control. iNKT cells were measured by flow cytometry in peripheral blood. Results Patients with hypercholesterolemia had significantly lower iNKT cell levels (percentage on the lymphocyte population) compared to control group (0.16 ± 0.04% vs 0.39 ± 0.08%, p = 0.03). iNKT cells significantly increased after 6 months treatment with simvastatin (from 0.15 ± 0.04% to 0.28 ± 0.11%, p = 0.03) but not with ezetimibe (from 0.16 ± 0.05% to 0.17 ± 0.06%, p = 0.55). Simvastatin treatment did not alter the activation status of iNKT cells as measured by HLA-DR expression. Changes of iNKT cells were independent from changes in total (r 2 = 0.009, p = 0.76) or LDL cholesterol (r 2 = 0.008, p = 0.78) reached by simvastatin. Conclusions Hyperlipidemic patients have reduced numbers of iNKT in peripheral circulation compared to individuals with normal cholesterol levels. Their number is increasing after long term administration of simvastatin 40 mg but not after ezetimibe. Content Type Journal ArticlePages 1-7DOI 10.1007/s10557-012-6387-zAuthors Evangelia Nakou, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceProdromos Babageorgakas, Department of Cardiology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceIrene Bouchliou, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceDimitrios N. Tziakas, Department of Cardiology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceParaskevi Miltiades, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceEmmanouil Spanoudakis, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceDimitrios Margaritis, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceIoannis Kotsianidis, Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, GreeceDimitrios A. Stakos, Department of Cardiology, Democritus University of Thrace Medical School, Alexandroupolis, Greece Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
- Novel Oral Anticoagulants After Acute Coronary Syndromes Abstract Purpose A number of novel oral anticoagulants, including direct thrombin inhibitors and direct factor Xa inhibitors, have been developed. This review discusses these agents and their respective clinical trials in patients with acute coronary syndromes. Methods This review discusses the results of phase 2 and 3 clinical trials with novel oral anticoagulants. Results Phase 2 clinical trials demonstrated that novel oral anticoagulants increase the risk of bleeding in a dose-related fashion, particularly when used in addition to dual antiplatelet therapy. What was less clear is their impact on recurrent ischemic events. In phase 3 trials, rivaroxaban was found to have a benefit on ischemic events and perhaps a greater benefit at the lower dose. The phase 3 trial with apixaban was stopped early due to increased bleeding without a meaningful reduction in ischemic events. Conclusions Novel oral anticoagulants represent a promising, potentially beneficial treatment for patients with a recent acute coronary syndrome but come with a risk of bleeding. The benefits and risks of these agents will need to be carefully weighed and may depend on both patient risk and concomitant therapy. Additional research is needed to determine how to best integrate these medications into the care of patients with acute coronary syndromes. Content Type Journal ArticleCategory REVIEW ARTICLEPages 1-7DOI 10.1007/s10557-012-6386-0Authors Newton B. Wiggins, Duke University Medical Center, Durham, NC, USAChristopher B. Granger, Duke Clinical Research Institute, Durham, NC, USAJohn H. Alexander, Duke Clinical Research Institute, Durham, NC, USA Journal Cardiovascular Drugs and TherapyOnline ISSN 1573-7241Print ISSN 0920-3206
Echocardiography
- Myocardial Mechanics: Understanding and Applying Three-Di... Speckle tracking echocardiography (STE) is an emerging tool to characterize and quantify myocardial segmental and rotational mechanics. This literature review is aimed at clinical and academic cardiologists to provide: (1) a conceptual framework of STE to initiate understanding of myocardial mechanics; (2) evidence that three-dimensional (3D) STE overcomes the problems of time-consuming data acquisition and postprocessing seen with two-dimensional STE; and (3) illustrative clinical cases with analysis of myocardial mechanics via 3D STE to show the incremental value of strain in clinical decision making. (Echocardiography 2012;**:1-12)
- Evaluation of Left Ventricular Relaxation and Filling Pre... Background: Hypertrophic cardiomyopathy (HCM) is usually associated with marked diastolic dysfunction, characterized by impaired myocardial relaxation and increased myocardial stiffness. The noninvasive evaluation of diastolic function in these patients remains a challenge since usual methods have shown a modest correlation with invasive measurements of left ventricular (LV) relaxation and filling pressures. Methods and Results: We retrospectively analyzed 44 patients with obstructive HCM who underwent cardiac catheterization and echocardiography performed within 48 hours. Standard echocardiographic diastolic parameters and systolic and diastolic myocardial mechanics (including longitudinal and circumferential strain [S] and strain rate [Sr]), LV rotation, and early reverse rotation rate (fraction of early apical reverse rotation [FEARR]) were correlated with diastolic hemodynamic indices. Estimated LA pressure by echo and the LV end-diastolic pressure (LVEDP) or the LV pre-A pressure did not correlate. Longitudinal strain was low and circumferential strain was abnormally higher than normal. FEARR and negative dp/dt inversely correlated (R =−0.57, P = 0.0001), and early diastolic Sr to systolic Sr ratio (SrE/SrS) correlated with the LVEDP (r = 0.61, P < 0.0001). Furthermore, a SrE to SrS ratio ≥0.79 had a sensitivity of 87% and a specificity of 75% for predicting elevated LVEDP (≥15 mmHg). Average circumferential strain rate during atrial contraction and LV pre-A pressure (r =−0.62, P < 0.001) inversely correlated. Conclusions: FEARR is decreased in HCM and appears to be a good measure of diastolic dysfunction. Myocardial mechanics can be used to assess LV relaxation and filling pressures in patients with obstructive HCM. (Echocardiography, 2012;**:1-9)
- Evaluation of Non-ST Segment Elevation Acute Chest Pain S... Background: This investigation was designed to test the hypothesis that continuous cardiac imaging using an ultrasound transducer developed in our laboratory (ContiScan) is superior to electrocardiogram (ECG) monitoring in the diagnosis of coronary artery disease (CAD) in patients with acute non-ST segment elevation chest pain syndromes. Methods: Seventy patients with intermediate to high probability of CAD who presented with typical anginal chest pain and no evidence of ST segment elevation on the ECG were studied. The 2.5-MHz transducer is spherical in its distal part mounted in an external housing to permit steering in 360 degrees. The transducer was placed at the left sternal border to image the left ventricular short-axis view and recorded on video tape at baseline, during and after episodes of chest pain. Two ECG leads were continuously monitored. The presence of CAD was confirmed by coronary arteriography or nuclear or echocardiographic stress testing. Results: Twenty-four patients had regional wall motion abnormalities (RWMA) on their initial echo which were unchanged during the period of monitoring. All had evidence of CAD. Twenty-eight patients had transient RWMA. All had evidence of CAD. Eighteen patients had normal wall motion throughout the monitoring period, 14 of these had no evidence of CAD, and four had evidence of CAD. These four patients did not have chest pain during monitoring. The sensitivity, specificity, and accuracy of echocardiographic monitoring for diagnosing non-ST elevation myocardial infarction was 88%, 100%, and 91% respectively. The sensitivity, specificity, and accuracy of the ECG for diagnosis of CAD were 31%, 100%, and 52%, respectively. Echocardiography was superior to ECG (P < 0.001). Conclusions: The data indicate that continuous cardiac imaging is superior to ECG monitoring for the diagnosis of CAD in patients presenting with acute non-ST segment elevation chest pain syndromes. This technique could be a useful adjunct to ECG monitoring for myocardial ischemia in the acute care setting.(Echocardiography, 2012;**:1–5)
- Evaluation of Myocardial Deformation in Patients with Sic... Background: Sickle cell disease (SCD) is a hemoglobinopathy that affects one in 500 African Americans. Although it is well established that patients with SCD have left ventricular (LV) diastolic dysfunction, it is not clear whether they have subtle LV systolic dysfunction despite preserved ejection fraction (EF). We used three-dimensional speckle tracking echocardiography (3DSTE) to assess changes in both systolic and diastolic LV function in SCD. Methods: Transthoracic real time 3D images were obtained (Philips iE33) in 56 subjects, including 28 stable outpatients with SCD (age 33 ± 7 years) and 28 normal controls (age 35 ± 9 years). 3DSTE was performed using prototype software (4DLV Analysis, TomTec) to obtain LV volume and deformation time curves, from which indices of systolic and diastolic LV function were calculated. Results: In SCD patients, 3DSTE-derived LV filling parameters were significantly different from normal controls, reflecting an increase in both rapid and atrial filling volumes and prolonged active relaxation, depicted by a decrease in filling volume fractions at fixed times and an increase in rapid filling duration. Global LV systolic function was not only preserved but increased compared to controls, as reflected by significantly increased global longitudinal strain. Importantly, twist angle and torsion as well as radial and circumferential components of 3D strain were similar in both groups. Conclusions: 3DSTE was able to confirm diastolic dysfunction, as expected in some patients with SCD. However, 3DSTE strain analysis did not reveal any changes in LV systolic function. These findings provide novel insight into the pathophysiology of the cardiovascular complications of SCD.(Echocardiography, 2012;**:1-8)
- Incremental Utility of Real Time Three-Dimensional Tranth... Objectives: To study the feasibility and additional value of real time three-dimensional transthoracic echocardiography (RT3D-TTE) for anatomical and functional assessment of malformed aortic valve (AV) compared to conventional two-dimensional TTE (2D-TTE). Methods: Malformed AV was evaluated in 35 patients (mean age 18 ±9.5years, 70% male) by both 2D-TTE and RT3D-TTE. The anatomical definition of aortic cusps (number, direction, and commissures) was evaluated by a 3-point visualization score (1: nonvisualized, 2: inadequate, 3: adequate). 2D-TTE and RT3D-TTE measurements included AV area and maximum diameters of both AV annulus and left ventricular outflow tract (LVOT). Results: Adequate visualization of AV cusps was achieved in 86% of patients by RT3D-TTE compared to 63% by 2D-TTE. The mean and median visualization score obtained by RT3D-TTE were higher than that by 2D-TTE. The opening of commissures was detected in (80%) of patients by RT3D-TTE compared to (34%) by 2D-TTE. AV area planimetry could be obtained in 77% of patients by RT3D-TTE compared to 43% by 2D-TTE. RT3D-TTE visualization score of AV cusps and commissures showed better interobserver agreement (Kappa: 0.62 and 0.72, respectively) than 2D-TTE (0.58 and 0.69, respectively). RT3D-TTE and 2D-TTE measurements of AV annulus and LVOT were well correlated (r = 0.85; P < 0.001) but the RT3D-TTE measurements were significantly larger than that obtained by 2D-TTE (2.05 ± 0.7 cm and 2.5 ± 0.86 cm vs 1.94 ± 0.67 cm and 1.98 ± 0.74 cm; P < 0.01). Conclusion: RT3D-TTE is a feasible technique that allows comprehensive quantitative and qualitative assessment of malformed AV.(Echocardiography, 2012;**:1-6)
- Real Time Three-Dimensional Echocardiographic Assessment ... Background: Accurate quantification of left ventricular (LV) volumes and ejection fraction (EF) is of critical importance. Cardiac magnetic resonance (CMR) is considered as the reference and three-dimensional echocardiography (3DE) is an accurate method, but only few data are available in heart failure patients. We therefore sought to compare the accuracy of real time three-dimensional echocardiography (RT3DE) and two-dimensional echocardiography (2DE) for quantification of LV volumes and EF, relative to CMR imaging in an unselected population of heart failure patients. Methods and Results: We studied 24 patients (17 men, age 58 ± 15 years) with history of heart failure who underwent echocardiographic assessment of LV function (2DE, RT3DE) and CMR within a period of 24 hours. Mean LV end-diastolic volume (LVEDV) was 208 ± 109 mL (121 ± 64 mL/m2) and mean LVEF was 31 ± 12.8%. 3DE data sets correlate well with CMR, particularly with respect to the EF (r: 0.8, 0.86, and 0.95; P < 0.0001 for LVEDV, LVESV, and EF, respectively) with small biases (–55 mL, –44 mL, 1.1%) and acceptable limits of agreement. RT3DE provides more accurate measurements of LVEF than 2DE (z= 2.1, P = 0.037) and lower variability. However, 3DE-derived LV volumes are significantly underestimated in patients with severe LV dilatation. In patients with LVEDV below 120 mL/m2, RT3DE is more accurate for volumes and EF evaluation. Conclusion: Compared with CMR, RT3DE is accurate for evaluation of EF and feasible in all our heart failure patients, at the expense of a significant underestimation of LV volumes, particularly when LVEDV is above 120 mL/m2.(Echocardiography 2012;**:1-8)
- Comparison of Intraoperative Three-Dimensional Doppler Co... Background: Three-dimensional (3D) transesophageal echocardiography (TEE) enables the determination of the vena contracta area (VCA), which is an approved parameter to quantify mitral regurgitation (MR). The aim of this study was to determine the VCA in the operative setting and to compare it to alternative 3D and standard 2D methods, with respect to different etiologies of MR. Methods: MR in 56 consecutive patients undergoing cardiac surgery was evaluated using 2D and 3D TEE. VCA, vena contracta (VC), and effective regurgitation orifice area (EROA) by 3D and 2D flow convergence methods were determined. The correlations among the methods and the determined areas were evaluated. Results: EROA determination using 3D flow convergence areas correlated strongly with VCA (r = 0.653), however the resulting areas were considerably smaller. VC measurements in the 3D data set correlated slightly less (r = 0.629). EROA, which was determined using 2D flow convergence areas, showed the strongest correlation among the 2D methods (r = 0.406). 2D VC measurements showed weak to no correlation with VCA. Although a correlation was detected when using the biplane method or the midesophageal long-axis view to measure VC, statistical significance was only reached in functional MR and MR due to simple prolapse. Conclusions: Intraoperative 3D methods to determine MR were feasible and showed improved correlation with VCA compared to 2D measurements. The agreement of 2D methods with VCA declined from functional MR to MR due to prolapse. We recommend the utilization of 3D color Doppler for intraoperative evaluation of MR, especially in patients with complex mitral valve prolapses.(Echocardiography 2012;**:1-9)
- Intraobserver Reliability of Two-Dimensional Ultrasound D... Aims: To determine the intraobserver reproducibility of peak and temporal values for myocardial strain (ɛ) and strain rate (SR) using a speckle tracking technique in the left ventricle (LV), right ventricle (RV), and left atrium (LA). Methods and Results: Myocardial speckle tracking echocardiograms of the LV, RV, and LA were obtained on 20 healthy adults to provide indices of longitudinal, radial, circumferential ɛ, and SR as well as LV rotation and twist. Each participant had two separate acquisitions approximately 30 minutes apart. No systematic bias was present in ɛ data. LV ɛ across all planes provided “good” to “very good” intraclass correlation coefficient (ICC) values (0.714–0.807), however radial ɛ was inferior in terms of coefficients of variation (CoV) (19%). SR data were more variable than ɛ with LV radial SR performing least favorably. RV and LA ɛ demonstrated excellent reproducibility (ICCs of 0.834, 0.959, and CoVs of 7% and 6%, respectively). RV and LA SR were again more variable but generally acceptable ICC > 0.6 and CoV < 15%. Peak basal and apical rotation demonstrated quite high variability while derived torsion had low variability and excellent agreement (ICC = 0.940, CoV = 10%). Time-to-peak values demonstrated acceptable agreement with the exception of systolic SR from all chambers. Conclusion: Good reproducibility was obtained for peak ɛ indices although radial ɛ performs less favorably. Intraobserver variation of peak ɛ appears superior to values obtained for peak SR. Time-to-peak values demonstrate very good intraobserver reproducibility across all planes of contraction with exception of (time-to-peak) systolic strain rate (SRS).(Echocardiography, 2012;**:1-10)
- Velocity Vector Imaging Fails to Quantify Regional Myocar... Background: Regional myocardial deformation patterns are important in a variety of cardiac diseases, including stress-induced cardiomyopathy. Velocity-vector-based imaging is a speckle-tracking echocardiography (STE)-based algorithm that has been shown to allow in-depth cardiac phenotyping in humans. Regional posterior wall myocardial dysfunction occurs during severe isoprenaline stress in mice. We have previously shown that regional posterior wall end-systolic transmural strain decreases after severe isoprenaline toxicity in mice. We hypothesize that STE can detect and further quantify these perturbations. Methods and results: Twenty-three mice underwent echocardiographic examination using the VEVO2100 system. Regional transmural radial strain and strain rate were calculated in both parasternal short-axis and parasternal long-axis cine loops using the VisualSonics VEVO 2100 velocity vector imaging (VVI) STE algorithm. Eight C57BL/6 mice underwent baseline echocardiographic examination using the VisualSonics VEVO 770 system, which can acquire >1,000 frames/s cine loops. In a parasternal short-axis cine loop, the heart was divided into six segments, and regional fractional wall thickening (FWT) was assessed manually. The same protocols were also performed 90 minutes post 400 mg/kg intraperitoneally isoprenaline. Regional myocardial FWT is uniform at baseline but increases significantly in anterolateral segments, whereas it decreases significantly in posterior segments (P < 0.05). A similar pattern is seen using the VVI algorithm although the variance is larger, and differences are smaller and fail to reach significance. Conclusions: VVI is less sensitive in detecting regional perturbations in myocardial function than manual tracing, possibly due to the low frame rate in the cine loops used. (Echocardiography, ****;**:1-9)
- Systolic Myocardial Mechanics in Patients with Anderson... Objectives: Anderson–Fabry disease (AFD) is a lysosomal storage disease, which can involve the heart, mimicking hypertrophic cardiomyopathy (HCM). The underlying mechanism of disease in AFD is an infiltrative, diffuse process, whereas HCM is a primary heart muscle condition with patchy distribution, which may prompt differences in myocardial mechanics. The aim of this study was to assess myocardial mechanics in AFD according to the presence of left ventricular hypertrophy (LVH) compared to nonobstructive HCM (NHCM) and healthy controls. Methods and Results: We carried out a single-center, retrospective study in a small, genetically confirmed AFD cohort, which was divided into a subgroup with LVH (LVH+, n = 19), and without LVH (LVH–, n = 21). Comparison groups were healthy controls (n = 40) and NHCM patients (n = 19). Vector Velocity Imaging was applied to two-dimensional echocardiography studies for assessment of longitudinal strain (LS), circumferential strain (CS), and base-to-apex CS gradients. AFD LVH+ patients had lower global LS than AFD LVH– patients (–14 ± 4% vs –17 ± 3%, P < 0.05), but similarly lowered global CS (–24 ± 5% vs –22 ± 5%, P = ns). AFD LVH+ and NHCM had similarly lowered global LS compared to normals, but significantly lower global CS was observed in AFD LVH+ (–24 ± 5% vs –28 ± 4%, P < 0.05), whereas it was significantly increased in NHCM (–31 ± 2% vs –28 ± 4%, P < 0.05). Unlike NHCM, in both AFD subgroups, patients lost their normal base-to-apex CS gradient. Conclusions: AFD patients without LVH already show abnormal systolic myocardial mechanics. Relevant differences in myocardial mechanics between AFD patients with LVH compared to NHCM reflect the different underlying mechanisms of disease. (Echocardiography, 2012;**:1-8)
High Blood Pressure & Cardiovascular Prevention
- How to Evaluate Microvascular Organ Damage in Hypertensio... Patients with essential hypertension are characterized by endothelial dysfunction and impaired nitric oxide availability secondary to oxidative stress production. A dysfunctioning endothelium is an early marker of the development of atherosclerotic changes and can also contribute to cardiovascular events. The autocrine/paracrine activity of endothelial cells makes it very difficult to investigate endothelial function in clinical research. Vascular reactivity tests represent the most widely used methods of clinical assessment of endothelial function. The aim of these tests is to activate or block endothelial cell function while measuring consequent changes in vascular tone in selected vascular districts. Many studies have evaluated the endothelium in hypertensive patients, using different techniques. Several methodologies were developed to study microcirculation (resistance arteries and arterioles), both in coronary and peripheral vascular districts. In particular, peripheral microcirculation can be evaluated in functionally isolated vascular districts such as the peripheral muscle (usually forearm), the subcutaneous tissue, or the skin. This article focuses on the most relevant available techniques in the research on endothelial dysfunction in essential hypertension, in particular their advantages and major limitations. The coronary microcirculation can be evaluated by measuring coronary blood flow with Doppler flow wire and quantitative angiography during the intracoronary infusion of endothelial agonists. The isolated and perfused forearm technique is the most often used approach in the assessment of endothelial function in peripheral muscle microcirculation. The subcutaneous small resistance arteries can be studied using the Mulvany myograph device, an in vitro, ex vivo technique. Finally, the use of the laser digital Doppler technique provides a non-invasive approach to the evaluation of the skin microcirculation. Each technique employed to assess endothelial function has specific limitations that hinder its applicability in large-scale screening. In addition, studies assessing the degree of correlation among measures of endothelial function, as evaluated in different vascular beds, have demonstrated a poor relationship and, while statistically significant, the findings are of no clinical relevance. Therefore, no one technique can be considered a surrogate for another. At the present time, the optimal methodology for investigating the multifaceted aspects of endothelial dysfunction is still under debate. Only the growing concordant results from different reproducible and reliable methods exploring endothelial function with different stimuli will support and strengthen experimental findings, thus providing conclusive answers in this area of research. Received for publication 7 November 2011; accepted for publication 4 December 2011.
- How to Assess Microvascular Structure in Humans Structural alterations of subcutaneous small resistance arteries, as indicated by an increased media to lumen ratio, are frequently present in hypertensive and/or diabetic patients. However, the evaluation of microvascular structure is not an easy task. Among the methods that may be applied to humans, plethysmographic evaluation of small arteries and wire or pressure micromyography were extensively used in the last decades. Media to lumen ratio of small arteries evaluated by micromyography was demonstrated to possess a strong prognostic significance; however, its extensive evaluation is limited by the invasiveness of the assessment, since a biopsy of subcutaneous fat is needed. Non-invasive approaches were then proposed, including capillaroscopy, which provides information about microvascular rarefaction. Recently, the interest of investigators has focused on the retinal microvascular bed. In particular, a non-invasive measurement of wall thickness to internal lumen ratio of retinal arterioles using scanning laser Doppler flowmetry has been recently introduced. Preliminary data suggest a fairly good agreement between this approach and micromyographic measurements, generally considered the gold standard approach. Therefore, the evaluation of microvascular structure is progressively moving from bench to bedside, and it could represent, in the immediate future, an evaluation to be performed in all hypertensive patients, in order to obtain a better stratification of cardiovascular risk. Received for publication 14 November 2011; accepted for publication 6 December 2011.
- Prevalence of Hypertension and Sociodemographic Factors w... Objective: The aim of this cross-sectional, community-based survey was to investigate the prevalence of hypertension, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and prehypertension according to sociodemographic features among the members of the households of the Scheduled Caste community of three selected villages (Chowgachha, Bagula and Chakdaha) of the District Nadia, West Bengal, India, in individuals aged 20–70 years. Methods: A door-to-door survey was conducted by the author (MB). Detailed information was collected from participants who were interviewed using a systematic random sampling method and a pretested structured questionnaire. Standard instruments were used to obtain data on weight, height and blood pressure. Data were analysed using the z-test and chi-square test. Results: Prevalence of prehypertension, hypertension, ISH and IDH in the study population was 19.28%, 17.93%, 8.07% and 6.72%, respectively. There was a significant development of hypertension with increasing age (p 11 g/day) were 11.92%, 22.22% and 27.27%, respectively. Conclusions: The results of this investigation clearly indicate that there was a significant (p < 0.001) role of dietary salt in the development of hypertension. Received for publication 15 October 2011; accepted for publication 4 November 2011.
- Role of Tissue Doppler Imaging for Detection of Diastolic... Background: The role of tissue Doppler imaging (TDI) in the assessment of diastolic dysfunction in elderly patients seen in echocardiographic practice is poorly defined. Objective: The aim of this study was to investigate the prevalence of diastolic dysfunction in a cohort of elderly patients referred to an echocardiographic examination for routine clinical indications and to compare the findings obtained by conventional Doppler with those obtained by TDI. Methods: A total of 457 elderly patients with preserved left ventricular (LV) systolic function (mean age 73 ± 5 years, 45% men, 76% with hypertension) underwent a comprehensive echo-Doppler examination; diastolic dysfunction was defined by the following conventional and TDI criteria: E/A ratio (ratio between transmitral peak velocity of E and A waves) 1.5 and lateral annular early diastolic peak velocity (Ei) 1.5. A higher proportion of participants (60.1%) had LV diastolic dysfunction according to TDI. Notably, more than one-half of the patients with ‘normal’ diastolic function by conventional criterion exhibited an abnormal Ei value. Conclusions: A large proportion of elderly patients with normal E/A ratios may have more subtle alterations in LV diastolic mechanics characterized by a reduced annular motion velocity. Thus, evaluation of diastolic function by the simple E/A ratio may markedly underestimate diastolic abnormalities. This finding supports the view that diastolic function should be routinely assessed by comprehensive Doppler methodologies including both conventional and tissue Doppler measurements in order to improve the management of elderly patients seen in clinical practice. Received for publication 15 September 2011; accepted for publication 24 October 2011.
- Microalbuminuria and Left Ventricular Mass in Overweight ... Background: Left ventricular hypertrophy (LVH) and microalbuminuria are common in hypertensive patients and are often associated with metabolic syndrome (MetS). However, it is not clear whether MetS could modify the association between cardiac and renal damage. Objective: The aim of this study was to assess if the relationship of albumin/creatinine ratio (ACR) and left ventricular mass (LVM) could be independent from MetS in hypertensive overweight/obese patients. Methods: 180 essential hypertensive and overweight/obese (body mass index [BMI] ≥25 kg/m2) patients referred to our Hypertension Centre from January 2006 to April 2009 because of blood pressure (BP) control-related problems were studied. Exclusion criteria were scarce adherence to antihypertensive drug therapy as investigated by the Morisky Medical Adherence Scale (MMAS), heart failure (New York Heart Association III or IV or left ventricular ejection fraction [LVEF] <50%), liver failure, cancer or other systemic severe diseases. MetS was defined according to the National Cholesterol Education Program (USA) Adult Treatment Panel III classification as modified by the American Heart Association. ACR was obtained from first morning urine specimens. Left ventricular dimensions, mass and ejection fraction, were measured by echocardiography following the American Society of Echocardiography recommendations. Results: Patients with microalbuminuria had a 6-fold higher risk for LVH/h2.7 and 2-fold higher risk for LVH/body surface area (BSA). Univariate linear regression analysis showed a positive relationship between ACR and LVM, expressed both as LVM/h2.7 or LVM/BSA, as well as a direct correlation between logACR and interventricular diameters and ejection fraction. Regression models including logACR, estimated glomerular filtration rate, BMI, age, hypertension duration, smoking and MetS (as a single variable as well as each single component), showed that only logACR, BMI, hypertension duration and systolic blood pressure (SBP) were independently associated with LVM/h2.7. Conclusion: Along with BP and BMI, albuminuria measured in a morning urine sample as ACR is a valuable low-cost index of cardiac organ damage and increased cardiovascular risk in hypertensive patients independently by MetS. On the other hand, MetS is not an independent risk factor for cardiac damage because it does not seem to add anything more than the sum of each of its components (especially SBP and adiposity indexed by BMI) to the relationship between cardiac and renal subclinical organ damage. Received for publication 7 November 2011; accepted for publication 5 December 2011.
Journal of Hypertension
- Joint statement of the European Association for the Study... Obese patients are prone to arterial hypertension, require more antihypertensive medications, and have an increased risk of treatment-resistant arterial hypertension. Obesity-induced neurohumoral activation appears to be involved. The association between obesity and hypertension shows large inter-individual variability, likely through genetic mechanisms. Obesity affects overall cardiovascular and metabolic risk; yet, the relationship between obesity and cardiovascular risk is complex and not sufficiently addressed in clinical guidelines. The epidemiological observation that obesity may be protective in patients with established cardiovascular disease is difficult to translate into clinical experience and practice. Weight loss is often recommended as a means to lower blood pressure. However, current hypertension guidelines do not provide evidence-based guidance on how to institute weight loss. In fact, weight loss influences on blood pressure may be overestimated. Nevertheless, weight loss through bariatric surgery appears to decrease cardiovascular risk in severely obese patients. Eventually, most obese hypertensive patients will require antihypertensive medications. Data from large-scale studies with hard clinical endpoints on antihypertensive medications specifically addressing obese patients are lacking and the morbidity from the growing population of severely obese patients is poorly recognized or addressed. Because of their broad spectrum of beneficial effects, renin-angiotensin system inhibitors are considered to be the most appropriate drugs for antihypertensive treatment of obese patients. Most obese hypertensive patients require two or more antihypertensive drugs. Finally, how to combine weight loss strategies and antihypertensive treatment to achieve an optimal clinical outcome is unresolved.
- Cardiovascular risk assessment beyond Systemic Coronary R... Background: Cardiovascular risk assessment in the clinical practice is mostly based on risk charts, such as Framingham risk score and Systemic Coronary Risk Estimation (SCORE). These enable clinicians to estimate the impact of cardiovascular risk factors and assess individual cardiovascular risk profile. Risk charts, however, do not take into account subclinical organ damage, which exerts independent influence on risk and may amplify the estimated risk profile. Inclusion of organ damage markers in the assessment may thus contribute to improve this process. Objective: Our aim was to evaluate the influence of implementation of SCORE charts with widely available indexes of organ damage, with the purpose to ameliorate individual risk assessment. Methodology: We searched www.Pubmed.gov for evidence about the predictive value of left ventricular hypertrophy (LVH), estimated glomerular filtration rate (eGFR), microalbuminuria (MAU) and metabolic syndrome on different risk profiles estimated by SCORE. Interventional and observational trials including at least 200 patients and published after 2000 were selected. Results: The presence of organ damage as well as the number of abnormal parameters indicating organ damage is associated with increased cardiovascular risk, independently of SCORE. In the area of high risk, the impact of different markers of organ damage is heterogeneous. Combined risk models of SCORE and subclinical organ damage have major impact on risk stratification and may impact on recommendation in primary prevention in all SCORE categories. Conclusion: Available evidence suggests a tangible clinical advantage of adding the evaluation of simple organ damage markers to risk charts in cardiovascular risk prediction.
- Blood pressure control in Italy: analysis of clinical da... Introduction: Blood pressure (BP) control is poorly achieved in hypertensive patients, worldwide. Aim: We evaluated clinic BP levels and the rate of BP control in hypertensive patients included in observational studies and clinical surveys published between 2005 and 2011 in Italy. Methods: We reviewed the medical literature to identify observational studies and clinical surveys on hypertension between January 2005 and June 2011, which clearly reported information on clinic BP levels, rates of BP control, proportions of treated and untreated patients, who were followed in different clinical settings (mostly in general practice, and also in outpatient clinics and hypertension centres). Results: The overall sample included 158 876 hypertensive patients (94 907 women, mean age 56.6 ± 9.6 years, BMI 27.2 ± 4.2 kg/m2, known duration of hypertension 90.2 ± 12.4 months). In the selected studies, average SBP and DBP levels were 145.7 ± 15.9 and 87.5 ± 9.7 mmHg, respectively; BP levels were higher in patients followed in hypertension centres (n = 10 724, 6.7%; 146.5 ± 17.3/88.5 ± 10.3 mmHg) than in those followed by general practitioners (n = 148 152, 93.3%; 143.5 ± 13.9/84.8 ± 8.9 mmHg; P < 0.01). More than half of the patients were treated (n = 91 318, 57.5%); among treated hypertensive patients, only 31 727 (37.0%) had controlled BP levels. Conclusion: The present analysis confirmed inadequate control of BP in Italy, independently of the clinical setting. Although some improvement was noted compared with a similar analysis performed between 1995 and 2005, these findings highlight the need for a more effective clinical management of hypertension.
- The quantitative relationship between road traffic noise ... Objective: Reviews have suggested that road noise exposure is associated with high blood pressure (hypertension). No reliable exposure–response relationship is as yet available. A meta-analysis was carried out in order to derive a quantitative exposure–response relationship between the exposure to road traffic noise and the prevalence of hypertension, and to gain some insight into the sources of heterogeneity among study results. Methods: Twenty-seven observational studies published between 1970 and 2010 in English, German or Dutch, were evaluated. Finally, the results of 24 studies were included into the data aggregation. Results: Road traffic noise was positively and significantly associated with hypertension: Data aggregation revealed an odds ratio (OR) of 1.034 [95% confidence interval (CI) 1.011–1.056] per 5 dB(A) increase of the 16 h average road traffic noise level (LAeq16hr) [range 45–75 dB(A)]. Important sources of heterogeneity were the age and sex of the population under study, the way exposure was ascertained, and the noise reference level used. Also the way noise was treated in the statistical model and the minimum years of residence of the population under study, gave an explanation of the observed heterogeneity. No definite conclusions can be drawn about the threshold value for the relationship between road traffic noise and the prevalence of hypertension. Conclusion: Based on the meta-analysis, a quantitative relationship is derived that can be used for health impact assessment. The results of this meta-analysis are consistent with a slight increase of cardiovascular disease risk in populations exposed to transportation noise.
- Development of structural kidney damage in spontaneously ... The spontaneously hypertensive rat (SHR) is one of the major models of hypertension. This article describes the current state of knowledge about the mechanism behind kidney damage in SHR in the context of human hypertension and hypertensive kidney disease. It will argue that hypertensive damage in the SHR is pressure-dependent and shows how initial vascular damage leads to a loss of autoregulation and arterial hypertrophy in the juxtamedullary cortex while the outer cortical structures are relatively protected. Progressive arteriolar media hypertrophy then leads to the collapse of some glomeruli followed by tubular atrophy. The reduced glomerular filtration, thus, leads to compensatory hyperfiltration in another population of glomeruli which develop proteinuria and glomerulosclerosis. This model provides some important questions for future research. The regulation of media hypertrophy will be of great interest, as it might slow nephron loss and interstitial fibrosis. Finally, the mechanism by which reduced tubular flow leads to tubular atrophy is another important area for future research. Initial findings indicate that cilia activation may be of major importance for maintaining tubular structure.
- Hypertension in pregnancy: is it time for a new approach... Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. The current definition and treatment recommendations for elevated blood pressure (BP) during pregnancy in the United States have remained unchanged for many years, unlike the recommendations for hypertension treatment in the general population. Clinical studies have provided convincing evidence that women with hypertensive pregnancy disorders are at both immediate and long-term risk for cardiovascular complications; these findings suggest that consideration be given to lowering the presently recommended BP thresholds, both for the initiation of therapy and for therapeutic targets, and to simplifying the approach to the management of elevated BP in pregnancy. This review focuses on the current treatment strategies for hypertensive pregnancy disorders, new developments in the field of hypertension, in general, and in pregnant patients, in particular, and their potential impact on contemporary BP goals and the use of specific antihypertensive medications in pregnancy.
- ‘Les liaisons dangereuses’: the inextricable link be... No abstract available
- Obesity, hypertension, and cardiovascular health: is the... No abstract available
- Workplace environment and risk of hypertension: is obesi... No abstract available
- Wall-to-lumen ratio of retinal arterioles: a reproducibl... No abstract available
Journal of Invasive Cardiology
- Frequency, Treatment, and Consequences of Device Loss and... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): Jose Miguel Iturbe, MD, Abdul-rahman R. Abdel-karim, MD, Aristotelis Papayannis, MD, Arif Mahmood, MD, Bavana V. Rangan, BDS, MPH, Subhash Banerjee, MD, Emmanouil S. Brilakis, MD, PhD Abstract: Background. Device loss and entrapment are infrequent but potentially grave complications of percutaneous coronary interventions (PCI). There are limited contemporary data on the frequency, treatment, and consequences of these complications. Methods. We reviewed 2338 consecutive PCI cases performed between 1/2005 and 5/2010 at our institution to identify cases of device loss or entrapment. The angiograms and outcomes of these patients were reviewed. read more
- Chronic Intrapericardial Catheterization for Repeated Dru... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): Fei Sun, MD1, Francisco M. Sánchez, DVM, PhD1, Javier Fernández-Portales, MD, PhD2, Verónica Crisóstomo, DVM, PhD1, Idoia Díaz-Güemes, DVM, PhD1, Claudia Báez-Díaz, DVM1, Jesús Usón, DVM, PhD1, Manuel Maynar, MD, PhD1,3 Abstract: Background. A minimally invasive pericardial access and chronic catheterization may enhance the therapeutic effects of intrapericardial drug delivery. We aimed to evaluate the technical feasibility of percutaneous intrapericardial implantation of a drug port system for chronic local drug delivery. Methods and Results. Under fluoroscopic guidance, a percutaneous subxiphoid access to the pericardial space was obtained with fine needle and micropuncture set in 6 Göttingen minipigs. read more
- Feasibility and Safety of the Second-Generation, Frequenc... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): Joo Heung Yoon, MD1, Luca Di Vito, MD1, Jeffrey W. Moses, MD2, William F. Fearon, MD3, Alan C. Yeung, MD3, Shaosong Zhang, MD, PhD4, Hiram G. Bezerra, MD5, Marco A. Costa, MD, PhD5, Ik-Kyung Jang, MD, PhD1 Abstract: Objectives. This study sought to assess the effectiveness and safety of the second-generation frequency-domain optical coherence tomography (FD-OCT) system. Background. The second-generation FD-OCT was recently developed, with simplified imaging technique and faster acquisition time compared to the first-generation time-domain OCT. read more
- Clinical Safety of Bivalirudin in Patients Undergoing Ca... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): Bryan D. Cogar, MD1,3, Siddharth A. Wayangankar, MD, MPH3, Mazen Abu-Fadel, MD3, Thomas A. Hennebry, MB BCh BAO3, Mohammad K. Ghani, MD2, Robert M. Kipperman, MD2, George S. Chrysant, MD1,3 Abstract: Background. Prior to June 2011, carotid artery stenting (CAS) had been limited to patients deemed high risk for surgical revascularization due to medical or anatomic reasons. Intraprocedural anticoagulation for CAS has traditionally been carried out with unfractionated heparin (UFH). The direct thrombin inhibitor bivalirudin has emerged as a possible alternative choice for anticoagulation in this patient population. read more
- Coronary Computed Tomography Angiography Indicates Comple... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): B.E. Stähli, MD1, F. Bonassin, MD1, R. Goetti, MD2, S.M. Küest, MD3, M. Frank, MD1, L.A. Altwegg, MD1, C. Gebhard, MD3, A. Levis, BSc2, M.B. Wischnewsky, PhD4, T.F. Lüscher, MD1, H. Alkadhi, MD, MPH2, P.A. Kaufmann, MD3, W. Maier, MD1 Abstract: Background. Coronary computed tomography angiography (CCTA) provides information regarding lesion morphology and three-dimensional coronary anatomy incremental to coronary angiography. We addressed the question whether preprocedural CCTA bears potential for guiding percutaneous coronary interventions (PCI). Methods and Results. Sixty-six coronary lesions attempted with PCI within 6 months of preprocedural CCTA were retrospectively assessed. read more
- Rotational Atherectomy Followed by Cutting-Balloon Plaque... Section: Original Contribution Issue Number: Volume 24 - Issue 5 - May 2012 Author(s): Shinichi Furuichi, MD, Tetsuya Tobaru, MD, Ryuta Asano, MD, Yusuke Watanabe, MD, Itaru Takamisawa, MD, Atsushi Seki, MD, Tetsuya Sumiyoshi, MD, Hitonobu Tomoike, MD Abstract: Background. Drug-eluting stent (DES) underexpansion has been reported as an independent factor for restenosis and thrombosis; therefore, adequate plaque modification prior to DES implantation is the key of calcified lesion treatment. Methods. Consecutive patients with severely calcified lesions undergoing rotational atherectomy (RA) followed by balloon dilatation before DES implantation were analyzed. read more
- Early and Late Reactions Following the Use of Iopamidol ... Section: Original Contribution Issue Number: Volume 15 - Issue 3 - March, 2003 Author(s): A.G.C. Sutton, *P. Finn, P.G. Campbell, D.J.A. Price, J.A. Hall, M.J. Stewart, A. Davies, N.J. Linker, A.A. Harcombe, M.A. de Belder ABSTRACT: Goal. To investigate the incidence of early (< 24 hours) and late (> 24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization. Methods and Results. A total of 2,108 patients undergoing cardiac catheterization in a Regional Cardiothoracic Unit were randomly assigned to receive 1 of 3 commonly used contrast agents in a prospective, double-blind study. read more
- Percutaneous Device Closure of Patent Foramen Ovale Using... Section: Original Contribution Issue Number: Volume 24 - Issue 4 - April 2012 Author(s): Nick J. Collins, FRACP1, Rachael Hatton, FRACP1, Kevin Ng, FRACP2, Rohan Bhagwandeen, FRACP1, John Attia, PhD3, Chris Oldmeadow, PhD3, Rohan Jayasinghe, PhD2 Abstract: Background. Percutaneous device closure is a therapeutic option in patients with presumed stroke complicating paradoxical emboli. Newer devices with lower profiles and potentially reduced thrombogenicity have emerged, such as the Premere PFO occlusion device (St Jude Medical, Inc.); there are limited data on the efficacy and procedural experience with this device. read more
- A Novel Method to Deliver the Filtrap Coronary Embolic Pr... Section: Original Contribution Issue Number: Volume 24 - Issue 4 - April 2012 Author(s): Shin Watanabe, MD1, Naritatsu Saito, MD1, Akihiro Tokushige, MD1, Bao Bingyuan, MD1, Yoshiaki Kawase, MD2, Takeshi Kimura, MD1 Abstract: Background. Although several types of distal embolic protection devices have been developed, they are usually difficult to use because of their stiff and bulky characteristics. We present a novel method to deliver the coronary embolic protection filter via a manual thrombectomy catheter. Methods. We modified the Filtrap embolic protection filter (Nipro Corporation) to pass through the aspiration thrombectomy catheter. read more
- Low-Dose Unfractionated Heparin Administration During Int... Section: Original Contribution Issue Number: Volume 24 - Issue 4 - April 2012 Author(s): Reza Arsanjani, MD, Avinash Khitri, MD, Mehrnoosh Hashemzadeh, PhD, Mohammad Reza Movahed, MD Abstract: Background. Full therapeutic heparin doses ranging from 5000-10,000 units or weight based (70-100 units/kg) have been recommended during percutaneous coronary interventions. However, there are currently no data available in regards to the appropriate dosing of unfractionated heparin during intravascular ultrasound (IVUS) studies without therapeutic coronary interventions. read more
Journal of Cardiovascular Pharmacology and Therapeutics
- Medical Therapy for Calcific Aortic Stenosis Severe aortic stenosis due to calcification of the aortic valve is the most common indication for aortic valve replacement in the United States and Europe. The standard therapy for symptomatic patients with severe aortic stenosis is replacement of the valve. Some of the risk factors and pathophysiologic mechanisms in atherosclerosis play an important role in the development of calcific aortic stenosis. In the last few years, there have been an increased number of publications regarding the use of medications in order to delay the progression of aortic stenosis. These medications include statins, angiotensin-converting enzyme inhibitors, and biphosphanates. This article describes and summarizes some of the medical approaches that have emerged to alter the progression of aortic stenosis. Currently, only statins have been evaluated in randomized, placebo-control trials. Furthermore, statins have not proven to alter the progression of aortic stenosis. Ongoing randomized controlled trials with the use of angiotensin-converting enzyme inhibitors, statins, and biphosphonates will determine the use of these medications to delay the progression of aortic stenosis.
- The Impact of Lipoic Acid on Endothelial Function and Pro... Background: We sought to determine whether a combination of angiotensin-converting enzyme inhibitors (ACEIs) and the nutraceutical α-lipoic acid (ALA) regulates blood pressure, endothelial function, and proteinuria in diabetic patients with Stage I hypertension. Methods: A total of 40 diabetic patients with Stage I hypertension were treated in a crossover double-blinded manner. Patients were administered quinapril ([QUI] 40 mg/d) for 8 weeks or QUI + ALA (600 mg/d) for 8 weeks. Measurements included blood pressure, 24-hour collection of urinary albumin, and endothelial-dependent flow-mediated dilation (FMD). Results: There was a change of metabolic parameters in both study groups after 8 weeks of therapy. In comparison to baseline, the 24-hour urinary albumin significantly decreased by 30% in the QUI group (P = .018, time comparison) and 53% in QUI + ALA group (P < .005, time and group comparison). Also, when compared with baseline, FMD significantly increased by 58% in QUI group (P < .005, time comparison) and by 116% in QUI + ALA group (P < .005, time and group comparison). Systolic and diastolic blood pressure reduced significantly by 10% with QUI treatment. There was no further blood pressure reduction when patients were administered both QUI and ALA. Conclusions: In diabetic patients with hypertension, QUI reduces blood pressure, proteinuria, and improves endothelial function. Moreover, this effect is strongly potentiated with a combination of QUI and ALA. These results may attenuate the progression of vascular pathophysiology seen in patients with a combination of diabetes and hypertension.
- Distinct Pharmacologic Substrate in Lidocaine-Sensitive, ... Lidocaine-sensitive, repetitive atrial tachycardia is an uncommon arrhythmia. The electrophysiologic substrate is still unknown, and the pharmacologic responses have not been fully explored. The aim of this study was to investigate the effects of intravenous adenosine and verapamil in patients with lidocaine-sensitive atrial tachycardia. In 9 patients with repetitive uniform atrial tachycardia, the response to intravenous adenosine (12 mg), lidocaine (1 mg/kg body weight), and verapamil (10 mg) were sequentially investigated. Simultaneous 12-lead electrocardiogram (ECG) was recorded at baseline and continuously monitored thereafter. Tracings were obtained at regularly timed intervals right after the administration of each drug to evaluate changes in the arrhythmia characteristics. Repetitive atrial tachycardia was abolished by intravenous lidocaine in the 9 patients within the first 2 minutes after the end of injection. Adenosine suppressed the arrhythmia in 2 patients and shortened the runs of atrial ectopic activity in 1 patient, while verapamil was effective in 2 patients, 1 of them insensitive to adenosine and the other 1 sensitive to this agent. In 5 patients, the arrhythmia was abolished by radiofrequency ablation at different sites of the right atrium. Lidocaine-sensitive atrial tachycardia may eventually be also suppressed by adenosine and/or verapamil. This suggests that this enigmatic arrhythmia may be caused by different underlying electrophysiologic substrates and that at least in some cases, delayed afterdepolarizations seem to play a determining role.
- The Effect of Low-Dose Pravastatin in Metabolic Syndrome ... The Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA) Study demonstrated the beneficial effect of low-dose pravastatin treatment (10-20 mg/d) on cardiovascular disease (CVD) in Japanese patients with mild-to-moderate hypercholesterolemia. However, it is not known whether mild lipid modification is effective even for patients at high risk. In this study, we evaluated low-dose pravastatin treatment in patients with metabolic syndrome in the MEGA Study. Metabolic syndrome (MetSyn) was defined according to the modified US National Cholesterol Education Program criteria. There were 72 coronary heart disease (CHD) events and 130 CVD events in 2636 patients with MetSyn, and 70 CHD events and 125 CVD events in 5196 patients without MetSyn (hazard ratios 1.85 and 1.90, respectively). No significant risk reduction in CHD was found in the diet plus pravastatin group compared with the diet group patients with MetSyn (hazard ratio .78, P = .29). On the other hand, there was a significant 36% CVD risk reduction (P = .01) in the diet plus pravastatin group compared with the diet group patients with MetSyn, with a small number needed to treat (45). These results indicate that low-dose pravastatin provides a substantial beneficial effect for the prevention of CVD in Japanese patients with MetSyn without known CVD, a population at proportionally high risk in primary prevention.
- Cyclosporine A, 2.5 mg/kg, Does Not Reduce Myocardial Inf... Background: In recent years, cyclosporine A (CsA) has emerged as a promising therapy to limit myocardial ischemic–reperfusion injury, presumably by inhibiting the opening of the mitochondrial permeability transition pore. Results from different large animal models are conflicting, however, with failure to prove beneficial effects of 10 mg/kg CsA administered at reperfusion. Recently, a small clinical study using a bolus of 2.5 mg/kg CsA showed promising but not unequivocal results. The aim of the present study was to estimate the magnitude of a possible infarct reduction with the use of the latter regimen in a closed-chest porcine model for ischemia and reperfusion. Materials and Methods: Pigs underwent catheterization with balloon occlusion of the left descending coronary artery for 40 minutes, followed by reperfusion for 4 hours. They were randomized to receive an intravenous bolus 7 minutes before reperfusion of either 2.5 mg/kg CsA (n = 12) or saline (control, n = 11). Hearts were stained to quantify area at risk and infarct size. Results: Throughout the experiment, there were no differences between the groups in baseline characteristics or hemodynamic variables. CsA treatment did not reduce infarct size as a proportion of area at risk compared with control (51% ± 6% and 54% ± 6%, respectively, P = .75). Conclusion: In a closed-chest porcine model for myocardial ischemia and reperfusion injury, 2.5 mg/kg CsA administered before reperfusion did not reduce infarct size.
- Ticagrelor Inhibits Adenosine Uptake In Vitro and Enhance... Aims: A routine secondary pharmacology screen indicated that reversibly binding oral P2Y12 receptor antagonist ticagrelor could inhibit adenosine uptake in human erythrocytes, suggesting that ticagrelor may potentiate adenosine-mediated responses in vivo. The aim of this study was to further characterize the adenosine uptake inhibition in vitro and study possible physiological consequences of adenosine uptake inhibition by ticagrelor in an anesthetized dog model of coronary blood flow compared to dipyridamole. Methods and Results: We measured [2-3H]adenosine uptake in purified human erythrocytes and several cell lines in the presence of ticagrelor or the known uptake inhibitor dipyridamole as a comparator. Using an open-chest dog model (beagles), we measured the left anterior descending (LAD) coronary artery blood flow during reactive hyperemia after 1 minute occlusion or intracoronary infusion of adenosine before and after administration of vehicle, ticagrelor, or dipyridamole (each n = 8). Ticagrelor concentration-dependently inhibited adenosine uptake in human erythrocytes and in cell lines of rat, canine, or human origin. In the dog model, ticagrelor and dipyridamole dose-dependently augmented reactive hyperemia after LAD occlusion, as assessed by percentage repayment of flow debt relative to control (both Ps < .05). Ticagrelor and dipyridamole also dose-dependently augmented intracoronary adenosine-induced increases in LAD blood flow relative to control (both Ps < .05). Conclusion: Ticagrelor inhibits adenosine uptake in vitro and subsequently augments cardiac blood flow in a canine model of reactive hypoxia- or adenosine-induced blood flow increases. These findings suggest that ticagrelor may have additional benefits in patients with acute coronary syndrome beyond inhibition of platelet aggregation.
- Adenosine and Opioid Receptors Do Not Trigger the Cardiop... Mild hypothermia (32°C-34°C) exerts a potent cardioprotection in animal models of myocardial infarction. Recently, it has been proposed that this beneficial effect is related to survival signaling. We, therefore, hypothesized that the well-known cardioprotective pathways dependent on adenosine and/or opioid receptors could be the trigger of hypothermia-induced salvage. Open-chest rabbits were accordingly exposed to 30 minutes of coronary artery occlusion (CAO) under normothermic (NT) or hypothermic ([HT] 32°C) conditions. In the latter, hypothermia was induced by total liquid ventilation with temperature-controlled perfluorocarbons in order to effect ultrafast cooling and to accurately control cardiac temperature. After 4 hours of reperfusion, infarct and no-reflow zone sizes were assessed and quantified as a percentage of the risk zone. In animals experiencing HT ischemia, the infarct size was dramatically reduced as compared to NT animals (9% ± 3% vs 55% ± 2% of the risk zone, respectively). Importantly, administration of opioid and adenosine receptor antagonists (naloxone [6 mg/kg iv] and 8-(p-sulfophenyl) theophylline [20 mg/kg iv], respectively) did not alter the infarct size or affect the cardioprotective effect of hypothermia. Doses of these 2 antagonists were appropriately chosen since they blunted infarct size reduction induced by selective opioid or adenosine receptor stimulation with morphine (0.3 mg/kg iv) or N 6-cyclopentyladenosine ([CPA] 100 μg/kg iv), respectively. Therefore, the cardioprotective effect of mild hypothermia is not triggered by either opioid or adenosine receptor activation, suggesting the involvement of other cardioprotective pathways.
- The Additive Effects of Ischemic Postconditioning and Cyc... Background: The interaction of diabetes with cardioprotection by postconditioning in ischemia/reperfusion injury remains unclear. The aim of this study was to investigate the concomitant effects of ischemic postconditioning (IPostC) and cyclosporine-A (CsA) on nitric oxide (NO) content and parameters of cardiac function of the diabetic myocardium injured by ischemia/reperfusion. Methods: Diabetes was induced by single injection of streptozotocin (50 mg/kg; intraperitoneally [ip]) in Wistar rats (250-320 g) and the diabetic period was 8 weeks. The hearts (n = 96) were removed quickly, mounted on Langendorff apparatus, and then subjected to 30-minute regional ischemia followed by 45-minute reperfusion. Ischemic postconditioning was induced by 3 cycles of 30-second reperfusion/ischemia at the onset of reperfusion. Myocardial function was measured throughout the experiment, and infarct size (IS) was identified by triphenyltetrazolium chloride (TTC) staining. Total amounts of NO metabolites were determined using Griess method and enzyme-linked immunosorbent assay (ELISA) reader. Results: Administration of either IPostC or CsA alone in nondiabetic animals significantly improved myocardial function and reduced the ISs (28% ± 1.9% or 23% ± 2.0% vs 41% ± 2.9% of the risk zone [RZ], respectively; P < .01), but they had no effect on diabetic hearts (35% ± 1.8% or 32% ± 2.1% vs 39% ± 3.1%, respectively). In addition, myocardial NO level was significantly increased by IPostC only in nondiabetic animals (P < .01). However, after administration of CsA (5 minutes before and 10 minutes after the onset of reperfusion) in postconditioned animals, the cardioprotective and NO-enhancing effects of IPostC were restored in diabetic rats (IS: 21% ± 1.1% vs 39% ± 3.1%), similar to those in nondiabetic controls (19% ± 1.3% vs 41% ± 2.9%; P < .01). Conclusion: The present study indicated that IPostC or CsA failed to affect NO levels and failed to protect the diabetic myocardium against ischemia/reperfusion injury. Moreover, concomitant administration of CsA and IPostC at reperfusion can increase NO content and protect the diabetic myocardium.
- All Preconditioning-Related G Protein-Coupled Receptors C... G protein-coupled receptors for adenosine (A1, A3, A2A, and A2B), bradykinin (B1) and opioids () are all involved in the mechanism of ischemic preconditioning. Although the heart is comprised of many tissue types, it has been assumed that preconditioning’s protective signaling occurs in the cardiomyocyte. We critically tested that hypothesis by testing for the presence of each of these receptors in isolated adult rabbit ventricular myocytes that had been transfected with cyclic nucleotide-gated (CNG) ion channels. Because subsarcolemmal cyclic adenosine monophosphate (cAMP) opens the CNG channels, we could monitor cAMP levels within a single cardiomyocyte by measuring channel current with a patch pipette. The presence of a receptor would be confirmed if we could alter cAMP in the cell with a selective agonist to the receptor being studied. Superfusion with the β-adrenergic Gs-coupled receptor agonist isoproterenol (50 nmol/L) transiently increased cAMP levels and, therefore, channel current. Pretreatment with selective agonists to A1 or A3 adenosine receptors (ARs) that are Gi-coupled markedly attenuated the response to isoproterenol, indicating inhibition of adenylyl cyclase by increased Gi activity. Agonists to bradykinin or -opioid receptors also attenuated isoproterenol’s response. A2AAR and A2BAR are Gs-coupled. The A2AAR–selective agonist CGS21680 increased current through CNG channels but only in the presence of phosphodiesterase (PDE) inhibitors, indicating low surface receptor activity and high intracellular PDE activity. As we previously reported, BAY 60-6583, an A2BAR-selective agonist which mimics preconditioning’s protection in rabbit heart, neither increased nor decreased membrane current in transfected cardiomyocytes, suggesting the absence or a markedly limited number of A2BAR in the sarcolemma. However, reverse transcription polymerase chain reaction (RT-PCR) of purified cardiomyocytes yielded an A2BAR band, implying that rabbit cardiomyocytes do indeed express A2BAR. These data reveal that all receptors reported to be involved in ischemic preconditioning do exist on or within the cardiomyocyte.
- Terminalia arjuna Enhances Baroreflex Sensitivity and Myo... Chronic heart failure (CHF) is characterized by left ventricular (LV) dysfunction along with impaired autonomic control functions. Herbal drugs are increasingly being used in the treatment of cardiovascular disorders. The present study was designed to examine the protective effect of Terminalia arjuna (T arjuna) bark extract on LV and baroreflex function in CHF and to elucidate the possible mechanistic clues in its cardioprotective action. The baroreflex was evaluated by measuring the changes in heart rate (HR) with changes in arterial blood pressure induced by bolus injections of phenylephrine (vasoconstrictor) and sodium nitroprusside (vasodilator). T arjuna bark extract and fluvastatin were tested/administered therapeutically and prophylactically in isoproterenol-induced rat model of CHF. Fifteen days after isoproterenol administration, rats exhibited cardiac dysfunction, hypertrophy, and LV remodeling along with reduced baroreflex sensitivity. Prophylactic and therapeutic treatment with T arjuna improved cardiac functions and baroreflex sensitivity. It also attenuated hypertrophy and fibrosis of the LV. Fluvastatin treatment exerted a similar protective effect against myocardial remodeling and heart failure. Further, T arjuna and fluvastatin significantly reduced oxidative stress and inflammatory cytokine level in CHF rats. In conclusion, T arjuna exerts beneficial effect on LV functions, myocardial remodeling, and autonomic control in CHF possibly through maintaining endogenous antioxidant enzyme activities, inhibiting lipid peroxidation and cytokine levels.
Journal of Cardiovascular Pharmacology
- Adenosine A2A and A3 Receptors Are Involved in the Human ... Abstract: Human endothelial progenitor cells (hEPC) are recruited to sites of neovascularization where they differentiate into endothelial cells. The signals/factors responsible for hEPC migration and adhesion to sites of injury are not well understood. Elevated levels of adenosine are known to increase mature endothelial cell migration in response to tissue injury. However, the understanding of the role of adenosine in the physiology of hEPC is very limited. Using quantitative polymerase chain reaction and western blot analyses, we detected the expression of the adenosine receptors A2A, A2B, and A3 in hEPC. Stimulation of adenosine receptors using adenosine or the nonselective agonist adenosine-5'-N-ethylcarboxamide (NECA) increased hEPC migration in 1.4-fold and 2.1-fold (P < 0.01), respectively. Stimulation of hEPC using the A2A-specific agonist CGS-21680 resembled the effect observed in migration when using adenosine or NECA. Consequently, NECA and CGS-21680-stimulated migration of hEPC were reverted using the A2A receptor antagonist ZM-241385. NECA-stimulated migration was inhibited in dose-dependent manner using MRS-1523 (Ki of 147 ± 0.016 nM), MRS-1754 (Ki of 1900 ± 0.02 nM), or ZM-241385 (Ki of 0.2 ± 0.01 nM). In conclusion, adenosine stimulates hEPC migration by activating A2A and A3 but not A2B receptors and provides evidence to support a role of adenosine in modulating angiogenic capacity of hEPC.
- Aspirin Inhibits the Production of Reactive Oxygen Specie... Abstract: Aspirin has antithrombotic activity and is commonly used to protect patients from cardiovascular disease attacks. The present study investigated whether aspirin reduces reactive oxygen species and proinflammatory proteins in oxidized low-density lipoprotein (ox-LDL)–stimulated human umbilical vein endothelial cells. The results showed that aspirin attenuated reactive oxygen species generation induced by ox-LDL and downregulated Nox4 and inducible nitric oxide synthase expression. Redox-sensitive transcription factor nuclear factor kappa B was inactivated by aspirin, significantly preventing nuclear factor kappa B p65 subunit translocation into the nucleus. The expression of the monocyte/macrophage chemotactic protein 1 also decreased, but endothelial nitric oxide synthase expression increased in aspirin-treated cells. Aspirin ameliorated oxidative stress by downregulating Nox4 and inducible nitric oxide synthase and improved endothelial cell function by increasing endothelial nitric oxide synthase expression. Thus, aspirin may possess protective effects against ox-LDL–induced endothelial cell injury.
- The Contribution of d-Tubocurarine–sensitive and Apamin... Abstract: The nature of the potassium channels involved in determining endothelium-derived hyperpolarizing factor–mediated relaxation was investigated in first-order small mesenteric arteries from male endothelial nitric oxide synthase (eNOS−/−)–knockout and control (+/+) mice. Acetylcholine-induced endothelium-dependent relaxation of small mesenteric arteries of eNOS−/− was resistant to Nω-nitro-L-arginine and indomethacin and the guanylyl cyclase inhibitor, 1H-(1,2,4) oxadiazolo (4,3-a) quinoxalin-1-one. Apamin and the combination of apamin and iberiotoxin or apamin and charybdotoxin induced a transient endothelium-dependent contraction of small mesenteric arteries from both eNOS−/− and +/+ mice. Acetylcholine-induced relaxation in eNOS−/− mice was unaffected by charybdotoxin or apamin alone but significantly inhibited by the combination of these agents. However, the combination of scyllatoxin and iberiotoxin did not mimic the inhibitory effect of the apamin/charybdotoxin combination. Tubocurarine alone completely blocked acetylcholine-induced relaxation in eNOS−/− mice. Single channel analysis of myocytes from small mesenteric arterioles revealed a large conductance calcium-activated potassium channel that was sensitive to iberiotoxin, charybdotoxin, and tetraethylammonium. Tubocurarine blocked this channel from the cytosolic side but not when applied extracellularly. Solutions of nitric oxide (NO) gas also relaxed small mesenteric arteries that had been contracted with cirazoline in a concentration-dependent manner, and the sensitivity to NO was reduced by iberiotoxin and the combination of apamin, scyllatoxin, or tubocurarine with charybdotoxin but not by apamin, charybdotoxin, scyllatoxin, or tubocurarine alone. These data indicate that acetylcholine-induced endothelium-derived hyperpolarizing factor–mediated relaxation in small mesenteric arteries from eNOS−/− involved the activation of tubocurarine and apamin-/charybdotoxin-sensitive K-channels. In eNOS+/+ mice, the acetylcholine-induced response was primarily mediated by NO and was sensitive to iberiotoxin and the combination of apamin and charybdotoxin.
- Ginsenoside-Rb1 and Tetramethylpyrazine Phosphate Act Syn... Abstract: Ginsenoside-Rb1 (Rb1) is known to be partially associated with the inhibition of heparin-binding epidermal growth factor-like growth factor (HB-EGF). Tetramethylpyrazine phosphate (TMPP) inhibits the activation of the calcium/calmodulin/calmodulin-dependent protein kinase (Ca2+/CaM/CaMKII) pathway. The α-myosin heavy chain cTnTR141W transgenic mouse was previously reported as a model for dilated cardiomyopathy (DCM), and it was used to test the effects of combinations of Rb1 and TMPP in reversing the progression of DCM and the potential mechanism. Survival, echocardiography, histologic features assessed the effectiveness of Rb1 and TMPP treatments. Western blot and reverse transcription polymerase chain reactions were used to determine expression levels of certain genes. This study clearly demonstrated that treatment with a combination of Rb1 and TMPP could inhibit the expression of HB-EGF, calmodulin1 (Calm1), and calcium/calmodulin-dependent protein kinase II beta (Camk2b). Rb1 alone mainly reduced the expression of HB-EGF, and TMPP alone mainly reduced the expression of Calm1 and Camk2b. Treatment with Rb1 and TMPP had synergistic effects on the amelioration of chamber dilation, contractile dysfunction, interstitial fibrosis, and ultrastructural degeneration in cTnTR141W mice when compared with the results of treatment with Rb1 or TMPP alone, and those were probably due to the inhibition of both HB-EGF and the Ca2+/CaM/CaMKII pathway.
- Protective Effect of Theaflavins on Homocysteine-Induced ... Abstract: A model of homocysteine-induced injury in vascular endothelial cells was established to evaluate the protective role of theaflavins on homocysteine-injured human vascular endothelial cells (HUVECs). The cells were co-incubated with 3 concentrations of theaflavins (5, 10, or 20 mg/L) and 0.5 mM homocysteine for 24 hours. The morphology and viability of the cells were determined, and the DNA damage was detected by a comet assay. Superoxide dismutase, malondialdehyde, glutathione peroxidase, nitric oxide, nitric oxide synthase, and endothelin-1 were measured. The results showed that theaflavins can reduce the changes in and damage of homocysteine-injured HUVECs, increase the viability of homocysteine-injured HUVECs, and alleviate DNA damage induced by homocysteine. These results indicate that theaflavins can inhibit homocysteine-induced injury of HUVECs. Further studies showed that theaflavins may reduce the production of homocysteine-induced reactive oxygen species and partly modulate the secretory dysfunction of vascular endothelial cells caused by homocysteine. This finding indicates that the mechanism by which theaflavins inhibit homocysteine-induced injury may relate to their antioxidant activity and the regulation of the secretion of endothelium-derived factors. These findings suggest that theaflavins may be beneficial in the prevention of atherosclerosis and cardiovascular disease.
- Levosimendan Attenuates Hypoxia-Induced Pulmonary Hyperte... Background: Levosimendan was hypothesized to attenuate hypoxic pulmonary vasoconstriction (HPV). Methods: Fourteen anaesthetized pigs (30.9 ± 1.0 kg) were studied in normoxia (FiO2∼0.21) and hypoxia (FiO2∼0.10), before and 10–90 minutes after infusion of placebo (n = 7) or levosimendan (n = 7). Results: Compared with normoxia, hypoxia baseline at FiO2∼0.10 (n = 14) increased pulmonary vascular resistance (PVR) by 1.9 ± 0.4 Wood Units (WU) (P < 0.001), mean pulmonary artery pressure (MPAP) by 14.3 ± 0.9 mm Hg (P < 0.001), mean right atrial pressure (MRAP) by 2.1 ± 0.4 mm Hg (P < 0.001), pulmonary capillary wedge pressure (PCWP) by 1.5 ± 0.3 mm Hg (P < 0.001), cardiac output (CO) by 1.3 ± 0.2 L/minute (P < 0.001) and heart rate (HR) by 19.9 ± 5.5 beats·per minute (P < 0.001). Systemic vascular resistance (SVR) decreased by 7.2 ± 1.0 WU (P < 0.001), MAP and stroke volume (SV) remained unaltered (P = ns). Compared with hypoxia baseline, levosimendan decreased MPAP and PVR (P < 0.05), by approximately 9% and 19%, respectively, plateauing between 10 and 90 minutes. SV increased (P < 0.05) by approximately 22%, plateauing after 60 minutes. MRAP, PCWP, HR, CO, MAP, SVR, and blood–O2 consumption remained unaltered (P = ns). Compared with hypoxia baseline, with placebo, MPAP remained stable (P = ns), PVR increased (P < 0.05) and CO decreased (P < 0.05) by approximately 20% and 11% after 60–90 and 30–90 minutes, respectively. SV decreased (P < 0.05) by approximately 8%, plateauing after 60–90 minutes. PCWP and MRAP decreased (P < 0.05) by approximately 12%, plateauing after 10–60 and 10–90 minutes, respectively. MPAP, HR, MAP, SVR, and blood–O2 consumption remained unchanged (P = ns), except at 60 minutes where MAP decreased (P < 0.05) by approximately 4%. Conclusions: Levosimendan attenuated HPV and the cardiodepressive effect of sustained hypoxia.
- Influence of Ethanol Extract of Ginkgo biloba Leaves on t... Abstract: In this study, we attempted to elucidate whether the effects of ethanol extract of Ginkgo biloba leaves (GBE) observed previously on isolated rat heart mitochondria may be realized in situ (in case of isolated heart perfused under normal conditions and under ischemia–reperfusion). We found that GBE at low concentrations (0.01, 0.05, and 0.1 μL/mL) does not affect the heart rate and parameters of electrocardiogram (ECG) but produces a small increase in the coronary flow. Higher concentration of GBE (0.2 and 0.3 μL/mL) diminished the heart rate, decreased the coronary flow, and tended to enhance the parameters of ECG. The contractility of isolated rat heart and mitochondrial nicotinamide adenine dinucleotide reduced form fluorescence decreased in a GBE concentration-dependent manner. Mitochondria isolated from hearts pre-perfused with GBE (0.05 μL/mL) for 20 minutes before nonflow global ischemia–reperfusion (45 min/15 min) showed higher respiratory rates with pyruvate + malate in state 2 and state 3, higher respiratory control index, and diminished H2O2 generation compared with untreated group. Higher GBE concentration, 0.4 μL/mL, had no effect on H2O2 generation and did not prevent the ischemia–reperfusion-induced decrease of pyruvate + malate oxidation in state 3 but even enhanced it. However, in the case of nonischemic perfusions, this GBE concentration had no significant effect on these parameters of respiratory functions of isolated heart mitochondria.
- SM-368229, a Novel Promising Mineralocorticoid Receptor A... Abstract: The purpose of this study was to evaluate the effects of SM-368229, a novel mineralocorticoid receptor (MR) antagonist with partial agonistic activity, and spironolactone (SPI) on systolic blood pressure (SBP) and serum potassium in spontaneously hypertensive rats. SM-368229 given for 2 weeks prevented the increase in SBP without serum potassium elevation, but the treatment with SPI prevented SBP increase with serum potassium elevation. To elucidate the contribution of partial agonistic activity of SM-368229 for MR in the mitigation of serum potassium elevation, we studied the relationships between sodium balance decrease, as an index of antimineralocorticoid action, and serum potassium elevation in adrenalectomized and/or potassium-loaded rats, using SM-368229 and its derivatives (DSR-11861 and DSR-14397) showing different partial agonist activities for MR (12%, 0%, and 36%, respectively). DSR-11861 and SPI reversed sodium balance and increased serum potassium. SM-368229 also reversed sodium balance but did not show apparent serum potassium increase. Although DSR-14397 did not show serum potassium increase, its antimineralocorticoid action was very weak. These findings indicate that serum potassium elevation is negatively related to partial agonistic activities for MR, and SM-368229 shows antihypertensive efficacy with minimal effect on serum potassium level, probably due to its partial agonistic property.
- Ghrelin Protects H9c2 Cardiomyocytes From Angiotensin II... Abstract: Ghrelin, a gastric hormone, exerts cardioprotective function by increasing myocardial contractility and vasodilation. Previous studies have reported that angiotensin II (Ang II) production increased in heart failure, which can induce cardiomyocyte apoptosis. In this study, we investigated the effect of ghrelin on Ang II–induced H9c2 cardiomyocyte apoptosis. The results showed that Ang II inhibited H9c2 cell viability, which was blocked by ghrelin. By annexin V–propidium iodide dual staining and 2′-deoxyuridine 5′-triphosphate nick end-labeling analysis, we found that Ang II induced H9c2 cell apoptosis, whereas coincubation of ghrelin with Ang II significantly reduced H9c2 cell apoptosis induced by Ang II. Simultaneously, the results revealed that ghrelin regulated the Ang II–induced imbalance of Bax and Bcl-2 expression and reduced Ang II–induced caspase-3 expression. Moreover, mRNA expressions of endoplasmic reticulum stress-related molecules GRP78, caspase-12, and C/EBP homologous protein were significantly upregulated by Ang II. However, their expressions were significantly inhibited by ghrelin. In addition, we found that ghrelin markedly inhibited Ang II–induced Ang II type 1 receptor expression. These data suggest that ghrelin may play an antagonistic role in Ang II–induced cardiomyocyte apoptosis via decreasing Ang II type 1 receptor expression and inhibiting the activation of endoplasmic reticulum stress pathway.
- Protein Phosphatase 1b in the Solitary Tract Nucleus is N... Abstract: Despite positive metabolic effects, genetic deletion of protein phosphatase 1b (PTP1b) results in sympathetically mediated elevations in arterial pressure (AP) in mice. Because several PTP1b-regulated peptides also impair the baroreflex sensitivity (BRS) for control of heart rate (HR), we hypothesized that PTP1b in the solitary tract nucleus (NTS) participates in the maintenance of resting baroreflex function. To test this hypothesis, we performed acute bilateral microinjection of an allosteric PTP1b inhibitor (100 nM/120 nL) in the NTS of urethane/chloralose anesthetized Sprague-Dawley rats and assessed the BRS, responses to cardiac vagal chemosensitive fiber activation, and resting AP and HR before and after the injection. PTP1b inhibition impaired the BRS for bradycardia (n = 6; 0.93 ± 0.14 baseline vs. 0.48 ± 0.04 at 10 minutes vs. 0.49 ± 0.04 millisecond/mm Hg at 60 minutes; P < 0.01), with no significant effect on the BRS for tachycardia (0.30 ± 0.16 baseline vs. 0.24 ± 0.08 at 10 minutes vs. 0.24 ± 0.12 millisecond/mm Hg at 60 minutes). The reduced BRS for bradycardia was associated with a significant decrease in alpha-adrenergic responsiveness to phenylephrine at 60 minutes after PTP1b inhibition. Injection of the PTP1b inhibitor in the NTS elicited transient decreases in AP and HR in these animals. However, there was no effect of the inhibitor on depressor or bradycardic responses elicited by activation of cardiac vagal chemosensitive fibers, which converge with baroreceptor afferents in the NTS. These results suggest that PTP1b within the NTS may be a novel molecular mechanism for preservation of resting baroreflex function and provides further evidence for deleterious cardiovascular effects associated with PTP1b inhibition.
The Journal of Clinical Hypertension
- Relationship of Resistant Hypertension and Treatment Outc... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.Resistant hypertension (RH) affects 8% to 30% of hypertensive patients. Blood pressure (BP) reflects the interaction between vascular compliance, resistance to flow, intravascular volume, and cardiac contractility. The relationship of RH with total arterial compliance index (TACI) has not been adequately explored. The RH period prevalence (RH at baseline or follow-up) was determined in a hypertensive cohort (N=156) and compared across quartiles of TACI. Age- and sex-adjusted systolic BP, diastolic BP, and antihypertensive therapeutic intensity score (TIS) were also determined at the time of first BP control. The cohort was 85.3% African American and 67.3% female. Median follow-up was 7 months. The prevalence of RH at baseline was 14.7% while the period prevalence was 43.6%. The period prevalence of RH by ascending quartile for TACI was 66%, 36.8%, 40%, and 30.8% (P=.008). The average BP and antihypertensive TIS at first BP control across TACI quartiles was 122.3/73.4 mm Hg (2.26), 120.7/72.5 mm Hg (1.88), 122.4/75.3 mm Hg (1.71), and 120.0/79.4 mm Hg (1.64) (P=.62, P=.03, P=.13). Low TACI was linked to higher RH prevalence and antihypertensive TIS at first attainment of goal BP according to the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. TACI provides prognostic information that is clinically and perhaps pathophysiologically relevant in RH.
- Aggressive Blood Pressure–Lowering Therapy Guided by Ho... J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.The authors tested the hypothesis that an aggressive antihypertensive treatment is beneficial in protecting against target organ damage (TOD) in patients with type 2 diabetes/prediabetes. The authors enrolled 60 patients with uncontrolled hypertension and diabetes/prediabetes and performed clinic, home, and ambulatory blood pressure (BP) monitoring. Irbesartan, amlodipine, and indapamide were used according to a titration schedule from step 1 to 5 for target home BP level ≤125/75 mm Hg. The flow-mediated vasodilation (FMD), radial augmentation index (AI), pulse wave velocity (PWV), and urinary albumin excretion ratio (UACR), as a surrogate marker of TOD, were measured at baseline and 6 months. Compared with baseline, clinic, home, and ambulatory BP measures were significantly lower in the sixth month. FMD was increased significantly and AI, PWV, and UACR were reduced by the treatment. The extent of the changes in PWV and UACR were associated with the changes in all BP measures, but only the change in home morning BP was associated with the change in FMD. The change in AI was not associated with the change in BP levels, but was associated with the change in PWV. A very aggressive antihypertensive therapy guided by home morning BP was effective for surrogate end points in patients with diabetes/prediabetes.
- Are Sleep Symptoms Predictors of Resistant Hypertension i... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.The aim of this study was to test the association of self-reported sleep symptoms to those identified with severe hypertension in a nationally representative sample of adults. Self-reported and study-measured health and sleep characteristics were collected by the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008. Of 10,526 individuals with completed sleep surveys participating in the study, the authors identified 379 patients with severe hypertension defined as those treated with ≥3 antihypertensive medications including a diuretic; 110 of these had resistant hypertension (RHTN) despite therapy, while 269 were controlled for severe hypertension (CSHTN). Patients with RHTN were more likely to be married, less educated, smoke, and self-report unsatisfactory health and diabetes when compared with patients with CSHTN. Multivariate analyses showed that poorly controlled diabetes (glycated hemoglobin >7%) was the strongest predictor of RHTN (odds ratio, 3.0; 95% confidence interval, 1.2–7.9). Unsatisfactory health (odds ratio, 1.7; 95% confidence interval, 1.7–2.7) was also associated with RHTN. Poorly controlled diabetes and self-reported unsatisfactory heath showed significant association with RHTN. Contrary to expectations, there was no significant association between self-reported snoring/snorting and RHTN, when other factors were examined. The association between poorly controlled diabetes and RHTN warrants further emphasis on strict control of diabetes in these individuals.
- Dietary Supplements and Hypertension: Potential Benefits ... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.Dietary supplements (DSs) are used extensively in the general population and many are promoted for the natural treatment and management of hypertension. Patients with hypertension often choose to use these products either in addition to or instead of pharmacologic antihypertensive agents. Because of the frequent use of DS, both consumers and health care providers should be aware of the considerable issues surrounding these products and factors influencing both efficacy and safety. In this review of the many DSs promoted for the management of hypertension, 4 products with evidence of possible benefits (coenzyme Q10, fish oil, garlic, vitamin C) and 4 that were consistently associated with increasing blood pressure were found (ephedra, Siberian ginseng, bitter orange, licorice). The goals and objectives of this review are to discuss the regulation of DS, evaluate the efficacy of particular DS in the treatment of hypertension, and highlight DS that may potentially increase blood pressure.
- Prognostic Impact of Baseline Low Blood Pressure in Hyper... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.The authors’ aim was to investigate the prognostic value of first-visit systolic and diastolic blood pressure (SBP/DBP) in hypertensive patients with stable coronary artery disease (sCAD) in conditions of contemporary daily clinical practice. From February 1, 2000, to January 31, 2004, 690 consecutive hypertensive patients with sCAD (mean age 68±10 years, 65% male) were prospectively followed in the outpatient cardiology clinic for major events (acute coronary syndrome, revascularization, stroke, heart failure, or death) and associations with baseline SBP/DBP were investigated. At first visit, median SBP/SDP were 130/75 mm Hg (interquartile range, 25–75; 120–140/70–80 mm Hg). After 25 months of follow-up (median), 19 patients died (2.8%); 10 from cardiovascular causes (1.5%), 87 patients experienced a coronary event (13%), and 130 patients (19%) a major event. After adjusting for baseline variables, DBP <75 mm Hg or SBP <130 mm Hg resulted in independent predictors of major events (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.07–2.16, P=.02; HR, 1.68; 95% CI, 1.18–2.40, P=.004, respectively), coronary events (HR, 1.78; 95% CI, 1.15–2.75, P=.009; HR, 1.84; 95% CI, 1.20–2.83, P=.005, respectively), and cardiovascular mortality (HR, 7.02; 95% CI, 1.26–39.04, P=.03; HR, 9.26; 95% CI, 1.33–64.32, P=.02, respectively). In this study, a low first-visit SBP or DBP was associated with an adverse prognosis in hypertensive patients with sCAD of contemporary daily clinical practice.
- Primary Aldosteronism in a Patient Who Exhibited Heart Fa...
- Antihypertensive Drug Use By Children: Are the Drugs Labe... J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.As a result of the Food and Drug Administration (FDA) Modernization Act and the Best Pharmaceuticals for Children Act, the number of medications with FDA-approved pediatric labeling has increased. To assess the success of these initiatives, we examined whether antihypertensive drugs used by children with hypertension in 2008 had FDA-approved pediatric labeling and indications. Using a nationwide commercial insurer database, 2915 children with primary (n=2607) and secondary (n=308) hypertension were identified. Drug user rate and days of supply were calculated from pharmacy claims. Drugs were categorized based on pediatric labeling and indication and whether they were recommended for pediatric use. Antihypertensive drugs were used by 889 (34%) children with primary hypertension and 200 children (65%) with secondary hypertension. User rates were 44.3% in hypertensive children younger than 6 years, 30.9% in those 6 years to older than 12 years, and 38.1% in those 12 years to older than 18 years. Seven percent of drugs were neither labeled for pediatric use nor considered recommended for use in children. In children younger than 6 years, 29% of drugs used were not indicated for use in that age group. Despite recent legislative initiatives, many drugs used by hypertensive children still lack pediatric labeling. Additional efforts are needed to close the gap between the availability of drugs that are labeled and indicated for pediatric use and actual drug usage in children.
- Pediatric Ambulatory Blood Pressure Monitoring: Indicatio... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient’s BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.
- The Present and Future of the American Society of Hyperte...
- Correlation of Blood Pressure Readings From 6-Hour Interv... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.Shorter-interval (6-hour) ambulatory blood pressure monitoring (ABPM) has been shown to correlate well with 24-hour ABPM in adults, but this has not been studied in children. The authors selected 131 patients aged 9 to 18 who underwent 24-ABPM from 2000–2008. Six-hour intervals beginning at different start times were compared with the daytime and 24-hour period, with subset analysis for normotensive and hypertensive patients. Concordance correlation coefficients (CCCs) were used to assess for agreement. Among normotensive patients, the mean difference between daytime and 6-hour intervals ranged from −0.1 mm Hg to 0.0 mm Hg for diastolic blood pressure (DBP) and −1.1 mm Hg to 0.6 mm Hg for systolic blood pressure (SBP) with CCCs of 0.88 to 0.93 for DBP and 0.93 to 0.96 for SBP. For hypertensive patients, mean difference ranged from −0.6 to 1.3 mm Hg for DBP and −0.8 to 1.1 mm Hg for SBP with CCCs of 0.89 to 0.98 for DBP and 0.86 to 0.95 for SBP. Shorter-interval monitoring correlates significantly with full daytime monitoring in children, allowing for assessment of blood pressure with improved convenience.
Journal of Human Hypertension
- Understanding the effects of chronic kidney disease on ca... Understanding the effects of chronic kidney disease on cardiovascular risk: are there lessons to be learnt from healthy kidney donors? Journal of Human Hypertension 26, 141 (March 2012). doi:10.1038/jhh.2011.46 Authors: W E Moody, C D Chue, N G Inston, N C Edwards, R P Steeds, C J Ferro & J N Townend
- Metabolic syndrome and microalbuminuria predict renal out... Metabolic syndrome and microalbuminuria predict renal outcome in non-diabetic patients with primary hypertension: the MAGIC study Journal of Human Hypertension 26, 149 (March 2012). doi:10.1038/jhh.2011.2 Authors: G Leoncini, F Viazzi, M Vercelli, G Deferrari & R Pontremoli
- Blood pressure control in the Hypertension in the Very El... Blood pressure control in the Hypertension in the Very Elderly Trial (HYVET) Journal of Human Hypertension 26, 157 (March 2012). doi:10.1038/jhh.2011.10 Authors: C J Bulpitt, N S Beckett, R Peters, G Leonetti, V Gergova, R Fagard, L A Burch, W Banya & A E Fletcher
- Pulse pressure and systolic night–day ratio interact in... Pulse pressure and systolic night–day ratio interact in prediction of macrovascular disease in patients with type 2 diabetes mellitus Journal of Human Hypertension 26, 164 (March 2012). doi:10.1038/jhh.2011.9 Authors: E Laugesen, N B Rossen, P L Poulsen, K W Hansen, E Ebbehøj & S T Knudsen
- Common matrix metalloproteinase 2 gene haplotypes may mod... Common matrix metalloproteinase 2 gene haplotypes may modulate left ventricular remodelling in hypertensive patients Journal of Human Hypertension 26, 171 (March 2012). doi:10.1038/jhh.2011.8 Authors: R Lacchini, A L B Jacob-Ferreira, M R Luizon, S Gasparini, M C S Ferreira-Sae, R Schreiber, W Nadruz & J E Tanus-Santos
- Polyunsaturated fatty acid intake and blood pressure in a... Polyunsaturated fatty acid intake and blood pressure in adolescents Journal of Human Hypertension 26, 178 (March 2012). doi:10.1038/jhh.2011.7 Authors: T A O'Sullivan, A P Bremner, L J Beilin, G L Ambrosini, T A Mori, R C Huang & W H Oddy
- Perception of uncontrolled blood pressure and behaviours ... Perception of uncontrolled blood pressure and behaviours to improve blood pressure: findings from the 2009 Survey on Living with Chronic Diseases in Canada Journal of Human Hypertension 26, 188 (March 2012). doi:10.1038/jhh.2011.5 Authors: M E Gee, N R C Campbell, C M Bancej, C Robitaille, A Bienek, M R Joffres, R L Walker, J Kaczorowski & S Dai
- VEGF and its soluble receptor VEGFR-2 in hypertensive dis... VEGF and its soluble receptor VEGFR-2 in hypertensive disorders during pregnancy: the Indian scenario Journal of Human Hypertension 26, 196 (March 2012). doi:10.1038/jhh.2011.17 Authors: G Rath & R Tripathi
- Angiogenic balance and diagnosis of pre-eclampsia: select... Angiogenic balance and diagnosis of pre-eclampsia: selecting the right VEGF receptor Journal of Human Hypertension 26, 205 (March 2012). doi:10.1038/jhh.2011.89 Authors: V Jha, P K Aggarwal, N Chandel & V Jain
- Angiogenic balance and diagnosis of pre-eclampsia: select... Angiogenic balance and diagnosis of pre-eclampsia: selecting the right VEGF receptor Journal of Human Hypertension 26, 207 (March 2012). doi:10.1038/jhh.2011.90 Authors: G Rath & R Tripathi
Clinical and Experimental Hypertension
- Relationship between Vitamin D Deficiency and Nondipper H... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-5, Early Online.
- Effect of Amiloride and Spironolactone on Renal Tubular F... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-13, Early Online.
- Association of CLCNKB Haplotypes and Hypertension in Mong... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-6, Early Online.
- Relationship of Ambulatory Blood Pressure and the Heart R... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-6, Early Online.
- Exercise Training Causes Sympathoinhibition through Antio... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-6, Early Online.
- Daily Serial Hemodynamic Data during Pregnancy and Season... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-7, Early Online.
- Individual and Concomitant Effects of Cardioprotective Pr... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-8, Early Online.
- Silent Cerebrovascular Damage and Its Early Correlates in... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-7, Early Online.
- Elevated Levels of MMP-9 in Untreated Patients with Stage... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-6, Early Online.
- Predictors of the Short-Term Effect of Isoleucine–Proli... Clinical and Experimental Hypertension, Volume 0, Issue 0, Page 1-5, Early Online.
Cardiovascular Revascularization Medicine
- CRT 2012 welcomed former President Bill Clinton For me, as the founder and chairman of the annual Cardiovascular Research Technologies (CRT) meeting for the last 15 years, the highlight of this year's meeting was the keynote address given by the 42nd president of the United States, Mr. Bill Clinton. This year we targeted a high-profile individual who could address the meeting's attendees from his own personal experience and share his perspective on health care reform during an election year. The topic remains a highlight of the political debate, especially when a new cardiovascular innovation faces regulatory and reimbursement challenges.
- CTO Club: revisiting the final frontier in PCI When Andrés Gruéntzig () took the first step to perform balloon angioplasty in 1977 in Zurich, Switzerland, we saw the beginning of a new era. Angioplasty first began as a therapy for single-vessel proximal stenosis, and in the early 1980s, with improvement in equipment and a few brave pioneers, this treatment went to the next level. Geoffrey Hartzler (), one of those early pioneers in angioplasty, advanced the therapy from very isolated patient subsets to the treatment of multivessel coronary disease. He also showed us the way to treat acute myocardial infarction, as well as patients with chronic total occlusions. His work showed that chronic total occlusion in percutaneous coronary intervention (PCI) even with rudimentary equipment could be approached effectively, and his group showed that there appeared to be a difference in outcome in chronic total occlusion (CTO) patients who were successfully or unsuccessfully treated. Dr. Hartzler also came up with the concept to approach CTOs in a retrograde fashion, in this case going across saphenous vein grafts, to advance into the native coronaries. The Japanese picked up the mantle on CTOs and basically made a statement to the world that all patients were fair game to be treated with PCI, and their expertise has transformed CTO therapy into a true specialty of interventional cardiology. Working with our Japanese colleagues and also applying some new technology and skills, a small group of us began the CTO Club in the United States. Greg Braden () and Don Baim () were leaders when we organized the first CTO Club. The original concept with the Club was that we would rotate the meeting to various sites in the United States involving not only our CTO gurus in the United States but also European and Japanese leaders.
- Impact of vascular approach (transradial vs. transfemoral... Abstract: Background: Manual thrombus aspiration improves the efficacy of percutaneous coronary interventions (PCIs) in ST-elevation acute myocardial infarction (STEMI). The transradial approach (TRA) is an emerging vascular approach for PCI but is associated with specific technical requirements. As data on the combination of thrombus aspiration and TRA are scarce, we sought to assess the feasibility of TRA manual thrombus aspiration in STEMI patients.Methods: All consecutive patients treated with manual thrombectomy for acute STEMI in three Italian hospitals were considered. Patients were divided according to the vascular approach into two groups: TRA and transfemoral (TFA). Two primary end points were defined: thrombectomy feasibility (ability to cross the occlusion with the device) and thrombectomy efficacy (absolute thrombus score reduction after device crossing).Results: From January 2008 to December 2009, 303 patients were included: 151 patients (63±13 years) were treated through TFA, and 152 patients (61±12 years, P=.25) were treated through TRA. There were no significant differences in thrombectomy feasibility (75% in the TRA compared to 74.8% in the TFA group, P=.97) or in thrombectomy efficacy (2.6±.8 for TRA and 2.9±2 for TFA, P=.15). In both groups, there was a significant reduction in thrombus score after manual thrombus aspiration. Angiographically evident distal embolization after device crossing was low and observed in seven cases (5%) either for TFA and TRA (P=.99).Conclusions: The present study suggests that, in the setting of acute STEMI, manual thrombus aspiration through TRA is feasible, and its efficacy is comparable to the TFA.
- A prospective multicenter registry of laser therapy for d... Abstract: Purpose: The primary aim of this study was to prospectively evaluate the safety and efficacy of Excimer laser atherectomy as a primary treatment strategy in consecutively eligible patients presenting for percutaneous coronary intervention (PCI) of degenerated saphenous vein graft (SVG) lesions using a multicenter registry. Prior single-center experience suggested that laser atherectomy may decrease acute procedural complications during treatment of degenerated SVGs, including lesions not amenable to distal protection devices (DPDs).Methods and materials: The COronary graft Results following Atherectomy with Laser investigators enrolled 98 patients at 18 centers between June 23, 2003, and October 4, 2004, with greater than 50% stenosis of an SVG who presented for PCI due to angina pectoris or objective evidence of myocardial ischemia in a concordant myocardial distribution. Laser atherectomy was planned. Patients were excluded if the operator planned to utilize a DPD. Inclusion and exclusion criteria were aligned to those in the Saphenous vein graft Angioplasty Free of Emboli Randomized (SAFER) trial.Results: The primary end point [30-day major adverse cardiac events (MACE)] occurred in 18/98 (18.4%) patients driven primarily by non-q-wave myocardial infarction. Major procedural complications included no reflow (n=5) and major dissection (n=1). No perforations occurred. Univariate predictors of 30-day MACE included lesion length, vessel angulation, plaque burden, SVG degeneracy score, number of laser pulses used, and larger-sized laser catheters.Conclusions: This study demonstrated that Excimer laser atherectomy of diseased SVGs is feasible with results comparable to the 30-day MACE in the control population from the SAFER trial. Whether the addition of laser to embolic protection devices is of any clinical utility remains to be tested in future studies.
- Stenting of the unprotected left main coronary artery in ... Abstract: Aims: High-risk patients with severe aortic stenosis (AS) who are candidates for transcatheter valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) may additionally require revascularization of the unprotected left main coronary artery (UPLM). We aimed to assess the feasibility and procedural safety of UPLM stenting in such patients.Methods and Results: Ten cases of UPLM stenting prior to BAV or TAVI at three medical centers over a 2-year period were identified. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm2, left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Intraaortic balloon counterpulsation was used in three patients. A single stent was used in seven patients, and two stents were used in three patients. One patient received a bare-metal stent, and the others received drug-eluting stents. No procedural complications occurred, and the patients were hemodynamically stable. Three patients subsequently underwent BAV, and seven underwent TAVI. During 6 months of follow-up, two patients died: one due to AS restenosis 6 months after BAV and one due to vascular complications 18 days after TAVI (34 days after UPLM stenting).Conclusions: Stenting of the UPLM in patients with severe AS prior to percutaneous valve intervention seems feasible and safe. This approach may enable more patients to achieve comprehensive percutaneous therapy for severe coronary and valvular disease.
- Randomized trial of insulin versus usual care in reducing... Abstract: Background: Diabetes status is an independent marker of restenosis after percutaneous coronary intervention (PCI). Previous studies suggest that metabolic abnormalities associated with diabetes increase stent restenosis by promoting intimal hyperplasia. Preclinical studies have indicated that insulin therapy reduces intimal hyperplasia. The objective of this study was to determine whether insulin-mediated glucose lowering reduces in-stent restenosis in patients with diabetes undergoing PCIs.Methods: We conducted a prospective, randomized, multicenter, open-labeled study with blinded outcomes. Patients were randomized 1:1 to daily bedtime subcutaneous NPH insulin (Novo Nordisk) versus usual therapy with oral hypoglycemic agents. The main outcomes were change in volume of intimal hyperplasia within the stent measured by intravascular ultrasound and late lumen loss by quantitative coronary angiography at 6 months post-PCI.Results: Seventy-eight patients (36 insulin, 42 usual care) were randomized. Eight patients in each group received drug-eluting stents. The insulin group achieved greater reductions in both glycosylated hemoglobin A1c (mean±S.D.) (insulin: 8.0%±1.2% to 6.7%±0.7% vs. control: 7.5%±1.2% to 7.1%±1.0 %, P=.0038) and fasting glucose (insulin: 9.3±3.8 to 5.8±1.7 vs. usual care: 8.4±2.4 to 7.7±2.0 mmol/l, P<.0001). There were no hypoglycemic events. At 6 months, there were no significant differences in either intravascular-ultrasound-determined neointimal volume (insulin: 41.2±38.9 vs. usual care: 48.4±40.2 mm3, P=.33) or late lumen loss by angiography (insulin: 1.29±0.74 mm vs. usual care: 1.02±0.71 mm, P=.17).Conclusions: Addition of a single bedtime dose of insulin in patients with diabetes does not influence in-stent restenosis.
- Percutaneous left ventricular support for high-risk PCI a... Abstract: Background: Temporary use of a percutaneous left ventricular assist device (PLVAD) may be beneficial in patients undergoing high-risk percutaneous coronary intervention (PCI) and those with cardiogenic shock (CS).Methods: Seventy-four consecutive patients undergoing high-risk PCI and those with CS receiving intraaortic balloon pump (IABP), TandemHeart (TH), or Impella device (IMP) were enrolled. Patient undergoing high-risk PCI (n=57) and those treated for CS (n=17) were analyzed as separate cohorts. Patients undergoing IABP-assisted PCI were compared to those undergoing PLVAD (TH and IMP)-assisted PCI. The primary end point was in-hospital major adverse cardiovascular events, and the secondary end point was in-hospital vascular complications.Results: For the high-risk PCI cohort (n=57), 22 received PLVAD and 35 received IABP. Patients receiving IABP were younger and less likely to have a prior myocardial infarction (MI) and less likely to be on dialysis compared to those receiving PLVAD support. Patients receiving PLVAD support had a higher baseline Syntax score, had a higher prevalence of unprotected left main disease, underwent treatment of more coronary lesions, received more coronary stents, and more likely received drug-eluting stents compared to those receiving IABP support. The primary and secondary end points were similar between both groups. For the CS cohort (n=17), 4 received PLVAD and 13 received IABP. Patients receiving PLVAD support were more likely to have a prior MI, had a lower ejection fraction, underwent treatment of more coronary lesions, and received more coronary stents compared to those receiving IABP support. The primary and secondary end points were similar between both groups.Conclusions: IABP compared with PLVAD use for high-risk PCI and CS is associated with significantly different baseline patient, clinical, procedural, and angiographic characteristics. In-hospital clinical outcome was similar between both groups in both the high-risk PCI and the CS cohorts. When physicians have access to each of these devices, short-term clinical outcome appears to be similar.
- Fluoroscopy use and left anterior descending artery angio... Abstract: Background: Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. Transapical AVR might reduce the risk in patients not suitable for the transfemoral approach. We aimed to describe the fluoroscopy and left anterior descending artery (LAD) angiography guidance technique for transapical AVR access and the initial related procedural results.Methods: Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD angiographic-guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Minithoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque marker to ensure puncture lateral to the LAD. Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root.Results: The population had a mean age of 83 years and was more frequently male (89%) with a high-risk profile (mean Society of Thoracic Surgeons score of 11%). Two patients received the 23-mm Edwards SAPIEN valve, and seven patients received the 26-mm SAPIEN device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications.Conclusion: Fluoroscopy and angiography for guidance of the transapical approach facilitate a safe and rapid access to the apex, insuring no risk of damage to the LAD or to large diagonals.
- Intravascular ultrasound insights from the Cobalt Chromiu... Abstract: Background: Dedicated IVUS analyses of the second CObalt chromium STent with Antiproliferative for Restenosis (COSTAR II) trial have not been documented. We aim to compare IVUS findings between CoStar paclitaxel-eluting stent (PES) and Taxus PES in patients enrolled in the COSTAR II trial. We also attempted to examine the possible regional impact of multiple stenting.Methods and materials: Among the 1700 patients enrolled, 238 were assigned to an IVUS cohort including 168 patients treated by provisional multiple stenting. At 9 months, qualitative and quantitative IVUS observations including incomplete stent apposition (ISA) and neointimal proliferation (neointimal obstruction: neointimal volume/stent volume ×100) were compared between CoStar and Taxus PESs.Results: In qualitative analysis, late-acquired ISA was observed in 1 patient treated by Taxus PES. Impaired strut continuity suggestive of stent fracture was observed in 2 out of 33 patients treated by multiple CoStar, and 4 out of 21 patients treated by multiple Taxus (P=.14). No such findings were found in single-stented patients in either stent subset. Quantitative analysis showed greater neointimal obstruction in CoStar (19.7%±13.4%, n=52) than in Taxus (10.7%±9.9%, n=38), whereas no significant difference in neointimal obstruction was found between single and multiple stenting in either CoStar or Taxus PES.Conclusions: The CoStar PES exhibits greater neointimal proliferation compared with Taxus PES at 9 months but with similar qualitative outcomes including late-acquired ISA. IVUS findings suggestive of stent fracture were found only in multiple-stenting cases irrespective of the stent used.
- Left main coronary stenting in a non surgical octogenaria... Abstract: Coronary artery bypass grafting is conventionally considered the standard treatment for significant left main coronary artery (LMCA) disease. The management of LMCA disease in octogenarians is however still debated. The aim of this study was to appreciate the safety and effectiveness of percutaneous coronary intervention (PCI) for LMCA disease in octogenarians who were denied for surgical revascularization. The study included 70 consecutive patients ≥80 years of age who had undergone PCI for the treatment of LMCA and who were primary denied by our center's heart team for surgical revascularization. Mean age was 83.4±2.6 years. Mean Euroscore was 21.1±16.7 and mean Syntax score was 28.6±8.7. Overall in-hospital mortality was 11%. Mean follow-up time was 30.5±24.2 months. Overall mortality at the end of follow-up was 28%. Cardiac death was found in 18 patients and 2 patients died from terminal renal insufficiency. One patient (2%) presented with a new STEMI, 7 (11.3%) with a new non-STEMI, 13 (21%) with heart failure, and 2 (3.2%) had minor hemorrhage. There was a percutaneous target vessel revascularization in 6 (10%) patients. During follow-up, the total major adverse cerebral and cardiovascular event (MACCE including death, non-fatal acute myocardial infarction (AMI), target lesion revascularization (TLR), or stroke) was 27.4%. Stent implantation was relatively safely applied for the treatment of LMCA disease in octogenarians who were refused for surgery and who represented a high risk population. Despite a non-negligible rate of MACCE, the clinical long term outcome seems correct for this specific population with heavy basal status.
Clinical Cardiology
- Genetics of Coronary Artery Disease in the 21st Century Coronary artery disease (CAD) is still the number-one killer in the world, and clinical trials indicate that it is preventable. Mortality and morbidity can be reduced by at least 30% to 40% by treating known risk factors. Genetic susceptibility is claimed to account for 50% of predisposition. The challenge of preventing CAD in this century, as claimed by some investigators, will require a more comprehensive prevention and treatment of environmental and genetic risk factors. Part of that challenge has been met by genome-wide association studies, which have identified 36 genetic variants with increased risk for CAD. All of these genetic variants have reached genome-wide significance (5×10−8) and replicate in independent populations with large sample sizes. More than 50% of these variants occur in >50% of the population, with 10 occurring in >75% of the population. The challenge and the opportunity lie in the observation that >66% of these risk variants do not mediate their risk through known conventional risk factors. These results suggest that genetic predisposition for CAD is conferred by common DNA variants and many factors contributing to the pathogenesis of CAD are yet to be determined. Comprehensive prevention of CAD will most likely require combating genetic and environmental risk factors. We are on the cusp of genetic screening, and new therapeutic targets are becoming available to manage both genetic and environmental risk factors for CAD.The authors are supported by grants from the Canadian Institutes of Health Research, nos. MOP82810 (RR) and MOP77682 (AFRS), and the Canada Foundation for Innovation, no. 11966 (RR). The authors have no other funding, financial relationships, or conflicts of interest to disclose.
- Treatment and Outcomes of Acute Coronary Syndrome in the ... Background:Randomized trials have established the benefit of medical therapy and revascularization in the treatment of acute myocardial infarction (MI). Cancer and cardiovascular disease are the 2 most common diseases worldwide. In clinical practice, cancer patients are frequently afflicted with MI. The benefit of medical and/or revascularization therapy in the cancer population with MI is less well known.Hypothesis:Medical and revascularization therapy reduces mortality in cancer patients with MI.Methods:After approval by the institutional review board, we retrospectively reviewed all patients with a discharge diagnosis of acute MI who were admitted to the University of Texas MD Anderson Cancer Center between December 2000 and October 2006 and evaluated the association between cardiac treatments with survival outcomes.Results:A total of 456 patients with a discharge diagnosis of acute MI were identified and included in the study, of which 386 had non–ST-segment elevation MI (NSTEMI) and 70 had ST-segment elevation MI (STEMI). Compared with patients with NSTEMI, patients who had STEMI were more often prescribed aspirin (66% vs 43%; P = 0.004), β-blockers (61% vs 46%; P = 0.018), and thrombolytic therapy (9% vs 0.3%; P = 0.0001). In the multivariable analysis, aspirin use was associated with a 23% decreased risk of death (hazard ratio [HR]: 0.77, 95% confidence interval [CI]: 0.60-0.98, P = 0.033) and β-blocker use was associated with a 36% decreased risk of death (HR: 0.64, 95% CI: 0.51–0.81, P = 0.0002). Statins (HR: 0.82, P = 0.18) and catheter-based revascularization (HR: 0.57, P = 0.09) did not have an impact on the risk of death. Compared with patients with limited cancer, advanced cancer patients were twice as likely to die (HR: 2.12, 95 CI: 1.47–3.04, P < 0.0001). Previous chemotherapy (P = 0.005) and chest radiotherapy (P = 0.017) were associated with increased 1-year mortality, whereas hyperlipidemia (P = 0.018) was protective.Conclusions:In this study of cancer patients with MI, medical therapy with aspirin and β-blockers was associated with improved survival.The authors have no funding, financial relationships, or conflicts of interest to disclose.
- Detection of Exercise-Induced Pulmonary Arterial Hyperten... Background:The pulmonary arterial pressure (PAP) response to exercise may provide a tool for the early detection of pulmonary arterial hypertension (PAH). Therefore, an accurate noninvasive method for evaluating exercise-induced PAH (EIPAH) is desirable.Hypothesis:We sought to examine if cardiopulmonary exercise testing (CPET) is able to indicate EIPAH.Methods:Fifty-three patients aged 67.1 ± 1.7 years (37 female, 16 male) with borderline PAH (resting mean PAP 21–24 mm Hg) performed CPET and right heart catheterization at rest and during handgrip testing.Results:When comparing patients with an exercise-induced mean PAP ≥35 mm Hg (group A, n = 24) and subjects with an exercise-induced mean PAP <35 mm Hg (group B, n = 29), group A had a significantly lower mean aerobic capacity (15.2 ± 1.2 vs 19.7 ± 1.2 mL/min/kg; P = 0.02), higher ventilatory equivalents for oxygen at the anaerobic threshold (34.3 ± 1.5 vs 29.9 ± 1.1; P = 0.02), a widening of the mean alveolar-arterial oxygen difference (37.8 ± 3.0 vs 26.8 ± 2.4 mm Hg; P = 0.007), an elevated mean functional dead space ventilation (29.5 ± 2.7 vs 21.2 ± 1.7%; P = 0.008), and a higher mean arterial to end-tidal carbon dioxide gradient at peak exercise (3.7 ± 0.9 vs 0.4 ± 0.8 mm Hg; P = 0.007).Conclusions:EIPAH is characterized by a decreased ventilatory efficiency due to ventilation to perfusion inequalities. CPET may be useful for the identification of EIPAH and serve to diagnose PAH at an early stage.Drs. Schwaiblmair, von Scheidt, and Berghaus conceived and designed the study. Drs. Schwaiblmair, Faul, and Berghaus acquired the study data. Dr. Schwaiblmair performed the statistical analysis and drafted the article. All authors participated in interpreting the data and revised the manuscript for important intellectual content.The authors have no funding, financial relationships, or conflicts of interest to disclose.
- Smoking Status on Outcomes After Percutaneous Coronary In... Background:The effect of smoking on prognosis among patients undergoing percutaneous coronary intervention (PCI) is controversial, and data on the importance of smoking cessation or reductions were lacking.Hypothesis:Smoking cessation or reductions could reduce the risk of adverse outcomes in patient after PCI.Methods:There were 19 506 consecutive patients who had undergone successful PCI between April 2004 and January 2010 followed. Extensive data, including self-reported smoking habits, were obtained at baseline and during follow-up.Results:Compared with post-PCI quitters and persistent smokers, the nonsmokers and pre-PCI quitters were older and had a higher prevalence of comorbid factors such as hypertension and impaired left ventricle function. The adjusted hazard ratios for mortality were 2.52 (95% confidence interval [CI]: 1.92–3.30) for nonsmokers, 0.52 (95% CI: 0.32–0.84) for pre-PCI quitters, and 0.11 (95% CI: 0.06–0.22) for post-PCI quitters, compared to persistent smokers. With respect to additional revascularizations, a higher risk was observed among the quitters (1.70 [95% CI: 1.40–2.08] for pre-PCI quitters and 1.59 [95% CI: 1.36–1.85] for post-PCI quitters) as well as the nonsmokers (1.40 [95% CI: 1.20–1.64]). Among persistent smokers, each reduction of 5 cigarettes/day was associated with a 72% decline in mortality risk (P < 0.001) but did not reach statistical significant for repeated revascularizations (0.80 [95% CI: 0.46–1.37], P = 0.4132).Conclusions:Despite a higher risk of revascularization, the cessation of smoking either before or after PCI is beneficial in all-cause mortality. The apparent smoker's paradox may be explained by the differences in baseline risk or the reduced sensitivity to adverse outcomes as well as the reluctance to seek medical help among smokers.This study received an unrestricted grant from Pfizer Investment Co., China. The authors have no other funding, financial relationships, or conflicts of interest to disclose.
- The Effectiveness and Safety of Triple-Antiplatelet Treat... The combination of cilostazol, aspirin, and clopidogrel (triple therapy) after percutaneous coronary intervention has been considered as an alternative therapy. We performed a meta-analysis based on 8 randomized controlled trials with a total of 3332 patients to compare the effectiveness and safety of this triple therapy with traditional dual therapy (aspirin and clopidogrel). Our findings suggested that the triple therapy is more effective than dual therapy in preventing restenosis (odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.40–0.66, P < 0.00001), maintaining minimal lumen diameter (OR: 0.15, 95% CI: 0.10–0.20, P < 0.00001), and avoiding target-vessel revascularization (OR: 0.62, 95% CI: 0.47–0.82, P = 0.001). There is also no significant difference in major adverse cardiac and cerebrovascular events between the 2 therapies, except the smaller occurrence rate of target-lesion revascularization in the triple-therapy group (OR: 0.42, 95% CI: 0.26–0.69, P = 0.0005). However, the triple therapy is associated with a higher level of adverse drug events, including rash (OR: 2.45, 95% CI: 1.41–4.23, P = 0.001), gastrointestinal disorders (OR: 2.59, 95% CI: 1.26–5.30, P = 0.009), and drug discontinuation (OR: 3.80, 95% CI: 1.59–9.10, P = 0.003), but it has no difference in bleeding compared with the dual therapy (OR: 1.05, 95% CI: 0.71–1.55, P = 0.80).Additional Supporting Information may be found in the online version of this article.Ping Wang, MS and Shijie Zhou, MS contributed equally to this article. The authors have no funding, financial relationships, or conflicts of interest to disclose.
- Catheter-Based Renal Denervation for Resistant Hypertensi... Hypertension represents a significant global public health concern, contributing to vascular and renal morbidity, cardiovascular mortality, and economic burden. The opportunity to influence clinical outcomes through hypertension management is therefore paramount. Despite adherence to multiple available medical therapies, a significant proportion of patients have persistent blood pressure elevation, a condition termed resistant hypertension. Recent recognition of the importance of the renal sympathetic and somatic nerves in modulating blood pressure and the development of a novel procedure that selectively removes these contributors to resistant hypertension represents an opportunity to provide clinically meaningful benefit across wide and varied patient populations. Early clinical evaluation with catheter-based, selective renal sympathetic denervation in patients with resistant hypertension has mechanistically correlated sympathetic efferent denervation with decreased renal norepinephrine spillover and renin activity, increased renal plasma flow, and has demonstrated clinically significant, sustained reductions in blood pressure. The SYMPLICITY HTN-3 Trial is a pivotal study designed as a prospective, randomized, masked procedure, single-blind trial evaluating the safety and effectiveness of catheter-based bilateral renal denervation for the treatment of uncontrolled hypertension despite compliance with at least 3 antihypertensive medications of different classes (at least one of which is a diuretic) at maximal tolerable doses. The primary effectiveness endpoint is measured as the change in office-based systolic blood pressure from baseline to 6 months. This manuscript describes the design and methodology of a regulatory trial of selective renal denervation for the treatment of hypertension among patients who have failed pharmacologic therapy. Clin. Cardiol. 2012. doi: 10.1002/clc.22008Dr. Kandzari receives research/grant support and consulting honoraria from Medtronic CardioVascular, Abbott Vascular and Boston Scientific; Dr. Bhatt receives honoraria from WebMD and research grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, and The Medicines Company. Dr. Oparil receives research/grant support from Merck and Co., NHLBI, Novartis, and Takeda, honoraria from Daiichi Sankyo and Pfizer, and is a consultant for Bayer, Medtronic, Novartis, Pfizer, and Daiichi Sankyo. Dr. Rocha-Singh is a consultant for Medtronic, Covidien, and Cardiosonic. Dr. Flack receives grant/research support from NIH, Daiichi Sankyo, sanofi aventis, and Novartis. He is on the Speaker Bureau for Novartis, Daiichi Sankyo, and Boehringer Ingleheim, and is a consultant for Glaxo-Smith-Kline, Novartis, NIH, Daiichi Sankyo, and Boehringer Ingleheim, Medtronic, and Back Beat Hypertension. Dr. Katzen is a consultant for Abbott, CRBard, Boston Scientific, WL Gore, and Medtronic. Dr. Massaro is a member of the Data Safety Monitoring Board and will no longer participate as a member of the SYMPLICITY HTN-3 Steering Committee. Dr. Leon, Dr. O'Neill, and Dr. Esler have nothing to disclose. Dr. Negoita, Dr. Sobotka, and Craig Straley are employees of Medtronic, Inc. Dr. Bakris receives grant/clinical trial support (paid directly to University of Chicago) from Forest Laboratories, Medtronic, and Relapysa, and is a consultant to Takeda, Abbott, CVRx, Johnson & Johnson, Eli Lilly, and the Food and Drug Administration. Dr. Bakris is on the Speaker Bureau for Takeda, and the Boards of the National Kidney Foundation and the American Society of Hypertension. He is Editor for the American Journal of Nephrology and Associate Editor for Diabetes Care and Nephrology Dialysis and Transplantation.
- Value of Coronary Computed Tomography as a Prognostic Tool Coronary computed tomography angiography (CCTA) has become an important part of our armamentarium for noninvasive diagnosis of coronary artery disease (CAD). Emerging technologies have produced lower radiation dose, improved spatial and temporal resolution, as well as information about coronary physiology. Although the prognostic role of coronary artery calcium scoring is known, similar evidence for CCTA has only recently emerged. Initial, small studies in various patient populations have indicated that CCTA-identified CAD may have a prognostic value. These findings were confirmed in a recent analysis of the international, prospective Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter (CONFIRM) registry. An incremental increase in mortality was found with a worse severity of CAD on a per-patient, per-vessel, and per-segment basis. In addition, age-, sex-, and ethnicity-based differences in mortality were also found. Whether changing our management algorithms based on these findings will affect outcomes is unclear. Large prospective studies utilizing targeted management strategies for obstructive and nonobstructive CAD are required to incorporate these recent findings into our daily practice. Clin. Cardiol. 2012 DOI: 10.1002/clc.22003The authors have no funding, financial relationships, or conflicts of interest to disclose.
- The Hospital's Role in Improving Survival of Patients Wit... Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Unfortunately, in spite of recurring updated guidelines, survival of patients with OHCA had been unchanged for decades. Recently, new approaches to patients with OHCA during the community and prehospital phases of therapy for cardiac arrest have resulted in a dramatic improvement in survival. Further improvement in survival has resulted from hospitals designated as Cardiac Receiving Centers. These centers are committed to the treatment of post-cardiac arrest syndrome by providing 24/7 therapeutic mild hypothermia, urgent cardiac catheterization and percutaneous coronary intervention, evidence-based termination of resuscitation protocols that limit premature withdrawal of care, protocol to address organ donation, commitment of cardiocerebral resuscitation training in their community, and a commitment and proven ability of data collection to assure that instituted changes result in improved survival. This newer aspect of hospital practice is an aspect that needs to be embraced by either becoming a Cardiac Receiving Center or partnering with other hospitals that can provide this critically important service. Clin. Cardiol. 2012 doi: 10.1002/clc.21992The authors have no funding, financial relationships, or conflicts of interest to disclose.
- Electromagnetic Interference and Implanted Cardiac Device... Electromagnetic interference produced by medical equipment can interact with implanted cardiac devices such as pacemakers and implantable cardioverter-defibrillators. The most commonly observed interaction is in the operating room with electrosurgery. The risk of interactions can often be mitigated by close communication between the cardiac-device specialist and the anesthesiology/surgical team to develop a patient-specific strategy that accounts for factors such as type of device, type of surgery, and whether the patient is pacemaker dependent. Although magnetic resonance imaging should generally not be used in patients with implanted cardiac devices, several published guidelines provide strategies and recommendations for managing risks if magnetic resonance imaging is required with no suitable diagnostic alternatives. Other common sources of electromagnetic interference in the medical environment are ionizing radiation and left ventricular assist devices. Clin. Cardiol. 2012 DOI: 10.1002/clc.21997The authors have no funding, financial relationships, or conflicts of interest to disclose.
- Can We Predict the Site of Entry Tear by Computed Tomogra... Background:In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention.Hypothesis:There are reliable indirect computed tomography (CT) findings to predict the entry site.Methods:In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta.Results:The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2–3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1–2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1–2.1, P = 0.048).Conclusions:We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels. Clin. Cardiol. 2012 DOI: 10.1002/clc.21991The authors have no funding, financial relationships, or conflicts of interest to disclose.
Journal of Electrocardiology
- International Congress on Electrocardiology 2011 in Kings... The 38th International Congress on Electrocardiology (ICE) was hosted in Kingston, Ontario, Canada, in June 8 to 11, 2011. With the financial help of Queen's University, the Kingston Economic Development Corporation and the device and drug industry, we have been able to organize a rich scientific agenda. We also had time to enjoy some of the Kingston pearls: the Gala Night was hosted at Fort Henry, built in 1812 near the mouth of the Cataraqui River where it flows into the St Lawrence River, at the upper end of the Thousand Islands. ICE meetings are characterized by broad areas of interest, and ICE 2011 was not the exception. Topics on clinical arrhythmias, inherited arrhythmic disorders, mathematical modeling, and new diagnostic imaging alternatives were discussed at the highest possible scientific level.
- Why the sudden PR prolongation?
- Coexisting early repolarization pattern and Brugada syndr... Abstract: The Brugada type 1 electrocardiographic (ECG) pattern and the early repolarization pattern (ERP) are 2 ECG patterns characterized by the appearance of J waves. Although Brugada type 1 ECG pattern in the context of the Brugada syndrome (BrS) is well known for predisposing to life-threatening ventricular arrhythmias, it has only recently come to light that ERP, which was previously believed to be benign, may also be a marker for arrhythmogenic potential. ERP and BrS share many remarkable cellular, ionic, and ECG similarities and behave comparably in terms of their response to heart rate, pharmacologic agents, and neuromodulation. The extent to which ERP and BrS may overlap remains unclear.Here, we present an illustrated case of a symptomatic patient whose ECG signature evolved spontaneously from ERP alone to ERP with a concomitant Brugada type 1 ECG pattern over a short number of days. This case lends further strength to the notion that these 2 ECG patterns may be more closely related than had been initially thought.
- Ventricular flutter triggered by fever in a patient with ... Abstract: Brugada syndrome is a clinical-electrocardiographic entity predisposing to malignant ventricular arrhythmias. The typical arrhythmia is polymorphic ventricular tachycardia, which can potentially degenerate to ventricular fibrillation. Monomorphic ventricular tachycardia is uncommon. Our group is reporting the case of a 39-year-old man with known Brugada syndrome who developed ventricular flutter while febrile. Fever has previously been shown to unmask Brugada changes and to induce ventricular arrhythmias. The appearance of monomorphic ventricular tachycardia potentially attributable to sodium-channel dysfunction further confounds the mechanism of arrhythmogenesis in Brugada syndrome. This curious occurrence further underlines the likely complex nature of arrhythmogenesis in Brugada syndrome.
- Long-term results of slow pathway ablation in patients wi... Abstract: Aims: The aim of this study was to report the short- and long-term results of slow pathway radiofrequency (RF) ablation in patients with atrioventricular (AV) nodal reentrant tachycardia (AVNRT) using a simplified approach (2 catheters and short applications of RF).Materials and Methods: This was a retrospective study that included consecutive patients with AVNRT. We used an anatomical approach with only 2 catheters. Decremental AV nodal conduction and atrial-His conduction interval jump were measured. To detect the onset of the QRS, we used surface lead II. During the stimulation protocol, we performed S2-QRS and S3-QRS measurements. An increase in the S3-QRS3 interval of 50 milliseconds or greater in response to a decrease in the S2-QRS2 coupling interval of 10 milliseconds was defined as a discontinuous AV nodal function curve and taken as evidence of dual antegrade AV pathways. Atrioventricular nodal reentrant tachycardia was demonstrated by the presence of dual AV nodal physiology, atrial echoes, and tachycardia induction with a 1:1 AV relationship and a VA interval of less than 70 milliseconds. Short RF applications (10-15 seconds) were delivered at an intermediate point between the posteroseptal and medioseptal regions of the Koch triangle. The applications were considered effective when junctional rhythm appeared. The end point was the demonstration of slow pathway modification without AVNRT induction.Results: Three hundred forty-four patients (age, 49.22 ± 17.47 years; 254 were female) were included. Discontinuous AV nodal function curves were found in 271 patients (78.77%), and short-term success was achieved in all patients. The anterograde jump in AV nodal conduction was abolished after RF in 222 patients (81.91%), and discontinuous AV nodal conduction and single AV nodal echo beats persisted in 49 cases (18%). The mean number of RF application was 7.79 ± 2.23, the mean number of effective applications was 4.63 ± 0.62, and the mean RF application time was 54.92 ± 8.03 seconds. The total procedure and fluoroscopy time was 29.45 ± 9.6 and 10.87 ± 2.36 minutes, respectively. After the procedure, all patients were followed up for a mean of 46.44 ± 18.89 months, and 7 patients (2%) presented AVNRT recurrences. Complications were observed in 4 patients (1.16%); no permanent AV block was observed.Conclusion: In this study, slow pathway RF ablation using a simplified approach technique is an effective and safe approach for the treatment of AVNRT.
- Optimized electrocardiographic criteria for prior inferio... Abstract: Background and Purpose: The first purpose of the study was to optimize empirically the detection of prior inferior myocardial infarction (IMI) and prior anterior myocardial infarction (AMI) by electrocardiogram (ECG). The second purpose was to compare the diagnostic performances of the new criteria with those of 3 widely used commercial diagnostic ECG algorithms.Materials and Methods: We analyzed the digital ECG data from 1138 subjects with suspected coronary artery disease in whom the presence or absence of prior IMI or AMI was documented by coronary angiography and left ventriculography. We used receiver operating characteristic curves to develop the new criteria for prior IMI and AMI using a training set of 562 subjects and then tested their diagnostic performances using a separate test set of 576 subjects. In both the training and test sets, we used χ2 test to compare the performances of the new criteria with those of 3 commercial computerized diagnostic algorithms.Results: The best criterion for prior IMI was the algebraic sum of the Q and T amplitudes in leads III and aVF. Its sensitivities/specificities were 71%/98% and 74%/98% in the training and test sets, respectively. The best criterion for prior AMI was the algebraic sum of the Q, R, and T amplitudes minus the Q duration in leads V2, V3, and V4. Its sensitivities/specificities were 68%/98% and 65%/98% in the training and test sets, respectively. In both the training and test sets, these diagnostic performances were generally superior to those of the 3 commercial algorithms.Conclusions: Using digital ECG data, we developed and tested new criteria for prior IMI and AMI whose diagnostic performances are generally superior to each of 3 widely used commercial ECG diagnostic algorithms.
- Exercise training slows down heart rate and improves dece... Abstract: Controlled physical training has been shown to be a valuable therapeutic addition to a pharmacological treatment in patients with chronic heart failure (CHF). It is speculated that repeated physical training can improve the autonomic modulation of the cardiovascular system in patients with CHF. The present study evaluates autonomic function in patients with CHF by means of heart rate variability and the phase-rectified signal averaging of heart rate that allows the quantification of the acceleration capacity and deceleration capacity. Two groups of patients with CHF treated with comparable pharmacological medications were enrolled into this study. One group entered a 24-week training program, whereas another group remained without it. After the completion of the study, there was a significant increase of mean RR interval, high- and low-frequency power of heart rate variability, and the magnitudes of deceleration capacity and acceleration capacity only in patients who underwent the cardiac rehabilitation program with controlled physical training.
- Compensatory properties of heart rate asymmetry Abstract: Background: Heart rate asymmetry (HRA) is a physiologic phenomenon that reflects a systematic and 1-directional difference between heart rate accelerations and decelerations. In terms of variance-based descriptors, HRA causes the contributions from heart rate decelerations to contribute more to short-term variability than accelerations, and for the long-term variability, the relation is reversed. The hypothesis tested in the present article is that this reversal is caused by a compensatory mechanism whose function is to keep the system in relative balance.Methods: Thirty-minute electrocardiographic recordings from 420 young healthy volunteers were analyzed. The variance-based HRA descriptors were calculated. Cases with both short- and long-term HRAs were considered to show compensation. In the binomial test, we looked for statistically significant departures from independence in the distribution of cases possessing both types of asymmetry.Results: Short-term asymmetry was observed in 77.6% of subjects (P < .0001), and long-term asymmetry, in 69.3% (P < .0001); both types of HRA coexisted in 66.9% (P < .0001) of the whole group. This result is significantly different (P < .0001) from the independent case (53.78%).Conclusion: The compensation effect between the short- and long-term asymmetries is present in supine resting electrocardiographic recordings in young healthy people.
- Semiautomated QT interval measurement in electrocardiogra... Abstract: Introduction: We postulated that it may be easier to identify earliest Q onset and latest T offset when the median beats from 12 leads are separated vertically by 5 to 10 mm (ungrouped superimposed median beat [SMB] method) rather than when their baselines closely (but rarely perfectly) overlap (grouped SMB method).Methods: Three readers manually adjudicated annotations placed by an automated algorithm, using grouped (gSMB) and ungrouped (uSMB) methods in 2658 electrocardiograms (ECGs) recorded in 38 subjects in a crossover design thorough QT study at predose and 6 time points postdosing with placebo or moxifloxacin.Results: Placebo-subtracted, moxifloxacin-induced QTcF prolongation was comparable with both methods. Maximum QTcF prolongation was seen at 2 hours—10.5 milliseconds (90% confidence interval, 7.9-13.1 milliseconds) with gSMB and 12.9 milliseconds (90% confidence interval, 9.9-15.8 milliseconds) by uSMB. Both methods showed good agreement; mean QT was 4 milliseconds greater by uSMB. Interreader variability of absolute differences in QT measurements was 1 millisecond lower with the uSMB method (6.8 ± 5.7 milliseconds by gSMB and 5.9 ± 4.5 milliseconds by uSMB).Conclusion: Mean QT was 4 milliseconds longer, and interreader variability, 1 millisecond lower with uSMB. Otherwise, both methods were comparable and detected the moxifloxacin effect.
- Individualized model of torso surface for the inverse pro... Abstract: Purpose: We studied the implementation of a patient-specific torso model created without the use of magnetic resonance imaging in the inverse problem of electrocardiology.Method: Three types of inhomogeneous numerical torso models were created, with different degrees of adjustment of the outer surface to patients, whereas the heart and lung models remained unchanged. The torso models were used in the inverse localization of small areas with repolarization changes from simulated difference integral QRST maps. The localization error (LE) was evaluated as the distance between the centers of the modeled and the inversely found area with repolarization changes.Results: The mean LE was 1.88 cm with the standard torso model. After adapting the torso shape, the mean LE was 1.83 cm, whereas after adapting both, the shape and electrode positions, the mean LE was 1.02 cm.Conclusion: If torso imaging is not available, a torso model with adapted shape and electrode positions gives only slightly less accurate results.
Clinical Research in Cardiology
- Heart rate at baseline influences the effect of ivabradin... Abstract Background We analysed the effect of ivabradine on outcomes in heart failure (HF) patients on recommended background therapies with heart rates ≥75 bpm and <75 bpm in the SHIFT trial. A cut-off value of ≥75 bpm was chosen by the EMEA for approval for the use of ivabradine in chronic heart failure. Methods The SHIFT population was divided by baseline heart rate ≥75 or <75 bpm. The effect of ivabradine was analysed for primary composite endpoint (cardiovascular death or HF hospitalization) and other endpoints. Results In the ≥75 bpm group, ivabradine reduced primary endpoint (HR 0.76, 95 % CI 0.68–0.85, P < 0.0001), all-cause mortality (HR 0.83, 95 % CI, 0.72–0.96, P = 0.0109), cardiovascular mortality (HR 0.83, 95 % CI, (0.71–0.97, P = 0.0166), HF death (HR 0.61, 95 % CI, 0.46–0.81, P < 0.0006), and HF hospitalization (HR 0.70, 95 % CI, 0.61–0.80, P < 0.0001). Risk reduction depended on heart rate after 28 days, with the best protection for heart rates <60 bpm or reductions >10 bpm. None of the endpoints was significantly reduced in the <75 bpm group, though there were trends for risk reductions in HF death and hospitalization for heart rate <60 bpm and reductions >10 bpm. Ivabradine was tolerated similarly in both groups. Conclusion The effect of ivabradine on outcomes is greater in patients with heart rate ≥75 bpm with heart rates achieved <60 bpm or heart rate reductions >10 bpm predicting best risk reduction. Our findings emphasize the importance of identification of high-risk HF patients by high heart rates and their treatment with heart rate-lowering drugs such as ivabradine. Content Type Journal ArticleCategory Original PaperPages 1-12DOI 10.1007/s00392-012-0467-8Authors Michael Böhm, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66424 Homburg/Saar, GermanyJeffrey Borer, Division of Cardiovascular Medicine and the Howard Gilman Institute for Heart Valve Disease, State University of New York Downstate Medical Center, Brooklyn, NY, USAIan Ford, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UKJose R. Gonzalez-Juanatey, Cardiology Department, University Hospital, Santiago de Compostela, SpainMichel Komajda, Department of Cardiology, University Pierre et Marie Curie Paris VI, La Pitié-Salpétrière Hospital, Paris, FranceJose Lopez-Sendon, Cardiology Department, Hospital Universitario La Paz, IdiPaz, UAM, Madrid, SpainJan-Christian Reil, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66424 Homburg/Saar, GermanyKarl Swedberg, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, SwedenLuigi Tavazzi, Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Fatal stress-induced cardiomyopathy in a young patient tr... Fatal stress-induced cardiomyopathy in a young patient treated with adrenomimetics Content Type Journal ArticleCategory Letter to the EditorsPages 1-2DOI 10.1007/s00392-012-0470-0Authors Bjorn Redfors, Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 16, 413 45 Gothenburg, SwedenYangzhen Shao, Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 16, 413 45 Gothenburg, SwedenElmir Omerovic, Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 16, 413 45 Gothenburg, Sweden Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Dual drainage of the right pulmonary veins: a rare varian... Dual drainage of the right pulmonary veins: a rare variant of Scimitar syndrome Content Type Journal ArticleCategory Letter to the EditorsPages 1-3DOI 10.1007/s00392-012-0464-yAuthors Gunter Kerst, Department of Pediatric Cardiology, Tübingen University Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, GermanyLudger Sieverding, Department of Pediatric Cardiology, Tübingen University Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, GermanyReiner Buchhorn, Department of Pediatrics, Caritas Krankenhaus Bad Mergentheim, Uhlandstr. 7, 97980 Bad Mergentheim, GermanyUlrich Baum, Department of Radiology, Caritas Krankenhaus Bad Mergentheim, Uhlandstr. 7, 97980 Bad Mergentheim, GermanyChristian Apitz, Department of Pediatric Cardiology, Tübingen University Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, GermanyJuergen F. Schaefer, Department of Pediatric Radiology, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076 Tübingen, GermanyMichael Hofbeck, Department of Pediatric Cardiology, Tübingen University Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- TNF-α, myocardial perfusion and function in patients wit... Abstract Aims To characterize the time course of tumor necrosis factor-α (TNF-α) serum levels along with myocardial perfusion and contractile function in patients with ST-segment elevation myocardial infarction (STEMI) and successful primary percutaneous coronary intervention (PCI). Methods Serum levels of TNF-α, interleukin 6 (IL-6), and C-reactive protein (CRP) were measured in 42 patients with STEMI before, one and 6 days after successful PCI. Myocardial perfusion was assessed by contrast-enhanced echocardiography (ceEcho), contractile function by unenhanced two-dimensional (2DE) and real-time three-dimensional echocardiography. In a subset of 18 patients, infarct size was quantified by late gadolinium enhancement cardiovascular magnetic resonance imaging (LGE-CMR) on day six. Results TNF-α serum levels were in the upper normal range within the first 12 h from symptom onset and increased continuously until day six, while IL-6 and CRP increased subsequently with a peak on day one after STEMI. Serum TNF-α on day one after PCI correlated with perfusion defects, wall motion abnormalities, and infarct size (ceEcho: r = 0.52, p = 0.005; 2DE: r = 0.56, p = 0.002; LGE-CMR: r = 0.83–0.86; p < 0.0001). Using multiple regression linear analysis, infarct size on day six was predicted by serum TNF-α 1 day after PCI (p = 0.006, adjusted R 2 0.638). Conclusion Our data reflect the clinical significance of early TNF-α elevation in patients with STEMI and primary PCI (Controlled Clinical Trials number, NCT00529607). Content Type Journal ArticleCategory Original PaperPages 1-13DOI 10.1007/s00392-012-0465-xAuthors Eva S. Kehmeier, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyWolfgang Lepper, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyMartina Kropp, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyChristian Heiss, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyUlrike Hendgen-Cotta, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyJan Balzer, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyMirja Neizel, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyChristian Meyer, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyMarc W. Merx, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyPablo E. Verde, Coordination Centre for Clinical Trials, Heinrich-Heine University, 40225 Duesseldorf, GermanyChristian Ohmann, Coordination Centre for Clinical Trials, Heinrich-Heine University, 40225 Duesseldorf, GermanyGerd Heusch, Center of Internal Medicine, Institute for Pathophysiology, University of Essen Medical School, 45122 Essen, GermanyMalte Kelm, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, GermanyTienush Rassaf, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Aachen, 52074 Aachen, Germany Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Renal dysfunction as a risk factor for painless myocardia... Abstract Aim Renal dysfunction has been associated with many types of neuropathy and the incidence of myocardial infarction (MI) presenting without chest pain can be expected to be higher in patients with renal dysfunction. We evaluated clinical outcomes of painless MI patients and relationship between renal dysfunction and painless MI. Methods and results Study population consisted of 9,735 patients (63 ± 13 years, men 70.7 %), whose discharge diagnosis by cardiac enzyme and electrocardiogram was MI. The study subjects were divided into two groups according to presence of chest pain (painful MI group, n = 8,249; painless MI group, n = 1486). Rates of in-hospital death, 1-month and 12-month composite MACE, cardiac death, and non-cardiac death were significantly higher in painless MI patients. In a multivariate logistic analysis, compared with glomerular filtration rate (GFR) > 90 mL/min/1.73 m2, odds ratio of painless MI was increased proportionally in patients with GFR of 30–59, 15–29 and <15 mL/min/1.73 m2 (odds ratio [OR] 1.25, 95 % confidence interval [CI] 1.05–1.49; OR 1.88, CI 1.39–2.53; OR 2.32, CI 1.65–3.26) In addition, the concomitant presence of renal dysfunction and diabetes mellitus significantly affected the prevalence of painless MI. Conclusion Poorer outcomes of painless MI patients and the increased probability of painless MI proportional to declining GFR indicate that the possibility of painless MI should be considered in patients with renal dysfunction, particularly concomitant with diabetes mellitus. Content Type Journal ArticleCategory Original PaperPages 1-9DOI 10.1007/s00392-012-0461-1Authors Joon Seok Choi, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaChang Seong Kim, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaJeong Woo Park, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaEun Hui Bae, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaSeong Kwon Ma, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaMyung Ho Jeong, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 KoreaYoung Jo Kim, Department of Internal Medicine, Yeungnam University, Daegu, KoreaMyeong Chan Cho, Department of Internal Medicine, Chungbuk National University, Cheongju, KoreaChong Jin Kim, Department of Internal Medicine, Kyunghee University, Seoul, KoreaSoo Wan Kim, Department of Internal Medicine, Chonnam National University Medical School, 671 Jebongro, Gwangju, 501-757 Koreaother Korea Acute Myocardial Infarction Registry Investigators Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Transbrachial insertion of an intra-aortic balloon pump f... Transbrachial insertion of an intra-aortic balloon pump for high-risk percutaneous coronary intervention Content Type Journal ArticleCategory Letter to the EditorsPages 1-4DOI 10.1007/s00392-012-0466-9Authors Trevor Simard, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, CanadaBenjamin Hibbert, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, CanadaBrendan Parfrey, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, CanadaEdward R. O’Brien, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Bidirectional ventricular tachycardia in a patient with e... Bidirectional ventricular tachycardia in a patient with exacerbation of chronic obstructive pulmonary disease Content Type Journal ArticleCategory Letter to the EditorsPages 1-2DOI 10.1007/s00392-012-0462-0Authors Oliver Adam, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, 66421 Homburg, Saarland, GermanyChristian Ukena, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, 66421 Homburg, Saarland, GermanyMichael Böhm, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, 66421 Homburg, Saarland, GermanyHans-Ruprecht Neuberger, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, 66421 Homburg, Saarland, Germany Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Retrograde, transsubclavian implantation of a SAPIEN XT... Retrograde, transsubclavian implantation of a SAPIEN XT™ aortic valve prosthesis with the Edwards NovaFlex+™ system Content Type Journal ArticleCategory Letter to the EditorsPages 1-3DOI 10.1007/s00392-012-0460-2Authors J. Blumenstein, Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyA. Van Linden, Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyJ. Kempfert, Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyWoung-Keung Kim, Department of Cardiology/Cardiac Surgery, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyC. Liebetrau, Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyC. Hamm, Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyH. Nef, Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyT. Walther, Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, GermanyH. Moellmann, Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, Germany Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Gender-specific predictors of early mortality after coron... Abstract Background Female gender is a risk factor for early mortality after coronary artery bypass graft surgery (CABG). Yet, the causes for this excess mortality in women have not been fully explained. Objectives To analyse gender differences in early mortality (30 days post surgery) after CABG and to identify variables explaining the association between female gender and excess mortality, taking into account preoperative clinical and psychosocial, surgical and postoperative risk factors. Methods A total of 1,559 consecutive patients admitted to the German Heart Institute Berlin (2005–2008) for CABG were included in this prospective study. A comprehensive set of prespecified preoperative, surgical and postoperative risk factors were examined for their ability to explain the gender difference in early mortality. Results Early mortality after CABG was higher in women than in men (6.9 vs. 2.4 %, HR 2.91, 95 % CI 1.70–4.96, P < 0.001). Women were older than men (+4.7 years, P < 0.001), had lower self-assessed preoperative physical functioning (−16 points on a scale from 0 to 100, P < 0.001), and had higher rates of postoperative low cardiac output syndromes (6.6 vs. 3.3 %, P = 0.01), respiratory insufficiency (9.4 vs. 5.3 %, P = 0.006) and resuscitation (5.2 vs. 1.8 %, P = 0.001). The combination of these factors explained 71 % of the gender difference in early mortality; age and physical functioning alone accounted for 61 %. Adjusting for these variables, HR for female gender was 1.36 (95 % CI 0.77–2.41, P = 0.29). Conclusions Age, physical function and postoperative complications are key mediators of the overmortality of women after aortocoronary bypass surgery. Self-assessed physical functioning should be more seriously considered in preoperative risk assessment particularly in women. Content Type Journal ArticleCategory Original PaperPages 1-7DOI 10.1007/s00392-012-0454-0Authors E. Lehmkuhl, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, GermanyF. Kendel, Institute of Medical Psychology, Charité-Universitätsmedizin Berlin, Berlin, GermanyG. Gelbrich, Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, GermanyA. Dunkel, Institute for Gender in Medicine, Charité-Universitätsmedizin Berlin, Berlin, GermanyS. Oertelt-Prigione, Institute for Gender in Medicine, Charité-Universitätsmedizin Berlin, Berlin, GermanyB. Babitsch, Berlin School of Public Health, Charité-Universitätsmedizin Berlin, Berlin, GermanyC. Knosalla, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, GermanyN. Bairey-Merz, Cedars Sinai Hospital, Los Angeles, USR. Hetzer, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, GermanyV. Regitz-Zagrosek, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
- Serum vitamin D concentration status and its correlation ... Serum vitamin D concentration status and its correlation with early biomarkers of remodeling following acute myocardial infarction Content Type Journal ArticleCategory Letter to the EditorsPages 1-2DOI 10.1007/s00392-012-0457-xAuthors Monica De Metrio, Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, Via Parea 4, 20138 Milan, ItalyValentina Milazzo, Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, Via Parea 4, 20138 Milan, ItalyGiancarlo Marenzi, Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, Via Parea 4, 20138 Milan, Italy Journal Clinical Research in CardiologyOnline ISSN 1861-0692Print ISSN 1861-0684
Progress in Cardiovascular Diseases
- Masthead
- Introduction Participation in recreational and competitive athletic activities such as marathon running has reached an all-time high in the United States and other developed nations. This trend is attributable in part to the recognition that routine physical exercise reduces the risk of cardiovascular disease through its beneficial effects on risk factors including obesity, diabetes, blood pressure, and serum lipids. Exercise is not, however, completely protective against the development of cardiovascular disease. The physiologic demands of exercise may precipitate symptoms or even sudden death in individuals with occult cardiac conditions. Exercise- or sports-related deaths are widely reported in the media and generate intense concern among medical providers and across the general community. In addition, many athletic individuals continue to participate in vigorous physical exercise well into their middle and old age. This confluence of increased athletic competition, concern about the cardiac risks of exercise, and the continuation of vigorous athletic activity in later life means that health care providers are increasingly faced with sports-related cardiac questions and athletic patients in clinical practice.
- Exercise-Induced Cardiac Remodeling Abstract: Early investigations in the late 1890s and early 1900s documented cardiac enlargement in athletes with above-normal exercise capacity and no evidence of cardiovascular disease. Such findings have been reported for more than a century and continue to intrigue scientists and clinicians. It is well recognized that repetitive participation in vigorous physical exercise results in significant changes in myocardial structure and function. This process, termed exercise-induced cardiac remodeling (EICR), is characterized by structural cardiac changes including left ventricular hypertrophy with sport-specific geometry (eccentric vs concentric). Associated alterations in both systolic and diastolic functions are emerging as recognized components of EICR. The increasing popularity of recreational exercise and competitive athletics has led to a growing number of individuals exhibiting these findings in routine clinical practice. This review will provide an overview of EICR in athletes.
- Assessment of Left Ventricular Hypertrophy in a Trained A... Abstract: Physiologic LV remodeling in young trained athletes as a consequence of chronic training can occasionally mimic certain pathologic conditions associated with sudden death, such as HCM. A small but important subset ofelite male athletes may show a borderline increased LV wall thickness of 13 to 15 mm, which defines a gray zone of overlap between the extreme expressions of athlete's heart and a mild HCM phenotype. Such diagnostic ambiguity can be resolved by using the paradigm of noninvasive parameters including testing with echocardiography (and, more recently, with CMR): left atrial and LV chamber dimensions and shape, brief periods of deconditioning to alter LV mass, measurement of oxygen consumption and diastolic filling, and recognition of familial occurrence of HCM or a pathogenic HCM-causing sarcomere mutation. Such distinctions between physiologic/benign athlete's heart and HCM, the most common cause of sudden death in the young in the United States, can be crucial. The recognition of HCM leads to disqualification from intense competitive sports to reduce sudden death risk and, when appropriate, permits initiation of therapeutic interventions.
- Evaluation of Suspected Right Ventricular Pathology in th... Abstract: Rigorous training remodels the heart of elite endurance athletes to produce the phenotype of the “athlete's heart.” This remodeling, which advantages cardiac performance, creates challenges in the diagnosis of cardiac disorders within this population. This is particularly so for right ventricular pathologies because of the limited number of studies documenting the impact of training on right ventricular remodeling. Although arrhythmogenic right ventricular cardiomyopathy is the focus of this review, several other pathologies that may mimic arrhythmogenic right ventricular cardiomyopathy, including right ventricular outflow tract tachycardia, Wolff-Parkinson-White syndrome, Brugada syndrome, pulmonary embolism, cardiac sarcoidosis, myocarditis, and right ventricular infarction, are also included. In particular, the electrocardiographic findings for each condition are highlighted because this is the most informative and easily accessible diagnostic clinical tool.
- Exercise-Induced Cardiac Injury: Evidence From Novel Imag... Abstract: Prolonged endurance exercise in humans has been associated with an acute impairment in diastolic and systolic cardiac function and the release of cardiac troponin. In this chapter, we review recent evidence from studies using novel echocardiographic parameters and highly sensitive cardiac troponin assays. We demonstrate that the mechanics of left and right ventricular functions are acutely impaired after completion of prolonged exercise and that this reduction in function is likely multifactorial in etiology. However, we highlight that exercise-induced cardiac troponin release is not a marker of exercise-induced pathology but likely a physiologic response to exercise. Finally, we discuss the potential link between prolonged exercise and the increased incidence of cardiac pathology in veteran athletes.
- Assessment and Management of Atherosclerosis in the Athle... Abstract: Many patients and physicians correctly associate physical activity with reduced cardiovascular morbidity and mortality. Vigorous physical exertion is paradoxically associated with a transient increase in the risk of cardiovascular events and sudden cardiac death. This review extrapolates data from the general population to the management of athletes with symptoms suspicious for coronary artery disease or with prior cardiac events. A history to elicit an athlete's concerns and symptoms combined with a physical examination should guide the decision for preparticipation exercise testing for athletes without prior cardiac events. Athletes with established coronary artery disease should receive aggressive secondary prevention regimens, with special attention to adverse effects that may be unique to this group. There may be benefit in taking time away from competitive athletics to allow for stabilization of coronary artery disease with cholesterol-lowering therapy and, therefore, reduction of future risk. Exercise testing is important for defining risk before the return to participation for athletes who have sustained a cardiac event. Many athletes will ultimately be able to return to full participation provided they have received aggressive therapy and understand the residual risk associated with vigorous physical exertion in the setting of coronary artery disease.
- Evaluation and Management of Arrhythmia in the Athletic P... Abstract: Athletes may present with palpitations, syncope, or arrest resulting in the diagnosis of arrhythmia, or screening may result in diagnosis of conditions with predisposition to arrhythmia. This chapter focuses on 3 common arrhythmic conditions in athletes—atrial fibrillation, premature ventricular contractions (PVCs), and the athlete with an implanted device.(1) Atrial fibrillation: most studies show that atrial fibrillation is more common in competitive athletes, particularly those participating in long-term endurance sports. Postulated mechanisms include morphologic changes such as atrial dilatation, autonomic changes such as increased vagal tone, or inflammatory changes due to sports participation. Treatment options include long-term antiarrhythmic agents, “pill in the pocket” medications, or radiofrequency ablation, a highly successful procedure in athletes.(2) Premature ventricular contractions: data conflict on whether the incidence of PVCs is increased in highly trained individuals. Very frequent PVCs in athletes, however, can be a manifestation of underlying heart disease, and athletes presenting with PVCs should undergo evaluation. In the absence of underlying heart disease, PVCs do not carry a poor prognosis, and US guidelines do not recommend restriction from sports.(3) Implanted devices: the safety of sports for the athlete with an implanted device is unknown, and current guidelines recommend against participation in vigorous competitive sports, based on postulated risks including failure to defibrillate and risk of injury. Many athletes with defibrillators and pacemakers do participate in sports. Ongoing research will better delineate the risks of sports for the athlete with an implanted device.
- Aortic Root Dilatation in Athletic Population Abstract: Remodeling of the aortic root may be expected to occur in athletes as a consequence of hemodynamic overload associated with exercise training; however, there are few data reporting its presence or extent. This review reports the current knowledge regarding the prevalence, upper limits, and clinical significance of aortic remodeling induced by athletic training.Several determinants impact aortic dimension in healthy, nonathletic individuals, including height, body size, age, sex, and blood pressure. Of these factors, anthropometric variables have the greatest impact. In athletes, the effect of exercise training appears to have only a modest additional influence on aortic dimension, although previous studies have produced some conflicting results. Specifically, data derived from the largest available athletic cohort suggest that the most hemodynamically intense endurance disciplines (eg, cycling and swimming) are associated with a significant but mild increase in aortic dimensions. Power disciplines, instead, (eg, weight lifting, throwing events) have only trivial, if any, impact. In contrast, selected data from a different athlete population suggest a more significant dimensional aortic remodeling in strength-trained individuals.In our experience, the 99th percentile value of aortic root diameter corresponds to 40 mm in males and 34 mm in females, which can reasonably be considered the upper limits of physiologic aortic root remodeling.However, a small proportion of apparently healthy male athletes (approximately 1%) show aortic enlargement above the upper limits, in the absence of systemic disease (ie, Marfan syndrome). Athletes presenting with aortic enlargement may demonstrate a further dimensional increase in midlife leading to clinically relevant aortic dilatation. Occasionally, dilation may be severe enough to warrant consideration for surgical treatment. Therefore, serial clinical and echocardiographic evaluations are recommended in athletes when aortic root exceeds the sex-specific thresholds.
- Syncope in the Athletic Patient Abstract: Syncope is a common but concerning event in athletic patients. As such, efforts must be made to distinguish presyncope from syncope with a critical distinction of syncope during exercise and postexercise syncope. Syncope most often occurs just after exercise and is usually benign; however, syncope during exercise may be a sign of pathologic structural or electrical cardiac issues. Solving this diagnostic puzzle mandates a detailed history and examination frequently augmented with diagnostic testing and imaging studies. Recommendations for treatment and potential restriction from activity also present challenging decisions to the health care provider.
Progress in Pediatric Cardiology
- Editorial Board
- Introduction Pediatric cardiology has always been at the forefront of cardiac device development. Portsmann described the first PDA device closure in 1967 and King and Mills performed the first transcatheter ASD closure in 1975. As a frame of reference, the first intracoronary balloon angioplasty was not performed until 1986. Our field has driven the development of smaller and more innovative devices and technology including pacemakers and ventricular assist devices such as the Berlin Heart. Most recently, Phillip Bonhoeffer, a pediatric cardiologist, was instrumental in bringing transcatheter valve therapy to fruition.
- The FDA review process for cardiac medical devices in chi... Abstract: Pediatric medical devices play a vital role in the treatment of children with cardiovascular disease. Most cardiac medical devices used in children today are used off-label where the risk–benefit of devices has not been well characterized. Pediatric medical devices face a variety of challenges to FDA approval largely due to the small target population, heterogeneity of the patient population and ethical considerations around device testing in children. While relatively few cardiac devices have received FDA approval in children, the number of devices navigating the approval process successfully appears to be growing. Most pediatric device approvals are being granted through the humanitarian device exemption (HDE) pathway, which is designed for rare diseases and therefore suitable for devices intended to treat most forms of congenital heart disease. This review summarizes the FDA review process for pediatric cardiovascular medical devices as it continues to evolve in response to the unique challenges of evaluating device performance in children with cardiovascular disease.
- Safety of cardiac devices in children Abstract: Implanted cardiac devices have improved and prolonged the lives of countless children. Some of these devices have undergone vigorous pre-market assessment and are US Food and Drug Administration (FDA) approved for use in children; however, many devices are used “off label” following approval in adults. The potential for unrecognized and/or under-estimated long term complications is a very real concern, particularly in children where there are unique constraints related to growth, development and need for prolonged device longevity. Long-term oversight is necessary to identify rare and unanticipated device related complications. Current systems include FDA surveillance via adverse event reporting databases and mandated post-approval studies, as well as device related registries. Adverse event reporting databases have provided important information on rare device-related complications but are hampered by a documented very low rate of reporting. Recently several large registries have been developed to track outcomes, however, registries are inherently more effective at tracking short-term safety and efficacy. Looking forward, it is incumbent on physicians, regulatory agencies, and manufacturers to recognize the potential for rare, but serious, device-related complications and to report such complications to established registries and FDA surveillance databases.
- Percutaneous closure of secundum atrial septal defects Abstract: In 1975 Drs. Terry King and Noel Mills performed the first percutaneous closure of a secundum atrial septal defect. This remarkable innovation sparked over 35years of dramatic advances resulting in a variety of devices designed for the sole purpose of closing secundum atrial septal defects. These devices have various shapes, sizes, and delivery methods. No device has been perfect, and each device increases our knowledge and understanding of percutaneous closure of secundum atrial septal defects. In this manuscript we review the history of percutaneous atrial septal defect closure and will provide a brief discussion of many of the devices from the past, present, and future.
- What is the optimal device for closure of a persistently ... Abstract: Transcatheter closure of persistently patent ductus arteriosus (PDA) has been performed since the early 1990s. Over the past 15years, there have been significant developments in the devices used to close PDA. The currently available devices in the United States that are or will soon be approved for PDA closure are: embolization coils, Amplatzer Duct Occluders I/II, and the Product For Medicine Nit-Occlud devices. Each device has its strengths and limitations. Three criteria will be used to determine which device is superior to close PDA. Safety, including the occurrence of hemolysis, pulmonary artery and/or aortic obstruction, vascular complications, and frequency of device embolization will be evaluated for each device. Efficacy will be determined at 6month echo follow-up regarding residual shunt. Finally, overall cost will be considered. After evaluating each device on these merits, we will conclude which device, if any, is superior for closure of PDA.
- Transcatheter device closure of congenital ventricular se... Abstract: Ventricular septal defects (VSD) are among the most commonly occurring congenital heart lesions. While successful surgical repair of VSDs has been possible for over 60years, peri-operative and late complications still occur and there are inherent risks associated with sternotomy and exposure to cardiopulmonary bypass. A desire to avoid these risks, as well as the successful application of catheter-based device closure for other intracardiac and vascular shunting lesions, has lead to an interest in developing a less invasive means by which to close VSDs. The aim of this article is (a) to understand the important differences in approach to catheter-based closure of congenitally occurring VSDs, based on their location, (b) to discuss the technical aspects of device closure of VSDs, from both a percutaneous and perventricular (hybrid) approach, and (c) to review the outcomes of the experience with these devices. Acquired (post-infarction, post-trauma) VSDs will not be addressed.
- Percutaneous pulmonary valve replacement Abstract: Each year in the United States more than 4000 newborns are diagnosed with complex congenital heart disease involving right ventricular outflow tract obstruction. Despite advances in surgical techniques with right ventricle to pulmonary artery conduits, progressive conduit failure often occurs within 4–12years. Consequently, the majority of these patients, prior to becoming adults, require 2–4 operations for the right ventricle outflow tract to reverse the adverse ventricular effects of a volume or pressure load. Fortunately, over the past decade, percutaneous pulmonary valve replacement has emerged as a nonsurgical intervention for right ventricle to pulmonary artery conduit failure.Currently, there are two percutaneous pulmonary valves available in the United States with the Edwards SAPIEN™ valve actively enrolling in a Phase II FDA approved clinical trial, and the Medtronic Melody® valve now FDA approved through a Humanitarian Device Exception pathway. In this article, we review indications, technique and outcomes for percutaneous pulmonary valve replacement and compare and contrast the available percutaneous stent valves.
- Pulmonary artery stents: Past, present and future Abstract: Stents can be used to treat many forms of congenital heart disease, however, the majority of use remains in the pulmonary arterial system. Initial experimental work in the 1990's proved that stents were an effective means for treating pulmonary artery stenosis. Subsequent experience demonstrated ways to overcome the limitations of small children, bifurcating stenoses, jailed side branches and the ways to cope with potential complications. We review the use of stents to rehabilitate the pulmonary arterial tree and outline the acute and long-term results. Finally, we discuss the potential improvements and opportunities with bioabsorbable stents and other future directions for bare metal stents as well.
- Stenting of aortic coarctation: Technical considerations ... Abstract: Coarctation of the aorta is one of the more common congenital cardiac lesions. While transcatheter approaches, such as balloon angioplasty and stent implantation are often considered the primary therapeutic strategies for most patients with recoarctation, there is still considerable controversy with regard to the best therapeutic strategy for older patients with primary coarctation, mainly related to the lack of long-term outcome data. This article will highlight technical and procedural considerations for stent implantation for aortic coarctation.
American Journal of Hypertension
- Highlights Highlights American Journal of Hypertension 25, 135 (February 2012). doi:10.1038/ajh.2011.251
- Cuff and Bladder: Overlooked Components of BP Measurement... Cuff and Bladder: Overlooked Components of BP Measurement Devices in the Modern Era? American Journal of Hypertension 25, 136 (February 2012). doi:10.1038/ajh.2011.213 Authors: Paolo Palatini & Gerhard N. Frick
- The Convergence of Ancient Chinese Medicine With Modern T... The Convergence of Ancient Chinese Medicine With Modern Therapeutics to Prevent Cardiac Fibrosis American Journal of Hypertension 25, 139 (February 2012). doi:10.1038/ajh.2011.226 Authors: Joseph S. Janicki & Scott P. Levick
- Systolic Blood Pressure and Adiposity: Examination by Rac... Systolic Blood Pressure and Adiposity: Examination by Race and Gender in a Nationally Representative Sample of Young Adults American Journal of Hypertension 25, 140 (February 2012). doi:10.1038/ajh.2011.177 Authors: Beverly H Brummett, Michael B Babyak, IIene C Siegler, Richard Surwit, Anastasia Georgiades, Stephen H Boyle & Redford B Williams
- Biomarkers Associated With Pulse Pressure in African-Amer... Biomarkers Associated With Pulse Pressure in African-Americans and Non-Hispanic Whites American Journal of Hypertension 25, 145 (February 2012). doi:10.1038/ajh.2011.193 Authors: Thais Coutinho, Stephen T. Turner, Thomas H. Mosley & Iftikhar J. Kullo
- Role of AMP-Activated Protein Kinase in α-Lipoic Acid–... Role of AMP-Activated Protein Kinase in α-Lipoic Acid–Induced Vasodilatation in Spontaneously Hypertensive Rats American Journal of Hypertension 25, 152 (February 2012). doi:10.1038/ajh.2011.196 Authors: Pao-Yun Cheng, Yen-Mei Lee, Ming-Tzeung Chung, Yen-Cheng Shih & Mao-Hsiung Yen
- Orthostatic Hypotension Is Associated With Nocturnal Chan... Orthostatic Hypotension Is Associated With Nocturnal Change in Systolic Blood Pressure American Journal of Hypertension 25, 159 (February 2012). doi:10.1038/ajh.2011.191 Authors: Shilo Voichanski, Chagai Grossman, Avshalom Leibowitz, Edna Peleg, Nira Koren-Morag, Yehonatan Sharabi, Ari Shamiss & Ehud Grossman
- Masked Hypertension, Endothelial Dysfunction, and Arteria... Masked Hypertension, Endothelial Dysfunction, and Arterial Stiffness in Type 2 Diabetes Mellitus: A Pilot Study American Journal of Hypertension 25, 165 (February 2012). doi:10.1038/ajh.2011.158 Authors: Kageumi Takeno, Tomoya Mita, Shiho Nakayama, Hiromasa Goto, Koji Komiya, Hiroko Abe, Fuki Ikeda, Tomoaki Shimizu, Akio Kanazawa, Takahisa Hirose, Ryuzo Kawamori & Hirotaka Watada
- A Predictive Model for Risk of Prehypertension and Hypert... A Predictive Model for Risk of Prehypertension and Hypertension and Expected Benefit After Population-Based Life-Style Modification (KCIS No. 24) American Journal of Hypertension 25, 171 (February 2012). doi:10.1038/ajh.2011.122 Authors: Chuen-Den Tseng, Amy Ming-Fang Yen, Sherry Yueh-Hsia Chiu, Li-Sheng Chen, Hsiu-Hsi Chen & Shu-Hui Chang
- Fruit and Vegetable Intake and the Risk of Hypertension i... Fruit and Vegetable Intake and the Risk of Hypertension in Middle-Aged and Older Women American Journal of Hypertension 25, 180 (February 2012). doi:10.1038/ajh.2011.186 Authors: Lu Wang, JoAnn E. Manson, J. Michael Gaziano, Julie E. Buring & Howard D. Sesso
The Journal of Thoracic and Cardiovascular Surgery
- Quantitative assessment of right ventricular function in ...
- A new echocardiographic window to visualize the mitral va...
- Historical perspectives of The American Association for T...
- Less invasive surgical treatment for aortic arch aneurysm... Objective For aortic arch aneurysms, conventional total arch replacement has been the standard surgical option. In selected high-risk patients, we have attempted less invasive hybrid procedure involving supra-aortic bypass and endovascular stent-graft placement. We review the early and midterm outcomes to clarify the impact of the hybrid procedure. Methods Between October 2007 and December 2010, 27 patients were treated with the hybrid procedure. During the same period, 191 patients underwent elective conventional total arch replacement. On retrospective analysis, the hybrid procedure was feasible in 103 patients (hybrid feasible) and not feasible in 88 patients (hybrid impossible). Patients undergoing the hybrid procedure attained significantly higher additive (11.6 ± 2.2 vs 9.5 ± 2.4, 10.3 ± 2.8, P < .001, P = .044) and logistic (31.1 ± 14.1 vs 18.8 ± 12.6, 23.7 ± 16.0, P < .001, P = .047) European System for Cardiac Operative Risk Evaluation scores than hybrid-feasible and hybrid-impossible groups. Results Although the patients in the hybrid group had significantly higher risk, the early outcomes including mortality and morbidity were similar among the 3 groups, as were the 2-year survivals during the follow-up period: 85.9% for the hybrid group, 89.6% for the hybrid-feasible group, and 86.7% for the hybrid-impossible group (P = .510, .850, log-rank test). In the hybrid group, 2 patients required reintervention for type I endoleak. Conclusions The early and midterm outcomes of the hybrid procedure for aortic arch aneurysms were satisfactory. This procedure has the potential to be an alternative for conventional total arch replacement for high-risk patients.
- Simplified perfusion strategy for removing retroperitonea... Objectives Our objective was to compare effectiveness and safety of a simplified approach for removing retroperitoneal tumors with extensive cavoatrial involvement using beating-heart cardiopulmonary bypass (CPB) versus hypothermic circulatory arrest (HCA). Methods From January 1984 to January 2009, 144 patients underwent radical nephrectomy and inferior vena caval tumor thrombectomy, 56 (39%) using CPB and 88 (61%) HCA. Compared with HCA patients, CPB patients were of similar age (62 ± 10 vs 60 ± 11 years, P = .4) and gender (39% vs 39% female, P > .9), with similar stroke history (3.6% vs 2.3%, P =.6), but had less pulmonary disease (18% vs 33%, P = .06) and lower preoperative creatinine concentration (1.3 ± 0.72 vs 1.5 ± 0.86 mg · dL–1, P = .04). Results Complete tumor removal was achieved in all patients by both strategies. Compared with HCA procedures, CPB times were shorter (50 ± 33 vs 94 ± 40 minutes, P < .0001). CPB patients required fewer blood transfusions (36% no transfusion vs 17%, and 45% ≥4 units vs 72%; P = .003) and had no statistical difference in morbidity, including reoperation for bleeding (3.8% vs 8.0%, P = .3), renal failure requiring dialysis (3.6% vs 10%, P = .14), respiratory insufficiency (21% vs 19%, P = .8), sepsis (5.4% vs 10%, P = .3), stroke (5.4% vs 1.1%, P = .13), and in-hospital mortality (7.1% vs 13%, P = .3). Ten-year survival (22% vs 22%, P > .9) and freedom from cancer recurrence (24% vs 28%, P = .8) were similar. Conclusions Radical nephrectomy and removal of inferior vena caval tumor–thrombus can be simply, effectively, and safely performed with beating-heart CPB, avoiding the deleterious effects of HCA and providing clinical benefit without increasing morbidity or mortality.
- A phase 2 prospective, randomized, double-blind trial com... Objective Ecallantide is a recombinant peptide in the same class as aprotinin that inhibits plasma kallikrein, a major component of the contact coagulation and inflammatory cascades. Therefore, ecallantide was expected to reduce blood loss associated with cardiac surgery requiring cardiopulmonary bypass. Methods This prospective multinational, randomized, double-blind trial enrolled patients undergoing cardiac surgery using cardiopulmonary bypass for procedures associated with a high risk of bleeding. Patients were randomly assigned to ecallantide (n = 109) or tranexamic acid (high dose, n = 24; low dose, n = 85). Efficacy was assessed from the volume of packed red blood cells administered within the first 12 hours after surgery. Results The study was terminated early after the independent data safety and monitoring board observed a statistically significantly higher 30-day mortality in the ecallantide group (12%) than in the tranexamic acid groups (4%, P = .041). Patients receiving ecallantide received more packed red blood cells within 12 hours of surgery than tranexamic acid-treated patients: median = 900 mL (95% confidence interval, 600–1070) versus 300 mL (95% confidence interval, 0–523) (P < .001). Similar differences were seen at 24 hours and at discharge. Patients treated with the higher tranexamic acid dose received less packed red blood cells, 0 mL (95% confidence interval, 280–600), than the group treated with the lower dose, 400 mL (95% confidence interval, 0–400) (P = .008). No deaths occurred in the higher dose tranexamic acid group. Conclusions Ecallantide was less effective at reducing perioperative blood loss than tranexamic acid. High-dose tranexamic acid was more effective than the low dose in reducing blood loss.
- Coronary perfusion: Impact of flow dynamics and geometric... Background Aortic valve replacement leads to improvement of coronary flow but not to complete normalization. Coronary hypoperfusion contributes to higher left ventricular mass persistence, arrhythmias, congestive heart failure and sudden death. This prospective study compares 2 similarly sized aortic prostheses (mechanical and porcine) regarding coronary flow and hemodynamic performances in patients who underwent surgery for pure aortic stenosis. Methods Sixty patients having undergone aortic valve replacement for pure aortic stenosis with Medtronic Mosaic Ultra bioprosthesis 21 mm (n = 30) or St Jude Regent mechanical valve 19 mm (n = 30) were evaluated preoperatively and 12 months postoperatively comparing the coronary flow and the hemodynamic behavior. Echocardiography and cardiac positron emission tomography were performed at rest and during exercise or adenosine maximal stimulation, respectively. Results The St Jude Regent mechanical valve, compared with the Medtronic Mosaic Ultra bioprosthesis, had reduced coronary flow reserve (2.1 ± 0.3 vs 2.3 ± 0.2; P = .003), less favorable systolic/diastolic time ratio (0.87 ± 0.02 vs 0.78 ± 0.03; P < .001), and higher mean transprosthetic gradient (46 ± 11 vs 38 ± 9; P = .003) during exercise. Multivariate analysis of impaired coronary reserve related indexed effective orifice area less than 0.65 cm/m2 (risk ratio [RR], 1.9; 95% confidence intervals [CI], 1.5-2.8; P < .001), mechanical valve (RR, 2.5; 95% CI, 1.7-3.3; P < .001), and systolic/diastolic time ratio greater than 0.75 (RR, 2.6; 95% CI, 1.8-3.8; P < .001), as well as high transprosthetic gradient (RR, 1.7; 95% CI, 1.3-2.4; P < .001) ) during exercise with coronary reserve less than 2.2. Conclusions Improvement of coronary flow and reserve was more evident for bioprostheses than for mechanical valves. The bioprostheses demonstrated superior hemodynamics during exercise, which may have some impact on exercise capability during normal daily life.
- Beneficial effects of the CorCap cardiac support device: ... Background The CorCap cardiac support device (Acorn Cardiovascular, Inc, St Paul, Minn) is the first device that specifically addresses ventricular remodeling in heart failure by reducing wall stress. We previously reported outcomes from the Acorn randomized trial to a common closing date (22.9 months of follow-up). This report summarizes results of extended followup to 5 years. Methods A total of 107 patients were enrolled in the no–mitral valve repair/replacement stratum including 57 in the CorCap treatment group and 50 in the control (optimal medical therapy alone) group. Patients were assessed every year, until completing 5 years of follow-up, for survival, adverse events, major cardiac procedures, New York Heart Association (NYHA) functional status, and echocardiograms, which were read at a core laboratory. Results Overall survivals were similar between the treatment and control groups, demonstrating no late adverse effect on mortality. The treatment group had significant reductions in left ventricular end-diastolic volume (P = .029) as well as a small increase in sphericity index. More patients in the treatment group improved by at least 1 NYHA functional class (P = .0005). There was no difference in rates of adverse events. In a subgroup of patients with an intermediate left ventricular end-diastolic dimension, there was a significant reduction in the Kaplan-Meier estimate of the freedom from the composite end point of death and major cardiac procedures (P = .04). Conclusions These cumulative data demonstrate the sustained reverse remodeling of the left ventricle and the long-term safety and efficacy of the CorCap cardiac support device as an adjunctive therapy for patients with heart failure who remain symptomatic despite optimal medical therapy.
- Tricuspid valve surgery: The past 10 years from the Natio... Objectives The purpose of this study was to examine the trends in tricuspid valve surgery over time. Methods We used 10 years (1999-2008) of NIS data to examine the population of patients undergoing tricuspid valve repair or replacement (ICD-9-CM codes 35.14, 35.27, and 35.28). Results We identified 28,726 admissions for tricuspid valve surgery. The total number of tricuspid procedures more than doubled over the 10- year period (1712 cases in 1999 vs 4072 cases in 2008). Although the absolute number of repairs and replacements increased over time, the tricuspid repair rate increased whereas there was a corresponding decrease in tricuspid replacement rate. Isolated tricuspid valve surgery accounted for 20% of the total tricuspid cases, whereas tricuspid surgery as a concomitant procedure to other cardiac operations accounted for the remaining 80%. There was a trend toward increased use of tissue over mechanical valves for tricuspid replacement. Overall hospital mortality was 10.6%. Over time, mortality decreased significantly for both repair and replacement. Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement (16.1% vs 10.1%; P = .0001). Conclusions There has been a dramatic increase in tricuspid interventions over time. This has been associated with an increase in tricuspid repair rates as well as use of bioprostheses for tricuspid replacement. The majority of tricuspid operations are performed concomitantly to other cardiac procedures. Mortality for tricuspid valve surgery remains considerable and significantly higher for replacement than for repair.
- Increased risk of dehiscence after tricuspid valve repair... Objectives Surgical management of tricuspid valve regurgitation mainly consists of tricuspid valve annuloplasty, usually performed with implantation of a rigid ring or a flexible band. Methods We performed a retrospective analysis on 820 patients who underwent tricuspid valve repair between March 2002 and July 2009 with either a flexible Cosgrove-Edwards band (n = 415; Edwards Lifesciences LLC, Irvine, Calif) or a rigid Carpentier-Edwards Classic annuloplasty ring (n = 405; Edwards Lifesciences). Mean patient age was 69.2 ± 9.5 years, 54.1% were female, and average logistic EuroSCORE was 13.3% ± 12.5%. Concomitant procedures were performed in 94.6% of patients (mitral valve surgery, 80.6%; aortic valve surgery, 28.2%; coronary artery bypass grafting, 24.5%; atrial fibrillation ablation, 44.5%). One fifth of the operations were reoperative procedures. Follow-up was 94% complete, with mean duration of 21.0 ± 19.0 months. Results Thirty-day mortality was 10.1% (Cosgrove-Edwards, 11.9%; Carpentier-Edwards, 8.4%), and 5-year survival was 62.4% (Carpentier-Edwards, 64.7%; Cosgrove-Edwards, 60.3%). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in tricuspid regurgitation grade from 2.3 ± 0.7 to 0.7 ± 0.7, and no differences between groups. Use of a Carpentier-Edwards ring, however, was associated with significantly higher risk of dehiscence (Carpentier-Edwards, 8.7%; Cosgrove-Edwards, 0.9%; P < .001), almost exclusively at the septal leaflet portion of the annulus. Multivariate analysis identified annuloplasty type as independently predicting ring dehiscence (odds ratio, 10.7; 95% confidence interval, 3.2–36.5; P < .001). Patients with annuloplasty dehiscence had more residual tricuspid regurgitation on predischarge echocardiography than did patients without dehiscence (1.4 ± 0.63 vs 0.7 ± 0.6; P < .001). Ten patients underwent reoperation for recurrent tricuspid regurgitation, 4 with ring dehiscence. Five-year freedom from reoperation was 95.3% (Cosgrove-Edwards, 97.7%; Carpentier-Edwards, 92.3%). Conclusions Although both rigid and flexible systems provide acceptable early tricuspid valve repair results, use of a rigid ring increases risk of subsequent ring dehiscence.
Cardiovascular Research
- Aims and Scope
- Cover Page
- Editorial Board
- Contents Page
- Announcement: Review Focus on Cardiovascular Systems Biology
- The shape of things to come: mitochondrial fusion and fis...
- RBM24: a 'Regional Business Manager' in charge of the mai...
- Nitric oxide-donating statins: a new concept to boost the...
- Tbx3: a new trick for an 'old' myocyte?
- The SDF-1/CXCR4 axis in stem cell preconditioning We review the pivotal role of the stromal derived factor (SDF)-1 chemokine in tissue ischaemia and how it orchestrates the rapid revascularization of injured, ischaemic, and regenerating tissues via the CXC chemokine receptors CXCR4 and CXCR7. Furthermore, we discuss the effects of preconditioning (PC), which is a well-known protective phenomenon for tissue ischaemia. The positive effect of both hypoxic and acidic PC on progenitor cell therapeutic potential is reviewed, while stressing the role of the SDF-1/CXCR4 axis in this process.
Journal of Vascular Surgery
- Cyber medicine enables remote neuromonitoring during aort... Objective: This study assessed the feasibility and effectiveness of remote neuromonitoring as an adjunct to spinal cord protection during surgical repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. Methods: Four aortic centers in three European countries participated in this prospective observational study. A similar surgical protocol was used in all centers, including assessment of spinal cord function by means of monitoring motor-evoked potentials (MEPs). MEP information was evaluated at one central neurophysiologic department in Maastricht, The Netherlands. Transfer of MEP data from all operating rooms to Maastricht was arranged by Internet connections. In all patients, the protective and surgical strategies to prevent paraplegia were based on MEPs. The on-site surgeons reacted in real time to the interpretation and feedback of the neurophysiologist. Results: Between March 2009 and May 2011, 130 patients (85 men) were treated by open surgical repair. Extent of aneurysms was equally distributed among the centers. Neuromonitoring was technically stabile and successful in all patients. The transfer of data from the operating room in the different vascular centers was undisturbed and without any technical problems. By maintaining a mean distal aortic pressure of 60 mm Hg, MEPs were undisturbed in 65 patients (50%). In another 65 patients (50%), significant changes in MEPs prompted the surgical teams to initiate additional protective and surgical strategies to restore spinal cord perfusion. These measures were not effective in five patients (3.8%), and acute paraplegia resulted. Delayed paraplegia occurred in 10 patients (7.7%) but improved in three and recovered completely in another three. No false-negative or false-positive MEP recordings were experienced. Conclusions: Remote neuromonitoring of spinal cord function during open repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms as a telemedicine technique is feasible and effective. It allows centralization of expertise and saves individual centers from investing in complex technology. The value of monitoring MEPs was confirmed in different aortic centers, resulting in adequate neurologic outcome after extensive aortic surgical procedures.
- Discussion Dr Richard Cambria (Boston, Mass). Was there a uniform surgical protocol for how to react to changes in motor-evoked potential monitoring across the four centers? Dr Michael Jacobs. Indeed, all surgeons from the different centers came to us and we agreed on the protocol, including cerebrospinal fluid (CSF) drainage and distal aortic perfusion, but also the strategic interventions when evoked potentials would disappear. The first logical step is to increase mean arterial and distal aortic pressure. The second step includes reattachment of intercostal arteries. Extremely important is that the anesthesiologists are well trained and well informed, because the equilibrium between anesthesia and evoked potentials is extremely sensitive. For example, if the patient receives too much muscle relaxant, evoked potentials are unreliable.
- Invited commentary Dr Jacobs and his colleagues are to be commended for this first of a kind enterprise using cyber medicine to provide remote neuromonitoring of motor evoked potentials during open thoracoabdominal aortic aneurysm repair. The authors have previously reported extensively on the use of motor evoked potentials as an adjunct for spinal cord protection during these procedures. The complexity, learning curve, and cost have limited the use of this mode of monitoring to a few tertiary centers around the world. With this study, the authors have demonstrated not only the feasibility of a central core center providing this mode of real-time neuromonitoring remotely but also its effectiveness by having achieved similar low rates of spinal cord ischemic complications in the peripheral centers as their own.
- Endovascular treatment of acute and chronic aortic pathol... Background: In patients with Marfan syndrome, the complications of aortic degeneration, including dissection, aneurysm, and rupture represent the main cause of mortality. Although contemporary management of ascending aortic disease requires open surgical reconstruction, endovascular repair is now available for management of descending thoracic and abdominal aortic pathology (ie, thoracic endovascular aortic repair [TEVAR], endovascular aneurysm repair [EVAR]). The short- and long-term benefit of endovascular repair in Marfan patients remains largely unproven. We examine our outcomes after EVAR in this patient population. Methods: All patients with a diagnosis of Marfan syndrome who were treated with TEVAR/EVAR were evaluated in a retrospective review. Perioperative, procedure-specific and patient covariate data were aggregated. Primary endpoints were overall mortality and procedural success as divided into three categories: (1) successful therapy, (2) primary failure, or (3) secondary failure. Results: Between 2000 and June 2010, 16 patients were identified as having undergone 19 TEVAR/EVAR procedures. These included three emergent operations (two for acute dissection/malperfusion and one for anastomotic disruption early after open repair). All 16 patients had previously undergone at least one (range, 1-5) open operation of the ascending aorta or arch at a time interval from 33 years to 1 week prior to the index endovascular repair. During a median follow-up of 9.3 months (range, 0-46 months), there were four deaths (25%). Six patients (38%) had successful endovascular interventions. Despite early success, there was one death in this group at 1 month postintervention. Seven patients (44%) experienced primary treatment failure with five undergoing open conversion and one undergoing left subclavian coil embolization (the seventh was lost to follow-up and presented 4 months later in cardiac arrest and expired without repair). There were three deaths in the primary treatment failure group. Two patients experienced secondary treatment failure. One underwent the index TEVAR for acute dissection with malperfusion and required a subsequent TEVAR for more distal aortic pathology. He is stable without disease progression. The other patient underwent open conversion after a second EVAR with four-vessel “chimney” stent grafts and is stable with his entire native aorta having been replaced. Conclusions: Aortic disease associated with Marfan syndrome is a complex clinical problem and many patients require remedial procedures. Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients. However, failure of endovascular therapy is common, and its use should be judicious with close follow-up to avoid delay if open surgical repair is required.
- Discussion Dr Eric D. Endean (Lexington, Ky). I would like to congratulate the group from the University of Florida for the courage of presenting their results for this difficult problem. The patients presented in this series clearly represent a group for which treatment options are difficult at best. To re-emphasize, 14 of the 16 patients were ASA class IV or IV-E and all were deemed poor candidates for open surgical intervention. Fifteen patients had undergone between one and five previous open aortic operations, averaging almost two open aortic operations per patient. Not unexpectedly, the results are sobering. Four patients died within months of the endovascular procedure and the results in <50% were classified as “successful.” Six patients, or 38%, were classified as primary treatment failures. All patients with treatment failures required an open repair and half of them died. Two patients were felt to have secondary failure, ie, successful treatment of the target pathology, but proximal or distal aortic degeneration requiring further intervention.
- Endografts with suprarenal fixation do not perform better... Objective: To determine if there are any differences in outcomes between infrarenal fixation (IF) and suprarenal fixation (SF) endograft systems for the endovascular treatment (endovascular aneurysm repair [EVAR]) of abdominal aortic aneurysms (AAAs) with short, straight proximal aortic necks (0.5 cm) noted in either group. Sac regression was observed at an average rate of 0.24 cm/year in the IF group and 0.26 cm/year in the SF group (P = NS). There were no aneurysm ruptures during the study period. Conclusions: There are no significant differences in endograft migration or in the incidence of early and late type 1a endoleaks between endografts that use IF (Gore Excluder) and SF (Cook Zenith) fixation for patients with short aortic necks undergoing EVAR.
- Higher mortality in patients hospitalized for acute aorti... Background: The management of acute aortic aneurysm rupture or dissection (AARD) requires specific medical expertise, diagnostic techniques, and therapeutic options, not always available in all hospitals through the entire week. The aim of our study was to evaluate whether an association exists between weekday (WD) or weekend (WE) admission and mortality for patients with ARRD. Methods: Based on the database of routinely collected hospital admissions of the region of Emilia Romagna (RER) of Italy, we examined the discharge sheets of all patients with AARD (January 1999 to December 2009). The risk of in-hospital death was calculated for admissions on the WE compared with the admissions during a WD. Results: The analysis considered 4559 events in 4461 patients. AARD admissions were most frequent on Monday (14.7%) and Friday (14.8%) and less frequent on Saturday (12.6%). The percentage of events admitted on Sunday/holiday was 15.0%, whereas the distribution of death rate with respect to day of admission was significantly different (χ2 = 23.472; P < .001) with the highest frequency peak on Sunday/holiday (17.4%) and the lowest on Tuesday (12.9%). WE admissions were associated with significantly higher in-hospital mortality (43.4%) than WD admissions (36.9%, P < .001). Multivariate regression analysis showed that WE admission was an independent risk factor for increased in-hospital mortality odds ratio 1.318; 95% confidence interval, 1.144-1.517; P < .001). Conclusions: Our findings show that hospitalization for AARD on WE is associated with a significantly higher mortality rate than hospitalization on WD. Further studies are needed to investigate whether ensuring optimal diagnostic and therapeutic approaches during the entire week might improve the overall survival of patients with ARRD.
- Retrograde ascending aortic dissection as an early compli... Objective: Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. Methods: A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. Results: The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1). Conclusions: rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.
- Outcomes of percutaneous endovascular intervention for ty... Objective: Type II endoleak (T2EL) with aneurysm expansion is believed to place patients at risk for aneurysm-related mortality (ARM). Treatment with glue and/or coil embolization of the aneurysm sac, inferior mesenteric artery (IMA), and lumbar branches via translumbar or transarterial approaches has been utilized to ablate such endoleaks, and thus decrease ARM. We evaluated the midterm results of percutaneous endovascular treatment of T2EL with aneurysm expansion. Methods: Single-institution, 5-year (January 2003 to August 2008) retrospective study of all endovascular interventions for T2EL with sac expansion. Blinded, independent review of all available pre- and post-T2EL intervention computed tomography (CT) scans was performed. Aneurysm sac maximal transverse diameters and aneurysm sac growth rates prior to and following T2EL intervention were analyzed. Results: Forty-two patients (34 male, eight female; mean age, 75) underwent T2EL intervention at 26 ± 20 months after endovascular aneurysm repair (EVAR) and were subsequently followed for 23 ± 20 months. Seven out of 42 patients (17%) underwent repeat T2EL intervention. Interventions included 44 translumbar sac embolizations, and transcatheter embolizations of nine IMAs and seven lumbar/hypogastric arteries. Aneurysm diameter was 6.1 ± 1.6 cm at EVAR, 6.6 ± 1.5 cm at initial T2EL treatment, and 6.9 ± 1.7 cm at last follow-up. There were no significant differences in the rates of aneurysm sac growth pre- and post-T2EL treatment. At last follow-up imaging, recurrent or persistent T2EL was noted in 72% of patients. Of 42 patients, nine (21%) received operative endoluminal correction of occult type I or type III endoleaks that were diagnosed during the T2EL angiographic intervention. There were no aneurysm ruptures or ARMs during follow-up; overall mortality for the 5-year study period was 24%. Conclusions: In this series, percutaneous endovascular intervention for type II endoleak with aneurysm sac growth does not appear to alter the rate of aneurysm sac growth, and the majority of patients display persistent/recurrent endoleak. However, diagnostic angiographic evaluation may reveal unexpected type I and III endoleaks and is therefore recommended for all patients with T2EL and sac growth. While coil and glue embolization of aneurysm sac and selected branch vessels does not appear to yield benefit in our series, the diagnosis and subsequent definitive treatment of previously occult type I and III endoleaks may explain the absence of delayed rupture and ARM in our series.
- Invited commentary This article questions our current assumptions concerning the treatment outcomes of type II endoleaks. While it is generally acknowledged that these leaks occur frequently and are usually merely annoying, the results of treating more pernicious type II endoleaks that are accompanied by sac enlargement are largely unknown. These latter leaks, while rare, are often complicated, involving several sets of lumbar arteries, the inferior mesenteric artery, and extensive collateral networks. It is not surprising that simple embolization of the lumber, mesenteric, or internal iliac branches would not control these leaks. In fact, several groups have pointed this out, recommending translumbar approaches with coils and glue, and insisting on complete obliteration of the leak “nidus” within the sac.
Hypertension Research - Issue - nature.com science feeds
- Hypertension and diabetes incidence: confounding factors Hypertension and diabetes incidence: confounding factors Hypertension Research 34, 1069 (October 2011). doi:10.1038/hr.2011.94 Authors: Arrigo FG Cicero & Sibel Ertek
- Does subclinical thyroid dysfunction affect blood pressure? Does subclinical thyroid dysfunction affect blood pressure? Hypertension Research 34, 1071 (October 2011). doi:10.1038/hr.2011.124 Author: Yukiko Nakata
- Prevention of perinatal death with low-dose aspirin in de... Prevention of perinatal death with low-dose aspirin in developing countries Hypertension Research 34, 1073 (October 2011). doi:10.1038/hr.2011.121 Authors: Emmanuel Bujold & Jean-Charles Pasquier
- Normotension, blood pressure variability and early target... Normotension, blood pressure variability and early target organ damage Hypertension Research 34, 1075 (October 2011). doi:10.1038/hr.2011.122 Author: Luis M Ruilope
- Blood pressure variability and its implications in people... Blood pressure variability and its implications in people of African descent Hypertension Research 34, 1076 (October 2011). doi:10.1038/hr.2011.138 Authors: Ifeoma I Ulasi, Benedict C Anisiuba & Chinwuba K Ijoma
- Ventricular repolarization before and after treatment in ... Ventricular repolarization before and after treatment in patients with secondary hypertension due to renal-artery stenosis and primary aldosteronism Hypertension Research 34, 1078 (October 2011). doi:10.1038/hr.2011.77 Authors: Simona Maule, Chiara Bertello, Franco Rabbia, Alberto Milan, Paolo Mulatero, Valeria Milazzo, Grazia Papotti & Franco Veglio
- The associations between G972R polymorphism of the IRS-1 ... The associations between G972R polymorphism of the IRS-1 gene, insulin resistance, salt sensitivity and non-dipper hypertension Hypertension Research 34, 1082 (October 2011). doi:10.1038/hr.2011.80 Authors: Joanna Dziwura, Agnieszka Bińczak-Kuleta, Tomasz Miazgowski, Joanna Ziemak & Krystyna Widecka
- Factors associated with prevalence, awareness, treatment ... Factors associated with prevalence, awareness, treatment and control of hypertension in urban adults from 33 communities in China: the CHPSNE Study Hypertension Research 34, 1087 (October 2011). doi:10.1038/hr.2011.99 Authors: Shen Tian, Guang-Hui Dong, Da Wang, Miao-Miao Liu, Qiao Lin, Xiu-Jun Meng, Li-Xia Xu, Hua Hou & Yu-Feng Ren
- The effect of body mass index and fasting glucose on the ... The effect of body mass index and fasting glucose on the relationship between blood pressure and incident diabetes mellitus: a 5-year follow-up study Hypertension Research 34, 1093 (October 2011). doi:10.1038/hr.2011.89 Authors: Won Young Lee, Chang Hee Kwon, Eun Jung Rhee, Jeong Bae Park, Young Kwon Kim, Sook Young Woo, Seonwoo Kim & Ki Chul Sung
- Blood pressure levels in patients with subclinical thyroi... Blood pressure levels in patients with subclinical thyroid dysfunction: a meta-analysis of cross-sectional data Hypertension Research 34, 1098 (October 2011). doi:10.1038/hr.2011.91 Authors: Yunfei Cai, Yongkui Ren & Jingpu Shi
Acute Cardiac Care
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The International Journal of Cardiovascular Imaging
- Reduced global longitudinal and radial strain with normal... Abstract We sought to determine whether global and regional left ventricular (LV) strain parameters were altered in repaired coarctation of the aorta (COA) with normal LV ejection fraction (EF) when compared with healthy adult controls, and whether such alterations were related to LV hypertrophy (LVH). We identified 81 patients after COA repair (31 female, age 25 ± 8.5 years) with inclusion criteria at follow-up CMR of: age ≥13 years, time post-repair ≥10 years, no aortic valve disease, LV-EF >50 %). LV deformation indices derived using CMR-feature tracking and volumetric EF were compared between COA patients and normal controls (n = 20, 10 female, age 37 ± 7 years), and between COA with versus without LVH. In repaired COA versus controls, LV-EF (%) was 62 ± 7.2 versus 58 ± 3.0 (p = 0.01), and LV mass (g/m2) 66 ± 16.8 versus 57.7 ± 6.0 (p = 0.0001). LV global longitudinal strain (GLS) was decreased to −17.0 ± 4.7 % in COA (−20 ± 5 % in controls, p = 0.02), and global radial strain (GRS) reduced to 40 ± 15 % (50 ± 12.4 % in controls, p = 0.003). The global circumferential strain (GCS) was preserved in COA at −23 ± 4.7 % (−24.6 ± 2.4 % in controls, p = 0.14). Regionally, LS decrease was marked in the basal segments (septal, p = 0.005, lateral, p = 0.013). In COA with LVH (n = 45, mass 76.3 ± 12.8 g/m2) versus without LVH (n = 36, mass 52.2 ± 10 g/m2), GLS was more markedly decreased (−15.7 ± 4.8 vs. −18.5 ± 4.2 %, p = 0.016, but GRS and GCS were similar (p = 0.49 and 0.27). In post-repair COA with normal LV-EF, GLS and GRS are reduced whilst GCS is preserved. GLS reduction is more pronounced in the presence of LVH. GLS may qualify as indicator of early LV dysfunction. Content Type Journal ArticleCategory Original PaperPages 1-10DOI 10.1007/s10554-012-0061-1Authors Shelby Kutty, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USASheela Rangamani, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USAJeeva Venkataraman, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USALing Li, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USAAndreas Schuster, Division of Imaging Sciences, King’s College London British Heart Foundation Center of Excellence, National Institute of Health Research Biomedical Research Center at Guy’s and St. Thomas’ NHS Foundation Trust, The Rayne Institute, St. Thomas’ Hospital, London, UKScott E. Fletcher, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USADavid A. Danford, Joint Division of Pediatric Cardiology, Children’s Hospital and Medical Center, University of Nebraska College of Medicine/Creighton University School of Medicine, 8200, Dodge Street, Omaha, NE 68114, USAPhilipp Beerbaum, Department for Radiology and Pediatric Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Non-invasive computed tomography coronary angiography as ... Abstract To determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent determinants of subsequent ICA and revascularization were evaluated. CTA studies were performed using a 64-row (n = 413) or 320-row (n = 224) multidetector scanner. The presence and severity of CAD were determined on CTA. Following CTA, patients were followed up for 1 year for the occurrence of ICA and revascularization. A total of 637 patients (296 male, 56 ± 12 years) were enrolled and 578 CTA investigations were available for analysis. In patients with significant CAD on CTA, subsequent ICA rate was 76 %. Among patients with non-significant CAD on CTA, subsequent ICA rate was 20 % and among patients with normal CTA results, subsequent ICA rate was 5.7 % (p < 0.001). Of patients with significant CAD on CTA, revascularization rate was 47 %, as compared to a revascularization rate of 0.6 % in patients with non-significant CAD on CTA and no revascularizations in patients with a normal CTA results (p < 0.001). Significant CAD on CTA and significant three-vessel or left main disease on CTA were identified as the strongest independent predictors of ICA and revascularization. CTA results are strong and independent determinants of subsequent ICA and revascularization. Consequently, CTA has the potential to serve as a gatekeeper for ICA to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA. Content Type Journal ArticleCategory Original PaperPages 1-8DOI 10.1007/s10554-012-0059-8Authors Fleur R. de Graaf, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsJoëlla E. van Velzen, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsStephanie M. de Boer, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsJacob M. van Werkhoven, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsLucia J. Kroft, Department of Radiology, Leiden University Medical Center, Leiden, The NetherlandsAlbert de Roos, Department of Radiology, Leiden University Medical Center, Leiden, The NetherlandsAllard Sieders, Department of Cardiology, Rijnland Hospital, Leiderdorp, The NetherlandsGreetje J. de Grooth, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsJ. Wouter Jukema, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsJoanne D. Schuijf, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsJeroen J. Bax, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsMartin J. Schalij, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The NetherlandsErnst E. van der Wall, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Diagnosis of viral myocarditis by cardiac magnetic resona... Abstract In patients with acute myocarditis, viral genome can be detected in plasma and peripheral leukocytes. Its relationship with active myocardial inflammation, however, is not well understood. Myocardial edema as a feature of inflammation and myocardial necrosis or fibrosis can be frequently observed in patients with acute myocarditis by cardiovascular magnetic resonance (CMR). We assessed the association of viral genome presence in peripheral blood samples with myocardial edema and irreversible injury. We examined consecutive patients with clinically suspected myocarditis after an episode of viral illness. State-of-the-art methods were used for detecting myocardial edema and irreversible injury using CMR and viral genome applying reverse transcribed, nested polymerase chain reaction in peripheral blood samples. The specificity of viral amplification products was confirmed by automatic DNA sequencing. Of a total of 55 patients (53.5 ± 15.6 years), 21 were positive for viral genome in peripheral leukocytes. Interestingly, 18 (86 %) of these patients also showed global myocardial edema, as compared to only 7/34 (21 %) without PCR evidence for viral genome. The overall agreement between CMR criteria for edema and viral PCR was 84 %. In contrast, there was no significant relationship of viral genome presence with myocardial necrosis or scars. In patients with clinically suspected myocarditis, myocardial edema but not irreversible myocardial injury is associated with the presence of viral genome in peripheral blood. Content Type Journal ArticleCategory Original PaperPages 1-9DOI 10.1007/s10554-012-0052-2Authors Michael Jeserich, Medical Practice, Cardiology and Angiology, Koenigstr. 39, 90402 Nuernberg, GermanyEva Brunner, Department of Molecular Pathology, University Hospital Tübingen, Tübingen, GermanyReinhard Kandolf, Department of Molecular Pathology, University Hospital Tübingen, Tübingen, GermanyManfred Olschewski, Department of Medical Biometry and Statistics, University of Freiburg, Freiburg im Breisgau, GermanySimone Kimmel, Medical Practice, Cardiology and Angiology, Koenigstr. 39, 90402 Nuernberg, GermanyMatthias G. Friedrich, Departments of Cardiac Sciences and Radiology, University of Calgary, CMR Centre at the Montreal Heart Institute, Hornstein Chair in Cardiovascular Imaging, 5000 Rue Belanger, Montréal, QC, CanadaDaniela Föll, Department of Cardiology and Angiology, Albert Ludwig University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, GermanyChristoph Bode, Department of Cardiology and Angiology, Albert Ludwig University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, GermanyAnnette Geibel, Department of Cardiology and Angiology, Albert Ludwig University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- In-stent area stenosis on 64-slice multi-detector compute... Abstract We aimed to prospectively assess the optimal cutoff value for a minimum lumen cross-sectional area (CSA) on a 64-slice multidetector computed tomography (MDCT) compared with an intravascular ultrasound (IVUS). In 39 patients with 43 stents, the minimum lumen diameter, stent diameter, diameter stenosis, minimum lumen CSA, stent CSA, and area stenosis at the narrowest point were measured independently on 64-slice MDCT and IVUS images. For the assessment of diameter and CSA, 64-slice MDCT showed good correlations with IVUS (r = 0.82 for minimum lumen diameter, r = 0.66 for stent diameter, r = 0.79 for minimum lumen CSA, and r = 0.75 for stent CSA, respectively, P < 0.0001). For the assessment of diameter and area stenoses, a 64-slice MDCT showed good correlations with IVUS (r = 0.89 and 0.91, respectively, P < 0.0001). The overall sensitivity, specificity, positive predictive value, and negative predictive value to detect in-stent area restenosis (≥50 % area stenosis) of a 64-slice MDCT were 77, 100, 100, and 91 %, respectively. The cutoff value of a 64-slice MDCT, determined by receiver operator characteristic (ROC) analysis, was 5.0 mm2 with 76.5 % sensitivity and 92.3 % specificity for significant in-stent area restenosis; the area under the ROC curve was 0.902 (P < 0.0001). A good correlation was found between a 64-slice MDCT and the IVUS, regarding the assessment of diameter and area stenoses of coronary stents in selected patients implanted with stents of more than 3 mm in diameter. Optimal cutoff value for the minimum lumen CSA of coronary stents on the 64-slice MDCT is 5 mm2 to predict a CSA of 4 mm2 on IVUS. Content Type Journal ArticlePages 1-11DOI 10.1007/s10554-012-0057-xAuthors Woocheol Kwon, Department of Radiology, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, Wonju, Republic of KoreaJiyoun Choi, Department of Radiology, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, Wonju, Republic of KoreaJang-Young Kim, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of KoreaSeong-Yoon Kim, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of KoreaJunghan Yoon, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of KoreaKyoung-Hoon Choe, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of KoreaSeung Hwan Lee, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of KoreaSung Gyun Ahn, Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, 162 Ilsan-dong, Wonju, Gangwon-do 220-701, Republic of Korea Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Flow-gated radial phase-contrast imaging in the presence ... Abstract To implement a flow-gating method to acquire phase-contrast (PC) images of carotid arteries without use of an electrocardiography (ECG) signal to synchronize the acquisition of imaging data with pulsatile arterial flow. The flow-gating method was realized through radial scanning and sophisticated post-processing methods including downsampling, complex difference, and correlation analysis to improve the evaluation of flow-gating times in radial phase-contrast scans. Quantitatively comparable results (R = 0.92–0.96, n = 9) of flow-related parameters, including mean velocity, mean flow rate, and flow volume, with conventional ECG-gated imaging demonstrated that the proposed method is highly feasible. The radial flow-gating PC imaging method is applicable in carotid arteries. The proposed flow-gating method can potentially avoid the setting up of ECG-related equipment for brain imaging. This technique has potential use in patients with arrhythmia or weak ECG signals. Content Type Journal ArticleCategory Original PaperPages 1-10DOI 10.1007/s10554-012-0056-yAuthors Hsu-Hsia Peng, Department of Biomedical Engineering and Environmental Sciences, College of Nuclear Science, National Tsing Hua University, Hsinchu, Taiwan, ROCTeng-Yi Huang, Department of Electrical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan, ROCFu-Nien Wang, Department of Biomedical Engineering and Environmental Sciences, College of Nuclear Science, National Tsing Hua University, Hsinchu, Taiwan, ROCHsiao-Wen Chung, Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan, ROC Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Analysis of electrical and mechanical left atrial propert... Abstract The study of left atrial (LA) mechanical function during atrial fibrillation (AFib) can provide valuable information, particularly if such profiling is related to the cavity electrical substrate and conveys prognostic information. To assess if there is any relation between LA mechanical and electrical asynchrony and if such evaluation can be of interest in stratifying AFib patients. 50 patients with persistent AFib who underwent electrical cardioversion (CV) were evaluated with pre-CV atrial electrograms (AEGs). Electrical asynchrony was classified according to Wells’ patterns of AEGs, ranging from most organized (I) to most dispersed (III) one. LA mechanical asynchrony was addressed by transthoracic 2D-speckle-tracking echo and quantified according to time-to-peak standard deviation (TP-SD) of wall strains and their peak values (PS) before CV, after 24 h, at 1 month. Pre-CV a linear, inverse relation between TP-SD and PS (p < 0.001) and a direct linear relation between TP-SD and Wells’ classes (p = 0.04) were observed. With sinus rhythm TP-SD decreased (p = 0.023) and PS increased (p < 0.001), suggesting improved LA mechanical milieu. A multivariate analysis, testing the effects of baseline variables in predicting post-CV recurrence of AFib, revealed that amount of TP-SD variation pre/24 h post-CV was the only independent predictor at 6 months (p = 0.046). Speckle tracking-derived LA parameters can describe LA wall forces during AFib, categorizing the asynchronous mechanistic profile of AFib that correlates with the degree of the dispersed LA electrical activity. The amount of changes in LA mechanical asynchrony pre/post-CV seems to have prognostic relevance in predicting SR maintenance. Content Type Journal ArticleCategory Original PaperPages 1-8DOI 10.1007/s10554-012-0053-1Authors Anna Degiovanni, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, ItalyMiriam Bortnik, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, ItalyGabriele Dell’Era, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, ItalyVirginia Bolzani, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, ItalyEraldo Occhetta, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, ItalyGiorgio Bellomo, Department of Cardiology, Clinical Chemistry, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Corso Mazzini 18, 28100 Novara, ItalyPaolo Marino, Department of Cardiology, Clinical Cardiology, Università del Piemonte Orientale, Corso Mazzini 18, 28100 Novara, Italy Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Left ventricular remodeling and torsion dynamics in hyper... Abstract Left ventricular (LV) torsion is a fundamental component of wall motion and plays an important role to optimize ventricular ejection fraction. The aim of our study was to calculate by speckle tracking echocardiography LV twist angle in patients with hypertension and LV remodeling, analyzing torsional indices in all patterns of hypertrophy, in comparison to torsional dynamics of age-matched healthy subjects. Hypertensive patients (n = 202) were divided in three groups, patients with concentric remodeling (n = 70), concentric hypertrophy (n = 68) and eccentric hypertrophy (n = 64), in relation to the echocardiographic measurements of relative wall thickness and LV mass, analyzing their torsional patterns by speckle tracking in comparison to age-matched control group. Compared to healthy controls, LV twist angle was increased in patients with hypertension and concentric remodeling (15.2° ± 1.9° vs. 11.0° ± 1.6°; p < 0.001), reaching the highest value in patients with concentric hypertrophy (19.4° ± 2.6°); instead LV twist angle presented depressed in the group of patients that presented eccentric hypertrophy (5.0° ± 1.1°). Regarding LV untwisting rate, it was higher in the concentric remodeling and concentric hypertrophy groups (−123.1°/s ± 12.1°/s and −145.1°/s ± 15.5°/s, respectively) in comparison with the controls (−90.0°/s ± 10.1°/s; p < 0.0001 for both). Instead, lower values of LV untwisting rate were observed in the eccentric remodeling group (−81.6°/s ± 8.1°/s), not significantly different to controls’ values (p = 0.09). Enhanced LV twist angle appears to be a compensatory mechanism in hypertensive patients during the earlier stages of concentric remodeling and concentric hypertrophy; this hyper-torsion is inevitably loss in the more advanced stage of eccentric hypertrophy. Content Type Journal ArticleCategory Original PaperPages 1-8DOI 10.1007/s10554-012-0054-0Authors Matteo Cameli, Department of Cardiovascular Diseases, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, ItalyMatteo Lisi, Department of Cardiovascular Diseases, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, ItalyFrancesca Maria Righini, Department of Cardiovascular Diseases, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, ItalyAlberto Massoni, Department of Cardiovascular Diseases, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, ItalySergio Mondillo, Department of Cardiovascular Diseases, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, Italy Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Contemporary assessment of stent strut coverage by OCT Contemporary assessment of stent strut coverage by OCT Content Type Journal ArticlePages 1-5DOI 10.1007/s10554-012-0046-0Authors Guilherme F. Attizzani, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USAHiram G. Bezerra, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Failed heart rate control with oral metoprolol prior to c... Abstract The purpose of this study was to evaluate the effect of intravenous (IV) metoprolol after a suboptimal heart rate (HR) response to oral metoprolol (75–150 mg) on HR control, image quality (IQ) and radiation dose during coronary CTA using 320-MDCT. Fifty-three consecutive patients who failed to achieve a target HR of < 60 bpm after an oral dose of metoprolol and required supplementary IV metoprolol (5–20 mg) prior to coronary CTA were evaluated. Patients with HR < 60 bpm during image acquisition were defined as responders (R) and those with HR ≥ 60 bpm as non-responders (NR). Two observers assessed IQ using a 3-point scale (1–2, diagnostic and 3, non-diagnostic). Effective dose (ED) was estimated using dose-length product and a 0.014 mSV/mGy.cm conversion factor. Baseline characteristics and HR on arrival were similar in the two groups. 58 % of patients didn’t achieve the target HR after receiving IV metoprolol (NR). R had a significantly higher HR reduction after oral (mean HR 63.9 ± 4.5 bpm vs. 69.6 ± 5.6 bpm) (p < 0.005) and IV (mean HR 55.4 ± 3.9 bpm vs. 67.4 ± 5.3 bpm) (p < 0.005) doses of metoprolol. Studies from NR showed a significantly higher ED in comparison to R (8.0 ± 2.9 vs. 6.1 ± 2.2 mSv) (p = 0.016) and a significantly higher proportion of non-diagnostic coronary segments (9.2 vs. 2.5 %) (p < 0.001). 58 % of patients who do not achieve a HR of <60 bpm prior to coronary CTA with oral fail to respond to additional IV metoprolol and have studies with higher radiation dose and worse image quality. Content Type Journal ArticleCategory Original PaperPages 1-8DOI 10.1007/s10554-012-0049-xAuthors Laura Jiménez-Juan, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaElsie T. Nguyen, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaBernd J. Wintersperger, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaHadas Moshonov, Joint Department of Medical Imaging, Mount Sinai Hospital, University Health Network, Lu Cliff Place 700 Bay street 2-201, Toronto, ON M7A 2H4, CanadaAndrew M. Crean, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaDjeven P. Deva, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaNarinder S. Paul, Cardiothoracic Division, Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, CanadaFelipe S. Torres, Cardiothoracic Division, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room AG56B, Toronto, ON M5N 3M5, Canada Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
- Is there a role for thoracic aortic calcium to fine-tune ... Abstract Screening asymptomatic subjects to streamline measures for the prevention of cardiovascular events remains a major challenge. The established primary prevention risk-scoring methods use equations derived from large prospective cohort studies, but further fine-tuning of cardiovascular risk assessment remains important as 25 % of individuals with low estimated risk may experience cardiac events. Independent studies provided evidence that extended risk assessment using coronary artery calcium quantification may improve risk stratification as it can lead to reclassification of persons at increased risk. Particularly in intermediate-risk subjects, coronary artery calcium scoring can help to correctly identify individuals at highest risk. Data on the extent of calcification of the ascending and descending thoracic aorta might be useful for additional cardiovascular risk stratification. Future analyses and studies will be required to answer the question of whether the implementation of such data may allow further fine-tuning of cardiovascular risk prediction in specific subpopulations—for instance in women or men with an increased risk of stroke and/or symptomatic peripheral vascular disease. Content Type Journal ArticlePages 1-3DOI 10.1007/s10554-012-0055-zAuthors Marc Hartmann, Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Haaksbergerstraat 55, 7513 ER Enschede, The NetherlandsClemens von Birgelen, Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Haaksbergerstraat 55, 7513 ER Enschede, The Netherlands Journal The International Journal of Cardiovascular Imaging (formerly Cardiac Imaging)Online ISSN 1573-0743Print ISSN 1569-5794
European Journal of Cardiovascular Prevention & Rehabilitation
- Can level of education, accreditation and use of database... Introduction: Professional skills, education and accreditation, along with clinical outcome assessment, are considered important factors to achieve comprehensive delivery and quality of cardiac rehabilitation (CR). This study assessed professional educational programmes, accreditation and use of databases in CR across the European countries. Materials and methods: Questions on professional education, accreditation and clinical databases from the European Cardiac Rehabilitation Inventory Survey, which is a postal questionnaire survey, conducted from November 2007 to January 2009 among national CR-related organizations in Europe; 28 countries responded (72%) to this survey. Results: Among the participating countries, 32% had guidelines on professional CR skills, 61% had formal educational programmes and 29% had accreditation systems for professional CR skills. One hundred and seventy-four ad-hoc educational and scientific activities were registered during 2005–2007. Forty-three percent of the countries had established CR programme accreditation systems, primarily aimed at phase 2. One in three (35%) countries had established clinical CR databases with a further 25% planning to do so. Conclusion: More than half of the European countries had developed formal CR educational programmes. Furthermore, many ad-hoc CR-related meetings and conference activities take place across Europe. Although only a quarter of countries had developed accreditation systems aimed at professionals, programme accreditation was somewhat more widespread with over a third having programme accreditation systems. Clinical databases were underdeveloped. A greater focus on education, accreditation and database implementation is needed to promote CR availability and the quality of CR services for the benefit of cardiac patients across Europe.
- Aerobic interval training reduces blood pressure and impr... Aims: Exercise is recommended as prevention, management, and control of all stages of hypertension. There are still controversies about the optimal training dose, frequency, and intensity. We aimed to study the effect of aerobic interval training on blood pressure and myocardial function in hypertensive patients. Methods and results: A total of 88 patients (52.0 ± 7.8 years, 39 women) with essential hypertension were randomized to aerobic interval training (AIT) (>90% of maximal heart rate, correlates to 85–90% of VO2max), isocaloric moderate intensity continuous training (MIT) (~70% of maximal heart rate, 60% of VO2max), or a control group. Exercise was performed on a treadmill, three times per week for 12 weeks. Ambulatory 24-hour blood pressure (ABP) was the primary endpoint. Secondary endpoints included maximal oxygen uptake (VO2max), mean heart rate/24 hour, flow mediated dilatation (FMD), total peripheral resistance (TPR), and myocardial systolic and diastolic function by echocardiography. Systolic ABP was reduced by 12 mmHg (p < 0.001) in AIT and 4.5 mmHg (p = 0.05) in MIT. Diastolic ABP was reduced by 8 mmHg (p < 0.001) in AIT and 3.5 mmHg (p = 0.02) in MIT. VO2max improved by 15% (p < 0.001) in AIT and 5% (p < 0.01) in MIT. Systolic myocardial function improved in both exercise groups, diastolic function in the AIT group only. TPR reduction and increased FMD were only observed in the AIT group. Conclusions: This study indicates that the blood pressure reducing effect of exercise in essential hypertension is intensity dependent. Aerobic interval training is an effective method to lower blood pressure and improve other cardiovascular risk factors.
- Motivational counselling for physical activity in patient... Background: Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. Design: A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. Method: One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. Results: Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µadd = 0.69, p < 0.05). Conclusion: Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.
- Changing the lexicon of 'Cardiac Rehabilitation': a progr...
- Implementation of a pharmacist-led intervention to enhanc... Background: Although statins have indisputably proven to reduce fatal and nonfatal events in patients with cardiovascular disease, many patients with established cardiovascular disease do not receive them. Research into the effective and efficient implementation of current guidelines on secondary prevention is therefore needed. Design: A cluster randomized implementation trial was conducted between September 2006 and February 2008. Methods: Experimental pharmacists received an intensive implementation programme, whereas control pharmacists received an educational manual only. Pharmacists in both the groups were asked to identify eligible patients and to provide general practitioners (GPs) with lists of these patients. Physicians received instructions from the pharmacists to review the patients regarding a statin indication and to start a statin when they considered this as appropriate. Main outcome measure was the percentage of identified patients who received one or more statin prescriptions at 6 months follow-up. Results: Although twice as many patients were reviewed for a statin indication by a GP in the experimental group (19.7 vs. 10.8%, P = 0.023), an equally low number of patients in the experimental group and the control group received statins (5.8 vs. 5.3%, P = 0.104). Conclusion: The intensive implementation programme had an impact on pharmacists and GPs, but did not result in more patients receiving statins.
- Heart rate recovery, exercise capacity, and mortality ris... Background: Both impaired heart rate recovery (HRR) and low fitness are associated with higher mortality risk. In addition, HRR is influenced by fitness status. The interaction between HRR, mortality, and fitness has not been clearly defined. Thus, we sought to evaluate the association between HRR and all-cause mortality and to assess the effects of fitness on this association. Methods: Treadmill exercise testing was performed in 5974 male veterans for clinical reasons at two Veterans Affairs Medical Centers (Washington, DC and Palo Alto, CA). HRR was calculated at 1 and 2 min of recovery. All-cause mortality was determined over a mean 6.2-year follow-up period. Results: Mortality risk was significantly and inversely associated with HRR, only at 2 min. A cut-off value of 14 beats/min at 2 min recovery was the strongest predictor of mortality for the cohort (hazard ratio = 2.4; CI 1.6–3.5). The mortality risk was overestimated when exercise capacity was not considered. When both low fitness and low HRR were present (≤6 metabolic equivalents and ≤14 beats/min), mortality risk was approximately seven-fold higher compared to the High-fit + High-HRR group (>6 metabolic equivalents and >14 beats/min). Conclusions: HRR at 2 min post exercise is strongly and inversely associated with all-cause mortality. Exercise capacity affects HRR-associated mortality substantially and should be considered when applying HRR to estimate mortality.
- A new cardiopulmonary exercise testing prognosticating al... In 2004, a cardiopulmonary exercise testing (CPET) prognosticating algorithm for heart failure (HF) patients was proposed. The algorithm employed a stepwise assessment of peak oxygen consumption (VO2), slope of regression relating minute ventilation to carbon dioxide output (VE/VCO2) and peak respiratory exchange ratio (RER), and was proposed as an alternative to the traditional strategy of using a single CPET parameter to describe prognosis. Since its initial proposal, the prognosticating algorithm has not been reassessed, although a re-evaluation is in order given the fact that new HF therapies, such as beta-blocker therapy, have significantly improved survival in HF. The present review, based on a critical examination of CPET outcome studies in HF patients regularly treated with beta-blockers, suggests a new prognosticating algorithm. The algorithm comprises four CPET parameters: peak RER, exertional oscillatory ventilation (EOV), peak VO2 and peak systolic blood pressure (SBP). Compared to previous proposals, the present preliminary attempt includes EOV instead of VE/VCO2 slope as ventilatory CPET parameter, and peak SBP as hemodynamic-derived index.
- The value of treadmill exercise test parameters together ... Background: Exercise test parameters (exercise ankle brachial index (ABI), walking distance and blood pressure response) separately are associated with long-term outcome in patients with known or suspected peripheral arterial disease (PAD). However, the clinical value of the combination of these parameters together is unknown. Methods: 2165 patients performed a treadmill exercise test to diagnose or to evaluate their PAD. Resting ABI, exercise ABI, abnormal blood pressure response (hypotensive and hypertensive) and walking distance (impairment <150 m) were measured. The study population was divided into patients with a resting ABI ≥ 0.90 and patients with PAD (resting ABI < 0.90). Results: The mean follow-up period was 5 years (0.5–14 years). Long-term mortality rate and risks increases when more exercise parameters became abnormal (p-value = 0.001). Patients with a normal resting ABI but with an abnormal exercise test had a higher mortality risk – HR 1.90 (1.32–2.73) – than patients with a normal exercise test. The highest mortality risk and cardiac death was observed in PAD patients with a walking impairment together with an abnormal blood pressure response – HR 3.48 (2.22–5.46). Conclusion: Exercise tests give multiple parameters, which together provide important prognostic information on long-term outcome in both patients with normal resting ABI and PAD.
- Exercise capacity after coarctation repair relates to the... Background: Even after excellent repair of aortic coarctation without restenosis there are limitations in exercise capacity at long-term follow-up. This study was performed to assess the contribution of inherited genomic polymorphisms to exercise capacity in patients without restenosis. Patients and methods: 122 patients aged 17–72 years, 46 female, 76 male, seen 2–27 years after repair of aortic coarctation with a residual brachial-ankle-gradient ≤20 mmHg were investigated. Genomic polymorphism of angiotensin converting enzyme (ACE I/D), angiotensinogen (AGT, c.704C > T), angiotensin II receptor type 1 (AGTR1, c.1166A > C), endothelin 1 (EDN1, EDN1/ex5-c.5665G > T), G protein (GNB3, c.825C > T), and two polymorphisms each of the ß1-adrenoreceptor (ADRB1, c.145G > A and c.1165C > G), ß2-adrenoreceptor (ADRB2, c.46A > G and c.79C > G), and endothelial NO synthase (NOS3, intron 4 I/D and NOS3, c.894G > T) were determined by PCR amplification and fragment length analysis. Exercise capacity was determined by an upright bicycle exercise test. Results: Only the c.46A > G polymorphism of the ADRB2 (p = 0.024) and the c.704T > C AGT polymorphism (p = 0.042) were positively correlated with peak workload. Patients with one or especially two polymorphic alleles showed a significant higher exercise performance compared with those patients homozygous for the wild type. Conclusions: In contrast to a previous study in heart failure patients, after coarctation repair adults had a better exercise capacity with the G allele of the ß2-receptor c.46A > G polymorphism. Therefore, the exercise capacity of coarctation patients does not profit from an enhanced down regulation of their beta receptors.
- Training prescription in patients on beta-blockers: perce... Background: Exercise prescription based on percentage of peak exercise variables has many limitations in patients taking beta-blockers. The aim of this study was to evaluate efficacy and safety of a training protocol based on the rating of perceived exercise (RPE) in patients taking beta-blockers after cardiac surgical revascularization. Design and methods: 71 patients treated with beta-blockers after recent coronary artery bypass grafting were randomly allocated to two different programmes with training intensity adjusted to keep heart rate close to first ventilatory threshold (36 subjects, AeT group) or RPE between grades 4 and 5 of 10-point category-ratio BORG scale (35 subjects, RPE group). Results: In the RPE group, mean training workloads and heart rate values were significantly higher than in the AeT group; during the last week of the programme, six RPE patients were training very close to anaerobic threshold. Aerobic peak capacity increased similarly in the two groups. Considering the potential effects on training intensity of prescriptions based on percentages of peak exercise variables, we found that only percentage heart rate reserve and peak workload methods were reliable in defining a safe upper limit of training intensity, with values of 50% and 65% respectively. Conclusions: Self-regulation of exercise training intensity between grades 4 and 5 of the 10-point category-ratio BORG scale is effective but may promote overtraining in some patients without significant functional advantages. For these reasons, RPE method should be integrated with objective indices based on percentage of heart rate reserve or of peak workload.
Clinical and Applied Thrombosis/Hemostasis
- Meta-Regression Analysis to Indirectly Compare Prophylaxi... Background: Dalteparin and enoxaparin are recommended as thromboprophylaxis for at least 10 days in patients undergoing abdominal surgery (AS) or hospitalized patients with acute medical illnesses. Even though both agents have proven clinical effectiveness through randomized trials, there have been no head-to-head studies. In this evaluation, indirect statistical techniques were used to compare safety and efficacy between dalteparin and enoxaparin in these 2 high-risk patient populations. Methods: A literature search was conducted from January 1980 to November 2010 for randomized trials evaluating dalteparin or enoxaparin prophylaxis following AS or in hospitalized patients. Binary outcomes for safety and efficacy were statistically pooled using fixed or random effects models in cases of significant heterogeneity. In trials where a common control was used (eg, unfractionated heparin [UH]), indirect statistical comparisons between dalteparin and enoxaparin were performed using meta-regression analysis with active drug as the primary independent variable. Results: The meta-analysis in AS patients showed that enoxaparin or dalteparin had comparable efficacy to UH in terms of venous thromboembolic events (VTEs; relative risk reduction [RR] = 0.87, P = .46). The indirect statistical comparison was unable to find significant differences between enoxaparin and dalteparin in terms of risk for VTE (P = .84), major bleeding (P = .38), heparin-induced thrombocytopenia ([HIT]; P = .084), or death (P = .97). In acutely ill medical patients, treatment with enoxaparin or dalteparin had a 52% VTE risk reduction compared to placebo (RR = 0.48, P < .001). The indirect comparison was also unable to find significant differences between enoxaparin and dalteparin in terms of VTEs (P = .15), major bleeds (P = .39), HIT (P = .48), and death (P = .41). Conclusions: The findings suggest comparable safety and efficacy between dalteparin and enoxaparin in AS and in acutely ill medical patients.
- Cross-Reactivity of Various Thrombin Products With Anti-R... JMI-thrombin is used as topical hemostatic agent. While earlier clinically available JMI were reported to produce immunologic responses upon repeated exposure, the improved JMI, Recothrom?, and Evithrom? are claimed to be less immunogenic. Recothrom, despite its reduced immunogenic nature, upon repeated administration may result in the generation of antibodies (Abs) and that may cross react with bovine and human thrombin. Therefore, groups of rabbits were challenged repeatedly with Recothrom, Evithrom, and JMI over a 9-month period. Pre-immune blood and antiserum were collected from each rabbit on different time point. To determine their relative cross reactivity, JMI, Recothrom, and Evithrom were evaluated by western blotting using the rabbit IgG fractions. The results suggest that anti-Recothrom Abs cross-react with Evithrom and JMI in a time dependent fashion. Anti-JMI Abs did not cross-react with Recothrom, and Evithrom. Also, anti-Evithrom did not show any cross-reactivity with Recothrom and JMI at any time.
- Platelet Function Profile Post-Clopidogrel Therapy in Pat... Platelet dysfunction contributes to the increased risk of thromboischemic complications after percutaneous coronary intervention (PCI), particularly in type 2 diabetes. Little is known about the effects of glycemic control on platelet reactivity. We assessed adenosine diphosphate-induced platelet aggregation and flow cytometric expression of P-selectin in 90 patients (56 diabetic and 34 nondiabetic patients) undergoing coronary stent implantation after administration of clopidogrel as a potential predictor of poststent complications and its relation to glycemic control. Posttreatment platelet reactivity was significantly elevated in diabetic compared with nondiabetic participants and was associated with smoking, hypercholesterolemia, overweight, and cardiovascular ischemic events. A linear relationship was found between hemoglobin A1c in diabetic patients and platelet reactivity. Both methods (standard aggregometry and P-selectin expression) used for assessment of platelet function were positively correlated. Low responsiveness to clopidogrel detected by posttreatment platelet reactivity is a risk factor for ischemic events after PCI in diabetic patients.
- Deep Venous Thrombosis in Acute Stroke Patients Deep venous thrombosis (DVT) is a complication of stroke. Our aim was to determine the frequency of DVT in patients with acute stroke, risk factors for its development, and its influence on the 3-month outcome. A total of 323 consecutive patients with acute stroke were enrolled. We performed ultrasound imaging within 7 days after stroke. Deep venous thrombosis was found in 8.7% of patients, only in those with ischemic stroke. Patients with DVT were more frequently female (71.4% vs 49.5%), had prestroke Modified Rankin scale (mRS) 3 to 5 (42.9% vs 15.3%), elevated C-reactive protein (CRP) serum level (65.4% vs 32.5%), and a trend toward elevated serum fibrinogen level (85.7% vs 70.1%; P = .08). In a multivariate analysis, elevated CRP (odds ratio [OR] 3.15) and prestroke disability (OR 2.89) were independent risk factors for DVT. Deep venous thrombosis occurs in <10% of patients with acute stroke and does not significantly affect the 3-month outcome. Prestroke dependency and elevated CRP level at baseline are independent risk factors for DVT.
- Prevention of Venous Thromboembolism Using Enoxaparin in ... We aimed to confirm the results of randomized, controlled trials on enoxaparin prophylaxis in unselected patients undergoing day surgery. The primary end point was the incidence of thromboembolic events during prophylaxis and up to 48 hours thereafter. A total of 11 794 patients, consisting of 52.1% male with mean age of 49.2 ± 15.7 were included. In all, 61.5% had no predisposing risk factors and 67.1% received no concomitant medication with the potential to increase bleeding. Patients were exposed to 20 mg (63.6%) and 40 mg (36.4%) of enoxaparin for a mean of 12.4 ± 9.8 days. Forty-four patients (0.39%) had confirmed symptomatic deep venous thrombosis and 1 patient confirmed pulmonary embolism. Bleeding occurred in 3.47% of patients (3.29% minor bleeding). Differences between 20 and 40 mg enoxaparin were negligible. Adverse drug reactions were experienced by 3.1% of patients. The present study results demonstrate that it is effective and tolerable to use a risk stratified dose of 20 or 40 mg enoxaparin in patients undergoing day surgery.
- Causes of Thrombocytopenia in Chronic Hepatitis C Viral I... We retrospectively studied 89 patients with chronic hepatitis C virus (HCV) infection, including 50 chronic hepatitis (CH) cases, 18 liver cirrhosis (LC) cases, and 21 LC with hepatocellular carcinoma (LC + HCC) cases, with regard to various factors related with thrombocytopenia. The platelet count decreased with the stage advancement of liver diseases. Multiple regression analysis revealed that splenomegaly and von Willebrand factor (vWF) were explanatory variables that correlated with thrombocytopenia. Splenomegaly appears to be the most responsible factor, although there are a considerable number of thrombocytopenic cases without splenomegaly, suggesting other factors may also be responsible. The vWF level is inversely correlated with the platelet count. Soluble thrombomodulin, a marker of endothelial dysfunction, increases with the advancement of liver fibrosis. It is positively correlated with vWF and inversely with the platelet count. Our present results imply that vascular endothelial dysfunction is also involved in thrombocytopenia during chronic HCV infection.
- Long-Term Outcomes in Acute Pulmonary Thromboembolism: Th... The long-term outcomes of pulmonary thromboembolism (PTE) and/or incidence of chronic thromboembolic pulmonary hypertension (CTEPH) are not well documented. Three hundred twenty-five consecutive cases objectively diagnosed with PTE monitored for an average 16.3 months (6-50.7 months) were investigated. Data concerning recurrence, residual thrombus, mortality, and CTEPH in particular were collected. Chronic thromboembolic pulmonary hypertension frequency acute first episode of PTE was 4.6%. Chronic thromboembolic pulmonary hypertension developed within 12 months after PTE attack in approximately 80% of patients and it did not occur after 2 years. Residual chronic thrombus was determined at the 3rd month in 48% of cases post-PTE, at the 6th month in 27.4%, and at the 12th month in 18.2%. At multivariate regression analysis, systolic pulmonary arterial pressure > 50 mm Hg, hazard ratio: 10.1 (95% confidence interval: 4.1-71.2) were predictors of CTEPH. Chronic thromboembolic pulmonary hypertension develops as a serious complication in a significant number of cases with PTE. Closer monitoring of high-risk cases in particular is important in terms of early diagnosis and treatment.
- Increased Plasma Soluble Thrombomodulin Levels in Cardioe... Soluble thrombomodulin (sTM) has been proposed as a potential marker of ischemic stroke. Results from previous studies remain controversial among different populations. We performed an analysis of plasma levels of sTM in Thai patients with acute ischemic stroke and determined whether sTM levels correlate with stroke subtypes, severity, and risk factors. Ninety-three patients and 76 controls were enrolled. Blood samples were obtained within 24 hours after stroke onset. Plasma sTM levels, measured using quantitative enzyme-linked immunosorbent assay, were significantly higher in patients than controls (P < .005), with the mean ±standard deviation (SD) levels of 3.08 ± 1.05 and 2.57 ± 1.15 ng/mL, respectively. Plasma levels of sTM in patients with cardioembolic subtype were significantly higher than in patients with other stroke subtypes, with the mean ± SD levels of 3.79 ± 1.26, 2.38 ± 0.68 (P < .009), and 2.38 ± 0.44 (P < .05) ng/mL for cardioembolism, large artery atherosclerosis, and small artery occlusion, respectively. Plasma sTM levels were not associated with stroke severity and risk factors of stroke; however, there was a slight relationship between high sTM levels and the presence of atrial fibrillation in the patient group. In conclusion, plasma sTM levels were increased in Thai patients with cardioembolic stroke and may be a potential marker during the acute phase.
- A Comparison of the Pharmacodynamic Behavior of Branded a... Pharmacodynamic behavior of branded and biosimilar enoxaparin was compared in a crossover study in primates. Blood samples collected at baseline and at 1, 4, 6, and 28 hours post-subcutaneous administration of Lovenox or Fibrinox were evaluated using clot-based and amidolytic assays. Anti-Xa levels following Fibrinox and Lovenox administration were not different. Anti-IIa levels were significantly higher in Lovenox-treated animals 1 to 6 hours post-administration. Higher drug levels were measured by Heptest in Fibrinox-treated animals from 4 to 6 hours. Pharmacokinetic differences were not observed using anti-Xa or Heptest assays. The area under the curve (anti-IIa) following Lovenox treatment was significantly larger than following Fibrinox treatment. When drug levels (anti-IIa) were plotted against anti-Xa or Heptest drug levels, a hysteretic relationship which was distinct for Fibrinox- and Lovenox-treated primates was observed suggesting a lack of bioequivalence for the low-molecular-weight heparin tested. In vivo behavior is an important consideration for defining pharmacoequivalence of complex biologic drugs.
- Compliance With Antithrombotic Guidelines in Surgery Pati... Despite the existence of antithrombotic guidelines, there is low compliance with these guidelines in clinical practice. Until now pharmacy interns (PIs) have not been involved in this process. The objectives were to involve PIs to evaluate compliance with antithrombotic guidelines for VTE prophylaxis in surgery patients, and in cases of noncompliance to carry out pharmaceutical interventions. The study was conducted in 7 hospitals in Germany involving 27 PIs within the project "Pharmacy interns on the ward" (P-STAT 2). Pharmacy interns determined the thromboembolic risk, documented antithrombotic medication, and checked the compliance with current antithrombotic guidelines. A total of 6491 patients were enrolled; 5695 patients received antithrombotic prophylaxis. Antithrombotic guideline was followed in 77.5% patients. Many patients are not receiving appropriate VTE prophylaxis or heparin bridging regimen despite the fact that evidence-based antithrombotic guidelines are available. Pharmacy interns may play an important role in antithrombotic management.
Angiogenesis
- Dual action of TGF-β induces vascular growth in vivo thr... Abstract The role of Transforming growth factor β (TGF-β) as a regulator of blood vessel endothelium is complicated and controversial, and the mechanisms by which TGF-β is able to induce angiogenesis in vivo are not well understood. Here we show that TGF-β causes in vivo a massive recruitment of tissue infiltrating hematopoietic cells. Concurrently, TGF-β induces strong vascular endothelial growth factor (VEGF) production in the recruited hematopoietic cells, resulting in activated angiogenesis and vascular remodeling. TGF-β also promoted abnormalities of α-smooth muscle actin-expressing pericytes on angiogenic capillaries. TGF-β-induced angiogenic effect was inhibited by a systemic treatment with VEGF-neutralizing antibodies. When studied in isolated human hematopoietic cells, physiological concentrations of TGF-β stimulated VEGF mRNA and protein expression in a dose- and time-dependent manner. This induction was p38 and p44/p42 mitogen activated kinase dependent. p38 and p44/p42 activation was also observed in vivo in TGF-β–treated angiogenic murine tissues. Taken together, our results provide a dual action mechanism by which TGF-β promotes angiogenesis in vivo via recruitment of paracrine VEGF-expressing hematopoietic effector cells. This mechanism may activate vascular growth and remodeling during inflammatory conditions and tumor growth when TGF-β activity is upregulated. Content Type Journal ArticleCategory Original PaperPages 1-9DOI 10.1007/s10456-012-9278-9Authors Shentong Fang, Department of Pathology and Research Programs, University of Helsinki, POB 63, 00014 Helsinki, FinlandNalle Pentinmikko, Department of Pathology and Research Programs, University of Helsinki, POB 63, 00014 Helsinki, FinlandMaritta Ilmonen, Department of Pathology and Research Programs, University of Helsinki, POB 63, 00014 Helsinki, FinlandPetri Salven, Department of Pathology and Research Programs, University of Helsinki, POB 63, 00014 Helsinki, Finland Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Erratum to: The elevation in maternal anti-angiogenic fac... Abstract Background Severe preeclampsia is associated with increased neutrophil activation and elevated serum soluble endoglin (sEng) and soluble Flt-1 (sFlt-1) in the maternal circulation. To dissect the contribution of systemic inflammation and anti-angiogenic factors in preeclampsia, we investigated the relationships between the circulating markers of neutrophil activation and anti-angiogenic factors in severe preeclampsia or systemic inflammatory state during pregnancy. Methods and results Serum sEng, sFlt-1, placenta growth factor (PlGF), interleukin-6 (IL-6), calprotectin, and plasma α-defensins were measured by ELISA in 88 women of similar gestational age stratified as: severe preeclampsia (sPE, n = 45), maternal systemic inflammatory response (SIR, n = 16) secondary to chorioamnionitis, pyelonephritis or appendicitis, and normotensive controls (CRL, n = 27). Neutrophil activation occurred in sPE and SIR, as α-defensins and calprotectin concentrations were two-fold higher in both groups compared to CRL (P < 0.05 for each). IL-6 concentrations were highest in SIR (P < 0.001) but were higher in sPE than in CRL (P < 0.01). sFlt-1 (P < 0.001) and sEng (P < 0.001) were ≈20-fold higher in sPE compared to CRL, but were not elevated in SIR. In women with sPE, anti-angiogenic factors were not correlated with markers of neutrophil activation (α-defensins and calprotectin) or inflammation (IL-6). Conclusions Increased systemic inflammation in sPE and SIR does not correlate with increased anti-angiogenic factors, which were specifically elevated in sPE indicating that excessive systemic inflammation is unlikely to be the main contributor to severe preeclampsia. Content Type Journal ArticleCategory ErratumPages 1-8DOI 10.1007/s10456-012-9273-1Authors Wenda Ramma, University/BHF Centre for Cardiovascular Sciences, Queen’s Medical Research Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ UKIrina A. Buhimschi, Department of Obstetrics, Gynecology and Reproductive Science, Yale University, New Haven, CT 06520, USAGuomao Zhao, Department of Obstetrics, Gynecology and Reproductive Science, Yale University, New Haven, CT 06520, USAAntonette T. Dulay, Department of Obstetrics, Gynecology and Reproductive Science, Yale University, New Haven, CT 06520, USAUnzila Ali Nayeri, Department of Obstetrics, Gynecology and Reproductive Science, Yale University, New Haven, CT 06520, USACatalin S. Buhimschi, Department of Obstetrics, Gynecology and Reproductive Science, Yale University, New Haven, CT 06520, USAAsif Ahmed, University/BHF Centre for Cardiovascular Sciences, Queen’s Medical Research Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ UK Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Endothelial cell-fatty acid binding protein 4 promotes an... Abstract Fatty acid binding protein 4 (FABP4) plays an important role in regulation of glucose and lipid homeostasis as well as inflammation through its actions in adipocytes and macrophages. FABP4 is also expressed in a subset of endothelial cells, but its role in this cell type is not known. We found that FABP4-deficient human umbilical vein endothelial cells (HUVECs) demonstrate a markedly increased susceptibility to apoptosis as well as decreased migration and capillary network formation. Aortic rings from FABP4−/− mice demonstrated decreased angiogenic sprouting, which was recovered by reconstitution of FABP4. FABP4 was strongly regulated by mTORC1 and inhibited by Rapamycin. FABP4 modulated activation of several important signaling pathways in HUVECs, including downregulation of P38, eNOS, and stem cell factor (SCF)/c-kit signaling. Of these, the SCF/c-kit pathway was found to have a major role in attenuated angiogenic activity of FABP4-deficient ECs as provision of exogenous SCF resulted in a significant recovery in cell proliferation, survival, morphogenesis, and aortic ring sprouting. These data unravel a novel pro-angiogenic role for endothelial cell-FABP4 and suggest that it could be exploited as a potential target for diseases associated with pathological angiogenesis. Content Type Journal ArticleCategory Original PaperPages 1-12DOI 10.1007/s10456-012-9274-0Authors Harun Elmasri, Division of Neonatology, Brigham and Women’s Hospital, Harvard Medical School, Thorn 1019, 75 Francis Street, Boston, MA, USAElisa Ghelfi, Division of Neonatology, Brigham and Women’s Hospital, Harvard Medical School, Thorn 1019, 75 Francis Street, Boston, MA, USAChen-wei Yu, Division of Neonatology, Brigham and Women’s Hospital, Harvard Medical School, Thorn 1019, 75 Francis Street, Boston, MA, USASamantha Traphagen, Division of Neonatology, Brigham and Women’s Hospital, Harvard Medical School, Thorn 1019, 75 Francis Street, Boston, MA, USAManuela Cernadas, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAHaiming Cao, Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, MA, USAGuo-Ping Shi, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAJorge Plutzky, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USAMustafa Sahin, Department of Neurology, The F.M. Kirby Neurobiology Center, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USAGokhan Hotamisligil, Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, MA, USASule Cataltepe, Division of Neonatology, Brigham and Women’s Hospital, Harvard Medical School, Thorn 1019, 75 Francis Street, Boston, MA, USA Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Vascular adaptation to a dysfunctional endothelium as a c... Abstract Vascular endothelial growth factor (VEGF)-A regulates angiogenesis, vascular morphology and permeability by signaling through its receptor VEGFR-2. The Shb adapter protein has previously been found to relay certain VEGFR-2 dependent signals and consequently vascular physiology and structure was assessed in Shb knockout mice. X-ray computed tomography of vessels larger than 24 μm diameter (micro-CT) after contrast injection revealed an increased frequency of 48–96 μm arterioles in the hindlimb calf muscle in Shb knockout mice. Intravital microscopy of the cremaster muscle demonstrated a less regular vasculature with fewer branch points and increased vessel tortuosity, changes that led to an increased blood flow velocity. Reduced in vivo angiogenesis was observed in Shb knockout Matrigel™ plugs. Unlike the wild-type situation, VEGF-A did not provoke a dissociation of VE-cadherin from adherens junctions in Shb knockout venules. The reduced angiogenesis and altered properties of junctions had consequences for two patho-physiological responses to arterial occlusion: vascular permeability was reduced in the Shb knockout cremaster muscle after ligation of one supplying artery and heat-induced blood flow determined by Laser-Doppler measurements was decreased in the hindlimb after ligation of the femoral artery. Consequently, the Shb knockout mouse exhibited structural and functional (angiogenesis and vascular permeability) vascular abnormalities that have implications for understanding the function of VEGF-A under physiological conditions. Content Type Journal ArticleCategory Original PaperPages 1-12DOI 10.1007/s10456-012-9275-zAuthors Gustaf Christoffersson, Department of Medical Cell Biology, Uppsala University, Box 571, Husargatan 3, 75123 Uppsala, SwedenGuangxiang Zang, Department of Medical Cell Biology, Uppsala University, Box 571, Husargatan 3, 75123 Uppsala, SwedenZhen W. Zhuang, Department of Cardiovascular Medicine, Yale University, New Haven, CT, USAEvelina Vågesjö, Department of Medical Cell Biology, Uppsala University, Box 571, Husargatan 3, 75123 Uppsala, SwedenMichael Simons, Department of Cardiovascular Medicine, Yale University, New Haven, CT, USAMia Phillipson, Department of Medical Cell Biology, Uppsala University, Box 571, Husargatan 3, 75123 Uppsala, SwedenMichael Welsh, Department of Medical Cell Biology, Uppsala University, Box 571, Husargatan 3, 75123 Uppsala, Sweden Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Quantitative assessment of tumor angiogenesis using real-... Abstract Purpose To develop and test a real-time motion compensation algorithm for contrast-enhanced ultrasound imaging of tumor angiogenesis on a clinical ultrasound system. Materials and methods The Administrative Institutional Panel on Laboratory Animal Care approved all experiments. A new motion correction algorithm measuring the sum of absolute differences in pixel displacements within a designated tracking box was implemented in a clinical ultrasound machine. In vivo angiogenesis measurements (expressed as percent contrast area) with and without motion compensated maximum intensity persistence (MIP) ultrasound imaging were analyzed in human colon cancer xenografts (n = 64) in mice. Differences in MIP ultrasound imaging signal with and without motion compensation were compared and correlated with displacements in x- and y-directions. The algorithm was tested in an additional twelve colon cancer xenograft-bearing mice with (n = 6) and without (n = 6) anti-vascular therapy (ASA-404). In vivo MIP percent contrast area measurements were quantitatively correlated with ex vivo microvessel density (MVD) analysis. Results MIP percent contrast area was significantly different (P < 0.001) with and without motion compensation. Differences in percent contrast area correlated significantly (P < 0.001) with x- and y-displacements. MIP percent contrast area measurements were more reproducible with motion compensation (ICC = 0.69) than without (ICC = 0.51) on two consecutive ultrasound scans. Following anti-vascular therapy, motion-compensated MIP percent contrast area significantly (P = 0.03) decreased by 39.4 ± 14.6 % compared to non-treated mice and correlated well with ex vivo MVD analysis (Rho = 0.70; P = 0.05). Conclusion Real-time motion-compensated MIP ultrasound imaging allows reliable and accurate quantification and monitoring of angiogenesis in tumors exposed to breathing-induced motion artifacts. Content Type Journal ArticleCategory Original PaperPages 1-10DOI 10.1007/s10456-012-9271-3Authors Marybeth A. Pysz, Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Room H1307, Stanford, CA, USAIsmayil Guracar, Siemens Healthcare, Ultrasound Business Unit, Mountain View, CA, USAKira Foygel, Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Room H1307, Stanford, CA, USALu Tian, Department of Health, Research and Policy, Stanford University, Stanford, CA, USAJürgen K. Willmann, Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Room H1307, Stanford, CA, USA Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Equal modulation of endothelial cell function by four dis... Abstract Mesenchymal stem cells (MSCs) can generate multiple end-stage mesenchymal cell types and constitute a promising population of cells for regenerative therapies. Additionally, there is increasing evidence supporting other trophic activities of MSCs, including the ability to enable formation of vasculature in vivo. Although MSCs were originally isolated from the bone marrow, the presence of these cells in the stromal vascular fraction of multiple adult tissues has been recently recognized. However, it is unknown whether the capacity to modulate vasculogenesis is ubiquitous to all MSCs regardless of their tissue of origin. Here, we demonstrated that tissue-resident MSCs isolated from four distinct tissues have equal capacity to modulate endothelial cell function, including formation of vascular networks in vivo. MSCs were isolated from four murine tissues, including bone marrow, white adipose tissue, skeletal muscle, and myocardium. In culture, all four MSC populations secreted a plethora of pro-angiogenic factors that unequivocally induced proliferation, migration, and tube formation of endothelial colony-forming cells (ECFCs). In vivo, co-implantation of MSCs with ECFCs into mice generated an extensive network of blood vessels with ECFCs specifically lining the lumens and MSCs occupying perivascular positions. Importantly, there were no differences among all four MSCs evaluated. Our studies suggest that the capacity to modulate the formation of vasculature is a ubiquitous property of all MSCs, irrespective of their original anatomical location. These results validate multiple tissues as potential sources of MSCs for future cell-based vascular therapies. Content Type Journal ArticleCategory Original PaperPages 1-13DOI 10.1007/s10456-012-9272-2Authors Ruei-Zeng Lin, Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, USARafael Moreno-Luna, Unidad Clínico-Experimental de Riesgo Vascular (UCAMI-UCERV), Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, and Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, SpainBin Zhou, Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, USAWilliam T. Pu, Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, USAJuan M. Melero-Martin, Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave., Enders 349, Boston, MA 02115, USA Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Inhibition of ARNT severely compromises endothelial cell ... Abstract Hypoxia inducible factor (HIF) is a master heterodimeric transcriptional regulator of oxygen (O2) homeostasis critical to proper angiogenic responses. Due to the distinctive coexpression of HIF-1α and HIF-2α subunits in endothelial cells, our goal was to examine the genetic elimination of HIF transcriptional activity in response to physiological hypoxic conditions by using a genetic model in which the required HIF-β subunit (ARNT, Aryl hydrocarbon Receptor Nuclear Translocator) to HIF transcriptional responses was depleted. Endothelial cells (ECs) and aortic explants were isolated from Arnt loxP/loxP mice and infected with Adenovirus-Cre/GFP or control-GFP. We observed that moderate levels of 2.5 % O2 promoted vessel sprouting, growth, and branching in control aortic ring assays while growth from Adenovirus-Cre infected explants was compromised. Primary Adenovirus-Cre infected EC cultures featured adverse migration and tube formation phenotypes. Primary pulmonary or cardiac ARNT-deleted ECs also failed to proliferate and survive in response to 8 or 2.5 % O2 and hydrogen peroxide treatment. Our data demonstrates that ARNT promotes EC migration and vessel outgrowth and is indispensible for the proliferation and preservation of ECs in response to the physiological environmental cue of hypoxia. Thus, these results demonstrate that ARNT plays a critical intrinsic role in ECs and support an important collaboration between HIF-1 and HIF-2 transcriptional activity in these cells. Content Type Journal ArticleCategory Original PaperPages 1-12DOI 10.1007/s10456-012-9269-xAuthors Yu Han, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USAKe Yang, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USAAaron Proweller, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USAGuangjin Zhou, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USAMukesh K. Jain, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USADiana L. Ramirez-Bergeron, Case Cardiovascular Research Institute, Department of Medicine, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, 2103 Cornell Road, Rm. 4-532, Cleveland, OH 44106, USA Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Semaphorin 4D cooperates with VEGF to promote angiogenesi... Abstract The semaphorins and plexins comprise a family of cysteine-rich proteins implicated in control of nerve growth and development and regulation of the immune response. Our group and others have found that Semaphorin 4D (SEMA4D) and its receptor, Plexin-B1, play an important role in tumor-induced angiogenesis, with some neoplasms producing SEMA4D in a manner analogous to vascular endothelial growth factor (VEGF) in order to attract Plexin-B1-expressing endothelial cells into the tumor for the purpose of promoting growth and vascularity. While anti-VEGF strategies have been the focus of most angiogenesis inhibition research, such treatment can lead to upregulation of pro-angiogenic factors that can compensate for the loss of VEGF, eventually leading to failure of therapy. Here, we demonstrate that SEMA4D cooperates with VEGF to promote angiogenesis in malignancies and can perform the same function in a setting of VEGF blockade. We also show the potential value of inhibiting SEMA4D/Plexin-B1 signaling as a complementary mechanism to anti-VEGF treatment, particularly in VEGF inhibitor–resistant tumors, suggesting that this may represent a novel treatment for some cancers. Content Type Journal ArticleCategory Original PaperPages 1-17DOI 10.1007/s10456-012-9268-yAuthors Hua Zhou, Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, 650 West Baltimore Street, 7-North, Baltimore, MD 21201, USANada O. Binmadi, Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, 650 West Baltimore Street, 7-North, Baltimore, MD 21201, USAYing-Hua Yang, Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, 650 West Baltimore Street, 7-North, Baltimore, MD 21201, USAPatrizia Proia, Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, 650 West Baltimore Street, 7-North, Baltimore, MD 21201, USAJohn R. Basile, Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, 650 West Baltimore Street, 7-North, Baltimore, MD 21201, USA Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Niacin improves ischemia-induced neovascularization in di... Abstract Niacin was shown to inhibit acute vascular inflammation and improves endothelial dysfunction independent of changes in plasma lipids. Here, we investigated whether niacin can increase blood flow recovery after tissue ischemia by enhancing endothelial progenitor cell (EPC) functions in diabetic mice. Starting at 4 weeks after the onset of diabetes, vehicle or niacin (40 mg/kg/day) was administered daily by gavage to streptozotocin (STZ)-induced diabetic mice and diabetic endothelial nitric oxide synthase (eNOS)-deficient mice. Unilateral hindlimb ischemia surgery was conducted after 2 weeks of vehicle or niacin treatment. Compared to the control group, the niacin group had significantly increased ischemic/non-ischemic limb blood perfusion ratio and higher capillary density. These effects were markedly reduced in STZ-induced diabetic eNOS-deficient mice. Flow cytometry analysis showed impaired EPC-like cell (Sca-1+/Flk-1+) mobilization after ischemia surgery in diabetic mice but augmented mobilization in the mice treated with niacin. Diabetes was induced by administering STZ to FVB mice that received eGFP mouse bone marrow cells to evaluate effects of niacin on bone marrow-derived EPC homing and differentiation to endothelial cells. Differentiation of bone marrow-derived EPCs to endothelial cells in the ischemic tissue around vessels in diabetic mice that received niacin treatment, was significantly increased than that in control group. By in vitro studies, incubation with niacin in high-glucose medium reduced H2O2 production, cell apoptosis, and improved high glucose-suppressed EPC functions by nitric oxide-related mechanisms. Our findings demonstrate that niacin increases blood flow recovery after tissue ischemia in diabetic mice through enhancing EPC mobilization and functions via nitric oxide-related pathways. Content Type Journal ArticleCategory Original PaperPages 1-13DOI 10.1007/s10456-012-9267-zAuthors Po-Hsun Huang, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, TaiwanChih-Pei Lin, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, TaiwanChao-Hung Wang, Institute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanChia-Hung Chiang, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, TaiwanHsiao-Ya Tsai, Institute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanJia-Shiong Chen, Institute and Department of Pharmacology, National Yang-Ming University, Taipei, TaiwanFeng-Yen Lin, Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei, TaiwanHsin-Bang Leu, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, TaiwanTao-Cheng Wu, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, TaiwanJaw-Wen Chen, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, TaiwanShing-Jong Lin, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
- Resveratrol and its synthetic derivatives exert opposite ... Abstract We examined the effect of resveratrol (RVT) and its two derivatives (3,3′,4,4′-tetrahydroxy-trans-stilbene and 3,3′,4,4′,5,5′-hexahydroxy-trans-stilbene) on human peritoneal mesothelial cell (HPMC)-dependent angiogenesis in vitro. To this end, angiogenic activity of endothelial cells (HUVEC, HMVEC, and HMEC-1) was monitored upon their exposure to conditioned medium (CM) from young and senescent HPMCs treated with stilbenes or to stilbenes themselves. Results showed that proliferation and migration of endothelial cells were inhibited in response to indirect (HPMC-dependent) or direct RVT activity. This effect was associated with decreased secretion of VEGF and IL-8/CXCL8 by HPMCs treated with RVT, which confirmed the experiments with recombinant forms of these angiogenic agents. Angiogenic activity of endothelial cells treated with CM from HPMCs exposed to RVT analogues was more effective. Improved migration was particularly evident in cells exposed to CM from senescent HPMCs. Upon direct treatment, RVT derivatives stimulated proliferation (but not migration) of HUVECs, and failed to affect the behaviour of HMVEC and HMEC-1 cells. These compounds stimulated production of VEGF and IL-8/CXCL8 by HPMCs. Studies with neutralizing antibodies against angiogenic factors revealed that augmented angiogenic reactions of endothelial cells exposed to CM from HPMC treated with RVT analogues were related to enhanced production of VEGF and IL-8/CXCL8. Collectively, these findings indicate that RVT and its synthetic analogues divergently alter the secretion of the angiogenic factors by HPMCs, and thus modulate HPMC-dependent angiogenic responses in the opposite directions. This may have implications for the attempts of practical employment of the stilbenes for treatment of pathologies proceeding with abnormal vascularisation of the peritoneal tissue. Content Type Journal ArticleCategory Original PaperPages 1-16DOI 10.1007/s10456-012-9266-0Authors Justyna Mikuła-Pietrasik, Department of Pathophysiology, Poznań University of Medical Sciences, Święcickiego 6 Str., 60-781 Poznań, PolandAngelika Kuczmarska, Department of Pathophysiology, Poznań University of Medical Sciences, Święcickiego 6 Str., 60-781 Poznań, PolandMałgorzata Kucińska, Department of Toxicology, Poznań University of Medical Sciences, Dojazd 30 Str., 60-631 Poznań, PolandMarek Murias, Department of Toxicology, Poznań University of Medical Sciences, Dojazd 30 Str., 60-631 Poznań, PolandMarcin Wierzchowski, Department of Pharmaceutical Technology of Drugs, Poznań University of Medical Sciences, Grunwaldzka 6 Str., 60-780 Poznań, PolandMarek Winckiewicz, Department of General and Vascular Surgery, Poznań University of Medical Sciences, Długa 1, 61-848 Poznań, PolandRyszard Staniszewski, Department of General and Vascular Surgery, Poznań University of Medical Sciences, Długa 1, 61-848 Poznań, PolandAndrzej Bręborowicz, Department of Pathophysiology, Poznań University of Medical Sciences, Święcickiego 6 Str., 60-781 Poznań, PolandKrzysztof Książek, Department of Pathophysiology, Poznań University of Medical Sciences, Święcickiego 6 Str., 60-781 Poznań, Poland Journal AngiogenesisOnline ISSN 1573-7209Print ISSN 0969-6970
Journal of Vascular Surgery
- Cyber medicine enables remote neuromonitoring during aort... Objective: This study assessed the feasibility and effectiveness of remote neuromonitoring as an adjunct to spinal cord protection during surgical repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. Methods: Four aortic centers in three European countries participated in this prospective observational study. A similar surgical protocol was used in all centers, including assessment of spinal cord function by means of monitoring motor-evoked potentials (MEPs). MEP information was evaluated at one central neurophysiologic department in Maastricht, The Netherlands. Transfer of MEP data from all operating rooms to Maastricht was arranged by Internet connections. In all patients, the protective and surgical strategies to prevent paraplegia were based on MEPs. The on-site surgeons reacted in real time to the interpretation and feedback of the neurophysiologist. Results: Between March 2009 and May 2011, 130 patients (85 men) were treated by open surgical repair. Extent of aneurysms was equally distributed among the centers. Neuromonitoring was technically stabile and successful in all patients. The transfer of data from the operating room in the different vascular centers was undisturbed and without any technical problems. By maintaining a mean distal aortic pressure of 60 mm Hg, MEPs were undisturbed in 65 patients (50%). In another 65 patients (50%), significant changes in MEPs prompted the surgical teams to initiate additional protective and surgical strategies to restore spinal cord perfusion. These measures were not effective in five patients (3.8%), and acute paraplegia resulted. Delayed paraplegia occurred in 10 patients (7.7%) but improved in three and recovered completely in another three. No false-negative or false-positive MEP recordings were experienced. Conclusions: Remote neuromonitoring of spinal cord function during open repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms as a telemedicine technique is feasible and effective. It allows centralization of expertise and saves individual centers from investing in complex technology. The value of monitoring MEPs was confirmed in different aortic centers, resulting in adequate neurologic outcome after extensive aortic surgical procedures.
- Discussion Dr Richard Cambria (Boston, Mass). Was there a uniform surgical protocol for how to react to changes in motor-evoked potential monitoring across the four centers? Dr Michael Jacobs. Indeed, all surgeons from the different centers came to us and we agreed on the protocol, including cerebrospinal fluid (CSF) drainage and distal aortic perfusion, but also the strategic interventions when evoked potentials would disappear. The first logical step is to increase mean arterial and distal aortic pressure. The second step includes reattachment of intercostal arteries. Extremely important is that the anesthesiologists are well trained and well informed, because the equilibrium between anesthesia and evoked potentials is extremely sensitive. For example, if the patient receives too much muscle relaxant, evoked potentials are unreliable.
- Invited commentary Dr Jacobs and his colleagues are to be commended for this first of a kind enterprise using cyber medicine to provide remote neuromonitoring of motor evoked potentials during open thoracoabdominal aortic aneurysm repair. The authors have previously reported extensively on the use of motor evoked potentials as an adjunct for spinal cord protection during these procedures. The complexity, learning curve, and cost have limited the use of this mode of monitoring to a few tertiary centers around the world. With this study, the authors have demonstrated not only the feasibility of a central core center providing this mode of real-time neuromonitoring remotely but also its effectiveness by having achieved similar low rates of spinal cord ischemic complications in the peripheral centers as their own.
- Endovascular treatment of acute and chronic aortic pathol... Background: In patients with Marfan syndrome, the complications of aortic degeneration, including dissection, aneurysm, and rupture represent the main cause of mortality. Although contemporary management of ascending aortic disease requires open surgical reconstruction, endovascular repair is now available for management of descending thoracic and abdominal aortic pathology (ie, thoracic endovascular aortic repair [TEVAR], endovascular aneurysm repair [EVAR]). The short- and long-term benefit of endovascular repair in Marfan patients remains largely unproven. We examine our outcomes after EVAR in this patient population. Methods: All patients with a diagnosis of Marfan syndrome who were treated with TEVAR/EVAR were evaluated in a retrospective review. Perioperative, procedure-specific and patient covariate data were aggregated. Primary endpoints were overall mortality and procedural success as divided into three categories: (1) successful therapy, (2) primary failure, or (3) secondary failure. Results: Between 2000 and June 2010, 16 patients were identified as having undergone 19 TEVAR/EVAR procedures. These included three emergent operations (two for acute dissection/malperfusion and one for anastomotic disruption early after open repair). All 16 patients had previously undergone at least one (range, 1-5) open operation of the ascending aorta or arch at a time interval from 33 years to 1 week prior to the index endovascular repair. During a median follow-up of 9.3 months (range, 0-46 months), there were four deaths (25%). Six patients (38%) had successful endovascular interventions. Despite early success, there was one death in this group at 1 month postintervention. Seven patients (44%) experienced primary treatment failure with five undergoing open conversion and one undergoing left subclavian coil embolization (the seventh was lost to follow-up and presented 4 months later in cardiac arrest and expired without repair). There were three deaths in the primary treatment failure group. Two patients experienced secondary treatment failure. One underwent the index TEVAR for acute dissection with malperfusion and required a subsequent TEVAR for more distal aortic pathology. He is stable without disease progression. The other patient underwent open conversion after a second EVAR with four-vessel “chimney” stent grafts and is stable with his entire native aorta having been replaced. Conclusions: Aortic disease associated with Marfan syndrome is a complex clinical problem and many patients require remedial procedures. Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients. However, failure of endovascular therapy is common, and its use should be judicious with close follow-up to avoid delay if open surgical repair is required.
- Discussion Dr Eric D. Endean (Lexington, Ky). I would like to congratulate the group from the University of Florida for the courage of presenting their results for this difficult problem. The patients presented in this series clearly represent a group for which treatment options are difficult at best. To re-emphasize, 14 of the 16 patients were ASA class IV or IV-E and all were deemed poor candidates for open surgical intervention. Fifteen patients had undergone between one and five previous open aortic operations, averaging almost two open aortic operations per patient. Not unexpectedly, the results are sobering. Four patients died within months of the endovascular procedure and the results in <50% were classified as “successful.” Six patients, or 38%, were classified as primary treatment failures. All patients with treatment failures required an open repair and half of them died. Two patients were felt to have secondary failure, ie, successful treatment of the target pathology, but proximal or distal aortic degeneration requiring further intervention.
- Endografts with suprarenal fixation do not perform better... Objective: To determine if there are any differences in outcomes between infrarenal fixation (IF) and suprarenal fixation (SF) endograft systems for the endovascular treatment (endovascular aneurysm repair [EVAR]) of abdominal aortic aneurysms (AAAs) with short, straight proximal aortic necks (0.5 cm) noted in either group. Sac regression was observed at an average rate of 0.24 cm/year in the IF group and 0.26 cm/year in the SF group (P = NS). There were no aneurysm ruptures during the study period. Conclusions: There are no significant differences in endograft migration or in the incidence of early and late type 1a endoleaks between endografts that use IF (Gore Excluder) and SF (Cook Zenith) fixation for patients with short aortic necks undergoing EVAR.
- Higher mortality in patients hospitalized for acute aorti... Background: The management of acute aortic aneurysm rupture or dissection (AARD) requires specific medical expertise, diagnostic techniques, and therapeutic options, not always available in all hospitals through the entire week. The aim of our study was to evaluate whether an association exists between weekday (WD) or weekend (WE) admission and mortality for patients with ARRD. Methods: Based on the database of routinely collected hospital admissions of the region of Emilia Romagna (RER) of Italy, we examined the discharge sheets of all patients with AARD (January 1999 to December 2009). The risk of in-hospital death was calculated for admissions on the WE compared with the admissions during a WD. Results: The analysis considered 4559 events in 4461 patients. AARD admissions were most frequent on Monday (14.7%) and Friday (14.8%) and less frequent on Saturday (12.6%). The percentage of events admitted on Sunday/holiday was 15.0%, whereas the distribution of death rate with respect to day of admission was significantly different (χ2 = 23.472; P < .001) with the highest frequency peak on Sunday/holiday (17.4%) and the lowest on Tuesday (12.9%). WE admissions were associated with significantly higher in-hospital mortality (43.4%) than WD admissions (36.9%, P < .001). Multivariate regression analysis showed that WE admission was an independent risk factor for increased in-hospital mortality odds ratio 1.318; 95% confidence interval, 1.144-1.517; P < .001). Conclusions: Our findings show that hospitalization for AARD on WE is associated with a significantly higher mortality rate than hospitalization on WD. Further studies are needed to investigate whether ensuring optimal diagnostic and therapeutic approaches during the entire week might improve the overall survival of patients with ARRD.
- Retrograde ascending aortic dissection as an early compli... Objective: Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. Methods: A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. Results: The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1). Conclusions: rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.
- Outcomes of percutaneous endovascular intervention for ty... Objective: Type II endoleak (T2EL) with aneurysm expansion is believed to place patients at risk for aneurysm-related mortality (ARM). Treatment with glue and/or coil embolization of the aneurysm sac, inferior mesenteric artery (IMA), and lumbar branches via translumbar or transarterial approaches has been utilized to ablate such endoleaks, and thus decrease ARM. We evaluated the midterm results of percutaneous endovascular treatment of T2EL with aneurysm expansion. Methods: Single-institution, 5-year (January 2003 to August 2008) retrospective study of all endovascular interventions for T2EL with sac expansion. Blinded, independent review of all available pre- and post-T2EL intervention computed tomography (CT) scans was performed. Aneurysm sac maximal transverse diameters and aneurysm sac growth rates prior to and following T2EL intervention were analyzed. Results: Forty-two patients (34 male, eight female; mean age, 75) underwent T2EL intervention at 26 ± 20 months after endovascular aneurysm repair (EVAR) and were subsequently followed for 23 ± 20 months. Seven out of 42 patients (17%) underwent repeat T2EL intervention. Interventions included 44 translumbar sac embolizations, and transcatheter embolizations of nine IMAs and seven lumbar/hypogastric arteries. Aneurysm diameter was 6.1 ± 1.6 cm at EVAR, 6.6 ± 1.5 cm at initial T2EL treatment, and 6.9 ± 1.7 cm at last follow-up. There were no significant differences in the rates of aneurysm sac growth pre- and post-T2EL treatment. At last follow-up imaging, recurrent or persistent T2EL was noted in 72% of patients. Of 42 patients, nine (21%) received operative endoluminal correction of occult type I or type III endoleaks that were diagnosed during the T2EL angiographic intervention. There were no aneurysm ruptures or ARMs during follow-up; overall mortality for the 5-year study period was 24%. Conclusions: In this series, percutaneous endovascular intervention for type II endoleak with aneurysm sac growth does not appear to alter the rate of aneurysm sac growth, and the majority of patients display persistent/recurrent endoleak. However, diagnostic angiographic evaluation may reveal unexpected type I and III endoleaks and is therefore recommended for all patients with T2EL and sac growth. While coil and glue embolization of aneurysm sac and selected branch vessels does not appear to yield benefit in our series, the diagnosis and subsequent definitive treatment of previously occult type I and III endoleaks may explain the absence of delayed rupture and ARM in our series.
- Invited commentary This article questions our current assumptions concerning the treatment outcomes of type II endoleaks. While it is generally acknowledged that these leaks occur frequently and are usually merely annoying, the results of treating more pernicious type II endoleaks that are accompanied by sac enlargement are largely unknown. These latter leaks, while rare, are often complicated, involving several sets of lumbar arteries, the inferior mesenteric artery, and extensive collateral networks. It is not surprising that simple embolization of the lumber, mesenteric, or internal iliac branches would not control these leaks. In fact, several groups have pointed this out, recommending translumbar approaches with coils and glue, and insisting on complete obliteration of the leak “nidus” within the sac.
PLoS ONE Alerts: Cardiovascular Disorders
- Partial Netrin-1 Deficiency Aggravates Acute Kidney Injury by Almut Grenz, Julee H. Dalton, Jessica D. Bauerle, Alexander Badulak, Douglas Ridyard, Aneta Gandjeva, Carol M. Aherne, Kelley S. Brodsky, Jae-Hwan Kim, Rubin M. Tuder, Holger K. Eltzschig The netrin family of secreted proteins provides migrational cues in the developing central nervous system. Recently, netrins have also been shown to regulate diverse processes beyond their functions in the brain, incluing the ochrestration of inflammatory events. Particularly netrin-1 has been implicated in dampening hypoxia-induced inflammation. Here, we hypothesized an anti-inflammatory role of endogenous netrin-1 in acute kidney injury (AKI). As homozygous deletion of netrin-1 is lethal, we studied mice with partial netrin-1 deletion (Ntn-1+/− mice) as a genetic model. In fact, Ntn-1+/− mice showed attenuated Ntn-1 levels at baseline and following ischemic AKI. Functional studies of AKI induced by 30 min of renal ischemia and reperfusion revealed enhanced kidney dysfunction in Ntn-1+/− mice as assessed by measurements of glomerular filtration, urine flow rate, urine electrolytes, serum creatinine and creatinine clearance. Consistent with these findings, histological studies indicated a more severe degree kidney injury. Similarly, elevations of renal and systemic inflammatory markers were enhanced in mice with partial netrin-1 deficiency. Finally, treatment of Ntn-1+/− mice with exogenous netrin-1 restored a normal phenotype during AKI. Taking together, these studies implicate endogenous netrin-1 in attenuating renal inflammation during AKI.
- MicroRNA Expression Analysis: Clinical Advantage of Propr... by Wenliang Zhu, Lei Yang, Hongli Shan, Yong Zhang, Rui Zhou, Zhe Su, Zhimin Du Background As playing important roles in gene regulation, microRNAs (miRNAs) are believed as indispensable involvers in the pathogenesis of myocardial infarction (MI) that causes significant morbidity and mortality. Working on a hypothesis that modulation of only some key members in the miRNA superfamily could benefit ischemic heart, we proposed a microarray based network biology approach to identify them with the recognized clinical effect of propranolol as a prompt. Methods A long-term MI model of rat was established in this study. The microarray technology was applied to determine the global miRNA expression change intervened by propranolol. Multiple network analyses were sequentially applied to evaluate the regulatory capacity, efficiency and emphasis of the miRNAs which dysexpression in MI were significantly reversed by propranolol. Results Microarray data analysis indicated that long-term propranolol administration caused 18 of the 31 dysregulated miRNAs in MI undergoing reversed expression, implying that intentional modulation of miRNA expression might show favorable effects for ischemic heart. Our network analysis identified that, among these miRNAs, the prime players in MI were miR-1, miR-29b and miR-98. Further finding revealed that miR-1 focused on regulation of myocyte growth, yet miR-29b and miR-98 stressed on fibrosis and inflammation, respectively. Conclusion Our study illustrates how a combination of microarray technology and functional protein network analysis can be used to identify disease-related key miRNAs.
- Differential Proteomic Analysis of Platelets Suggested Po... by Chao Ma, Yan Yao, Qing-Xi Yue, Xin-Wen Zhou, Peng-Yuan Yang, Wan-Ying Wu, Shu-Hong Guan, Bao-Hong Jiang, Min Yang, Xuan Liu, De-An Guo Background Salvianolic acid B (SB) is an active component isolated from Danshen, a traditional Chinese medicine widely used for the treatment of cardiovascular disorders. Previous study suggested that SB might inhibit adhesion as well as aggregation of platelets by a mechanism involving the integrin α2β1. But, the signal cascades in platelets after SB binding are still not clear. Methodology/Principal Findings In the present study, a differential proteomic analysis (two-dimensional electrophoresis) was conducted to check the protein expression profiles of rat platelets with or without treatment of SB. Proteins altered in level after SB exposure were identified by MALDI-TOF MS/MS. Treatment of SB caused regulation of 20 proteins such as heat shock-related 70 kDa protein 2 (hsp70), LIM domain protein CLP-36, copine I, peroxiredoxin-2, coronin-1 B and cytoplasmic dynein intermediate chain 2C. The regulation of SB on protein levels was confirmed by Western blotting. The signal cascades network induced by SB after its binding with integrin α2β1 was predicted. To certify the predicted network, binding affinity of SB to integrin α2β1 was checked in vitro and ex vivo in platelets. Furthermore, the effects of SB on protein levels of hsp70, coronin-1B and intracellular levels of Ca(2+) and reactive oxygen species (ROS) were checked with or without pre-treatment of platelets using antibody against integrin α2β1. Electron microscopy study confirmed that SB affected cytoskeleton structure of platelets. Conclusions/Significance Integrin α2β1 might be one of the direct target proteins of SB in platelets. The signal cascades network of SB after binding with integrin α2β1 might include regulation of intracellular Ca(2+) level, cytoskeleton-related proteins such as coronin-1B and cytoskeleton structure of platelets.
- Activated Met Signalling in the Developing Mouse Heart Le... by Christian Leo, Valentina Sala, Mara Morello, Amedeo Chiribiri, Ilan Riess, Daniele Mancardi, Stefano Schiaffino, Carola Ponzetto, Tiziana Crepaldi Background The Hepatocyte Growth Factor (HGF) is a pleiotropic cytokine involved in many physiological processes, including skeletal muscle, placenta and liver development. Little is known about its role and that of Met tyrosine kinase receptor in cardiac development. Methodology/Principal Findings In this study, we generated two transgenic mice with cardiac-specific, tetracycline-suppressible expression of either Hepatocyte Growth Factor (HGF) or the constitutively activated Tpr-Met kinase to explore: i) the effect of stimulation of the endogenous Met receptor by autocrine production of HGF and ii) the consequence of sustained activation of Met signalling in the heart. We first showed that Met is present in the neonatal cardiomyocytes and is responsive to exogenous HGF. Exogenous HGF starting from prenatal stage enhanced cardiac proliferation and reduced sarcomeric proteins and Connexin43 (Cx43) in newborn mice. As adults, these transgenics developed systolic contractile dysfunction. Conversely, prenatal Tpr-Met expression was lethal after birth. Inducing Tpr-Met expression during postnatal life caused early-onset heart failure, characterized by decreased Cx43, upregulation of fetal genes and hypertrophy. Conclusions/Significance Taken together, our data show that excessive activation of the HGF/Met system in development may result in cardiac damage and suggest that Met signalling may be implicated in the pathogenesis of cardiac disease.
- The Vasoactive Potential of Kisspeptin-10 in the Peripher... by Iain Sawyer, Sarah-Jane Smillie, Jennifer V. Bodkin, Elizabeth Fernandes, Kevin T. O'Byrne, Susan D. Brain Splice products of the Kiss1 protein (kisspeptins) have been shown to be involved in a diverse range of functions, including puberty, metastasis and vasoconstriction in large human arteries. Circulating Kisspeptin-10 (Kp-10) plasma levels are low in normal individuals but are elevated during various disease states as well as pregnancy. Here, we investigated the potential of Kp-10, the shortest biologically active kisspeptin, to influence microvascular effects, concentrating on the cutaneous vasculature. Kp-10 caused a dose-dependent increase in oedema formation (0.3–10nmol/injection site), assessed by Evans Blue albumin dye extravasation, in the dorsal skin of CD1 mice. Oedema formation was shown to be inhibited by the histamine H1 receptor antagonist mepyramine. The response was characterised by a ring of pallor at the injection site in keeping with vasoconstrictor activity. Therefore, changes in dorsal skin blood flow were assessed by clearance of intradermally injected 99mtechnetium. Kp-10 was found to significantly reduce clearance, in keeping with decreased blood flow and providing further evidence for vasoconstrictor activity. The decreased clearance was partially inhibited by co-treatment with the cyclo-oxygenase inhibitor indomethacin. Finally evidence for the kisspeptin receptor gene (Kiss1R), but not the kisspeptin peptide gene (Kiss1), mRNA expression was observed in heart, aorta and kidney samples from normal and angiotensin II induced hypertensive mice, with similar mRNA levels observed in each. We have evidence for two peripheral vasoactive roles for kisspeptin-10. Firstly, plasma extravasation indicative of ability to induce oedema formation and secondly decreased peripheral blood flow, indicating microvascular constriction. Thus Kp-10 has vasoactive properties in the peripheral microvasculature.
- Development and Feasibility of a Smartphone, ECG and GPS ... by Charles Worringham, Amanda Rojek, Ian Stewart Background Despite its efficacy and cost-effectiveness, exercise-based cardiac rehabilitation is undertaken by less than one-third of clinically eligible cardiac patients in every country for which data is available. Reasons for non-participation include the unavailability of hospital-based rehabilitation programs, or excessive travel time and distance. For this reason, there have been calls for the development of more flexible alternatives. Methodology and Principal Findings We developed a system to enable walking-based cardiac rehabilitation in which the patient's single-lead ECG, heart rate, GPS-based speed and location are transmitted by a programmed smartphone to a secure server for real-time monitoring by a qualified exercise scientist. The feasibility of this approach was evaluated in 134 remotely-monitored exercise assessment and exercise sessions in cardiac patients unable to undertake hospital-based rehabilitation. Completion rates, rates of technical problems, detection of ECG changes, pre- and post-intervention six minute walk test (6 MWT), cardiac depression and Quality of Life (QOL) were key measures. The system was rated as easy and quick to use. It allowed participants to complete six weeks of exercise-based rehabilitation near their homes, worksites, or when travelling. The majority of sessions were completed without any technical problems, although periodic signal loss in areas of poor coverage was an occasional limitation. Several exercise and post-exercise ECG changes were detected. Participants showed improvements comparable to those reported for hospital-based programs, walking significantly further on the post-intervention 6 MWT, 637 m (95% CI: 565–726), than on the pre-test, 524 m (95% CI: 420–655), and reporting significantly reduced levels of cardiac depression and significantly improved physical health-related QOL. Conclusions and Significance The system provided a feasible and very flexible alternative form of supervised cardiac rehabilitation for those unable to access hospital-based programs, with the potential to address a well-recognised deficiency in health care provision in many countries. Future research should assess its longer-term efficacy, cost-effectiveness and safety in larger samples representing the spectrum of cardiac morbidity and severity.
- Autoantibodies to Endothelial Cell Surface ATP Synthase, ... by Jean-Eric Alard, Sophie Hillion, Loïc Guillevin, Alain Saraux, Jacques-Olivier Pers, Pierre Youinou, Christophe Jamin Background Heat shock protein (hsp) 60 that provides “danger signal” binds to the surface of resting endothelial cells (EC) but its receptor has not yet been characterized. In mitochondria, hsp60 specifically associates with adenosine triphosphate (ATP) synthase. We therefore examined the possible interaction between hsp60 and ATP synthase on EC surface. Methodology/Principal Findings Using Far Western blot approach, co-immunoprecipitation studies and surface plasmon resonance analyses, we demonstrated that hsp60 binds to the β-subunit of ATP synthase. As a cell surface-expressed molecule, ATP synthase is potentially targeted by anti-EC-antibodies (AECAs) found in the sera of patients suffering vasculitides. Based on enzyme-linked immunosorbent assay and Western blotting techniques with F1-ATP synthase as substrate, we established the presence of anti-ATP synthase antibodies at higher frequency in patients with primary vasculitides (group I) compared with secondary vasculitides (group II). Anti-ATP synthase reactivity from group I patients was restricted to the β-subunit of ATP synthase, whereas those from group II was directed to the α-, β- and γ-subunits. Cell surface ATP synthase regulates intracellular pH (pHi). In low extracellular pH medium, we detected abnormal decreased of EC pHi in the presence of anti-ATP synthase antibodies, irrespective of their fine reactivities. Interestingly, soluble hsp60 abrogated the anti-ATP synthase-induced pHi down-regulation. Conclusions/Significance Our results indicate that ATP synthase is targeted by AECAs on the surface of EC that induce intracellular acidification. Such pathogenic effect in vasculitides can be modulated by hsp60 binding on ATP synthase which preserves ATP synthase activity.
- Targeting Vascular NADPH Oxidase 1 Blocks Tumor Angiogene... by Sarah Garrido-Urbani, Stephane Jemelin, Christine Deffert, Stéphanie Carnesecchi, Olivier Basset, Cédric Szyndralewiez, Freddy Heitz, Patrick Page, Xavier Montet, Liliane Michalik, Jack Arbiser, Curzio Rüegg, Karl Heinz Krause, Beat Imhof Reactive oxygen species, ROS, are regulators of endothelial cell migration, proliferation and survival, events critically involved in angiogenesis. Different isoforms of ROS-generating NOX enzymes are expressed in the vasculature and provide distinct signaling cues through differential localization and activation. We show that mice deficient in NOX1, but not NOX2 or NOX4, have impaired angiogenesis. NOX1 expression and activity is increased in primary mouse and human endothelial cells upon angiogenic stimulation. NOX1 silencing decreases endothelial cell migration and tube-like structure formation, through the inhibition of PPARα, a regulator of NF-κB. Administration of a novel NOX-specific inhibitor reduced angiogenesis and tumor growth in vivo in a PPARα dependent manner. In conclusion, vascular NOX1 is a critical mediator of angiogenesis and an attractive target for anti-angiogenic therapies.
- Renalase Deficiency in Heart Failure Model of Rats—A Po... by Rong Gu, Wen Lu, Jun Xie, Jian Bai, Biao Xu Background Sympathetic overactivity and catecholamine accumulation are important characteristic findings in heart failure, which contribute to its pathophysiology. Here, we identify a potential mechanism underlying norepinephrine accumulation in a rat model of heart failure. Methodology/Principal Findings Initially, we constructed a rat model of unilateral renal artery stenosis (n = 16) and found that the expression of renalase, a previously identified secreted amine oxidase, was markedly reduced in the ischemic compared to the non-ischemic kidney (protein: 0.295±0.085 versus 0.765±0.171, p Conclusions/Significance Renalase expression is influenced by renal blood flow and impaired synthesis of renalase by the kidney may represent a potential mechanism underlying circulating norepinephrine accumulation in heart failure.
- Sildenafil Reduces Insulin-Resistance in Human Endothelia... by Caterina Mammi, Donatella Pastore, Marco F. Lombardo, Francesca Ferrelli, Massimiliano Caprio, Claudia Consoli, Manfredi Tesauro, Lucia Gatta, Massimo Fini, Massimo Federici, Paolo Sbraccia, Giulia Donadel, Alfonso Bellia, Giuseppe M. Rosano, Andrea Fabbri, Davide Lauro Background The efficacy of Phosphodiesterase 5 (PDE5) inhibitors to re-establish endothelial function is reduced in diabetic patients. Recent evidences suggest that therapy with PDE5 inhibitors, i.e. sildenafil, may increase the expression of nitric oxide synthase (NOS) proteins in the heart and cardiomyocytes. In this study we analyzed the effect of sildenafil on endothelial cells in insulin resistance conditions in vitro. Methodology/Principal Findings Human umbilical vein endothelial cells (HUVECs) were treated with insulin in presence of glucose 30 mM (HG) and glucosamine 10 mM (Gluc-N) with or without sildenafil. Insulin increased the expression of PDE5 and eNOS mRNA assayed by Real time-PCR. Cytofluorimetric analysis showed that sildenafil significantly increased NO production in basal condition. This effect was partially inhibited by the PI3K inhibitor LY 294002 and completely inhibited by the NOS inhibitor L-NAME. Akt-1 and eNOS activation was reduced in conditions mimicking insulin resistance and completely restored by sildenafil treatment. Conversely sildenafil treatment can counteract this noxious effect by increasing NO production through eNOS activation and reducing oxidative stress induced by hyperglycaemia and glucosamine. Conclusions/Significance These data indicate that sildenafil might improve NOS activity of endothelial cells in insulin resistance conditions and suggest the potential therapeutic use of sildenafil for improving vascular function in diabetic patients.
Cardiovascular Therapeutics
- Effects Of Acute And Chronic Atorvastatin On Cadioprotect... Myocardial reperfusion therapy remains the most effective strategy to limit infarct size and improve clinical outcome. However, reperfusion injury is still inevitable, and a number of strategies have been developed to ameliorate its lethal outcome. The beneficial roles of ischemic postconditioning (Ipost) have regained more interest in targeting myocardial reperfusion phase to improve cardioprotection. Because Statins are given often to patients with acute myocardial infarction, this study was to determine whether acute or chronic treatment with atorvastatin affects cardioprotection when it was combined with Ipost. Acute or chronic atorvastatin treatment significantly reduced infarct size and recovered contractile dysfunction during reperfusion. When Ipost was combined with atorvastatin treatment, chronic, but not acute, atorvastatin therapy attenuated the cardioprotective effects of Ipost. Chronic, but not acute atorvastain, treatment also abolished Ipost-induced phosphorylation level of Akt and eNOS. Chronic atorvastatin treatment could interfere with cardioprotective effects of Ipost on limiting infarct size and contractile dysfunction, possibly via inhibition of Akt and eNOS activity. This study suggests that Ipost should be used carefully when atorvastatin is taken by patients with acute myocardial infarction.©2012 Blackwell Publishing Ltd
- Induction of angiogenesis by controlled delivery of VEGF ... AimsThe study reports the feasibility and efficiency of vascular endothelial growth factor (VEGF) delivery using nanoparticles synthesized from glycidyl methacrylated dextran (Dex-GMA) and gelatin for therapeutic angiogenesis.MethodsThe nanoparticles were prepared using phase separation method and the drug release profile was determined by ELISA study. The bioactivity of VEGF incorporated nanoparticles (VEGF-NP) were determined using tube formation assay. A rabbit hind limb ischemia model was employed to evaluate the in vivo therapeutic effect. Blood perfusion was measured by single photon emission computed tomography (SPECT). Vessel formation was evaluated by contrast angiography and immunohistochemistry.ResultsThe nanoparticles synthesized were spherical in shape with evenly distributed size of about 130±3.5 nm. The VEGF encapsulated was released in a bi-phase manner, with the majority of 69% released over 1-12 days. Tube formation assays showed increased tubular structures by VEGF-NP compared to empty nanoparticles and no treatment. Both free VEGF and VEGF-NP significantly increased blood perfusion compared to empty nanoparticles (both P<0.001), but it was much higher in VEGF-NP treated limbs (P<0.001). Contrast angiography and immunohistological analysis also revealed more significant collateral artery formation and higher capillary density in VEGF-NP treated limbs.ConclusionsDex-GMA and gelatin based nanoparticles could provide sustained release of VEGF and may serve as a new way for angiogenesis.©2012 Blackwell Publishing Ltd
- Mind Your Language: Conveying the Results of Clinical Tri...
- Second Line Options for Hyperlipidemia Management after C... Despite widespread statin therapy, 91% of cardiac transplant patients have hyperlipidaemia within five years from cardiac transplantation. The implications of this are profound, particularly given that coronary allograft vasculopathy is a leading cause of death. Unfortunately the solution is not easy, with problems of toleration at higher statin doses and a lack of good quality evidence for second line agents. We review the literature and discuss some of the key issues transplant physicians are faced with when considering alternatives to statin therapy.
- Effect of Chronic Pretreatment of Angiotensin-Converting ... Aims: Angiotensin receptor blockers (ARBs) exert favorable effects on the vascular system, which are not directly related to hypertension lowering function. The no-reflow phenomenon determines the prognosis in patients after acute myocardial infarction (AMI). Early ARB treatment has many beneficial effects on the prognosis after AMI. In the present study, we tested the hypothesis that ARB treatment before admission would have beneficial effects on the development of the no-reflow phenomenon after infarction. Methods: We investigated 276 consecutive patients with AMI undergoing successful primary percutaneous coronary intervention (PCI). No-reflow was defined as Thrombolysis in Myocardial Infarction (TIMI) flow grade <3, which was determined by the TIMI frame count method using angiographic images obtained just after PCI and stenting. Results: Compared with patients without ARB treatment, patients with ARB had more frequently hypertension and ST resolution (P<0.05 respectively), but no significant difference was found in the other clinical characteristics (age, sex, Hyperlipidaemia, Diabetes mellitus, etc) between the two groups. A total of 51 patients receiving chronic ARB treatment before admission have lower incidence of the no-reflow phenomenon than those without chronic ARB treatment (8.7% and 26.7%, P = 0.003). However, the incidence of the no-reflow phenomenon between the patients with and without hypertension had no significant difference. Multivariable logistic regression analysis revealed that ARB pretreatment was a significant predictor of the no-reflow phenomenon, whereas blood pressure was found to be insignificant. Conclusion: Chronic pre-treatment of ARB is associated with the reduction of the no-reflow phenomenon in patients with reperfused AMI and could preserve microvascular integrity after AMI independent of blood pressure lowering, which may contribute to better functional recovery.
- Cardiac Shock Wave Therapy for Chronic Refractory Angina ... Background: Cardiac shock wave therapy (CSWT) delivered to the myocardium increases capillary density and regional myocardial blood flow in animal experiments. In addition, non enzymatic nitric oxide production and the up-regulation of vascular growth factor's mRNA by CSWT have been described. The aim of the study was therefore to test its potential to relieve symptoms in patients with chronic stable angina pectoris.Methods: 21 patients (mean age 68.2±8.3 years, 14 males) with chronic refractory angina pectoris and evidence of inducible myocardial ischemia during MIBI-SPECT imaging, were randomised into a treatment (n = 11) and a placebo arm (n = 10). The region of exercise induced ischemia was treated with echocardiographic guidance during nine sessions over a period of 3 months. One session of CSWT consisted of 200 shots/ spot with an energy intensity of 0.09 mJ/ mm2. In the control group acoustic simulation was performed without energy application. Medication was kept unchanged during the whole treatment period.Results: In the treatment group, symptoms improved in 9/11 patients, and the ischemic threshold, determined by cardiopulmonary exercise stress testing, increased from 80±28 to 95±28 W (p = 0.036). In the placebo arm, only 2/10 patients reported an improvement and the ischemic threshold remained unchanged (98±23 to 107±23 W; p = 0.141). The items “physical functioning” (p = 0.043), “general health perception” (p = 0.046) and “vitality” (p = 0.035) of the SF-36 questionnaire significantly improved in the treatment arm, whereas in the placebo arm, no significant change was noted. Neither arrhythmias, troponin rise nor complications were observed during treatment.Conclusions: This placebo controlled trial shows a significant improvement in symptoms, quality of life parameters and ischemic threshold during exercise in patients with chronic refractory angina pectoris treated with CSWT. Thus, CSWT represents a new option for the treatment of patients with refractory AP.
- Efficacy of Cilostazol on Uncontrolled Coronary Vasospast... Background: Although an angina attack by vasospastic angina (VSA) can usually be relieved or controlled with nitrates and calcium channel blockers, there are some patients who cannot be controlled even by higher doses and combinations of these drugs. Cilostazol is a selective inhibitor of phosphodiesterase 3 that increases intracellular cAMP contents. A stimulation of cAMP signal transduction increases coronary nitric oxide production. We examined whether Cilostazol improved angina symptoms in patients with VSA uncontrolled by conventional treatment. Methods: This study was conducted in a prospective, multicenter, non-randomized manner. The subject consisted of 21 patients (13 men, 57 ± 9 year-old) who were diagnosed with VSA and had at least two angina attacks during the past one week despite of conventional medications such as calcium channel blockers and/or nitrates. They took Cilostazol 100 mg twice daily for two weeks in addition to the conventional medications. The patients recorded the frequency of angina attack and wrote down the numeric rating scale of a ‘severity of angina attack’ while taking conventional medications and Cilostazol for two weeks, and also recorded an averaged scale or total number of event during the last week at the time of the assessment. Using the Wilcoxon rank-sum test, we compared the changes in the scores of frequency and severity of angina attack before and after adding Cilostazol to the conventional medications. Results: After adding Cilostazol to the conventional medications, there were 78.9% relative reduction of the score of angina intensity and 73.5% of angina frequency (p < 0.001). There were four patients (19%) who were forced to stop Cilostazol due to headache as an adverse event. Conclusions: Cilostazol appears to be an effective therapy in VSA uncontrolled with conventional medical treatment. A further prospective, randomized, placebo-controlled study will be needed to validate this result.
- When Should We Use Nitrates in Congestive Heart Failure? Organic nitrates remain among the oldest and most commonly employed drugs in cardiology. While, in most cases, their use in acute and chronic heart failure is based on clinical practice, only a few clinical trials have been conducted to evaluate their use in acute and chronic heart failure, most of which compare them with other drugs to evaluate differing endpoints. The purpose of this review is to examine the various trials that have evaluated the use of nitrates in acute and chronic heart failure.
- Opportunity Nox: The Future of NADPH Oxidases as Therapeu... Over 40 years ago, NADPH (nicotinamide adenine dinucleotide phosphate) oxidase 2 (Nox2) was discovered in phagocytes and found to be essential in innate immunity. More than 20 years passed before additional Nox isoforms were discovered; and since then, studies have revealed that several of these isoforms (Nox1, Nox2, Nox4, and Nox5) are found in human cardiac and vascular cells and contribute to the pathogenesis of cardiovascular diseases (CVDs). Recently, major efforts have focused on identifying inhibitors capable of ameliorating Nox-mediated CVD. In this review, we briefly discuss the role of each Nox isoform in CVD, identify steps in Nox signaling that will serve as potential targets for the design of therapeutics, and highlight innovative strategies likely to yield effective Nox inhibitors within the next decade.
- Coronary Flow Velocity Reserve Is Improved by PPAR-α Ago... SUMMARY Introduction: Fenofibrate, an agonist of peroxisome proliferator-activated receptor-α (PPAR-α), has a vascular protective effect. Aims: We investigated the effect of the PPAR-α agonist on coronary artery endothelial function in patients with hypertriglyceridemia. Methods: Fifty-eight patients with hypertriglyceridemia were divided into two groups: control (no treatment; n = 23) and fenofibrate treatment (n = 35), 200 mg/d, for 6 months. The patients had undergone rest and adenosine treatment to induce hyperemia for quantification of coronary flow velocity reserve (CFVR) by noninvasive Doppler echocardiography before treatment and at 6-month follow-up. Pulse wave velocity (PWV) was measured before treatment and at 6-month follow-up. Results: CFVR was significantly improved with fenofibrate treatment as compared with baseline level and control group (3.14 ± 0.36 vs. 2.80 ± 0.58 and 2.79 ± 0.65, P < 0.01 and 0.05, respectively), with no difference between baseline levels and untreated controls. In addition, at 6 months, plasma level of homocysteine was significantly increased with fenofibrate treatment as compared with at baseline and control group (median 18.13 [range 14.46–22.02]μmol/L vs. 14.09 [12.01–18.81] and 13.34 [9.69–17.06]μmol/L, P < 0.001 and 0.01, respectively). Furthermore, at 6 months, PWV was significantly decreased with fenofibrate treatment as compared with control group (1446 ± 136 cm/s vs. 1570 ± 203 cm/s, P < 0.05). Conclusions: Treatment with PPAR-α agonist fenofibrate significantly improved CFVR and arterial stiffness in patients with hypertriglyceridemia. This endothelial protective effect may be reduced in part by the side effect of increasing homocysteine.
Herz
- Pharmakologie der neuen oralen Antikoagulanzien Zusammenfassung Die neuen oralen Antikoagulanzien wie Dabigatran, Rivaroxaban, Apixaban oder Edoxaban zeigen pharmakokinetische und pharmakodynamische Kenndaten vergleichbar denjenigen niedermolekularer Heparine. Maximale Wirkspiegel werden 2 bis 4 Stunden nach Einnahme erreicht, die Halbwertszeiten liegen bei 7 bis 14 Stunden. Die Substanzen unterscheiden sich insbesondere hinsichtlich der renalen Elimination. Dosisanpassung erfolgt lediglich bei Nierenfunktionsstörungen, erhöhtem Blutungsrisiko sowie bei bestimmten Begleitmedikationen. Durch die kurze Wirkdauer der Substanzen ist eine präoperative Therapieumstellung nicht erforderlich. Spezifische Antidots stehen bisher nicht zur Verfügung, eine Antagonisierung der gerinnungshemmenden Wirkung wird allerdings aufgrund der kurzen Wirkdauer nur selten erforderlich sein. Für die Konzentrationsbestimmung im Blut stehen inzwischen spezielle Testverfahren zur Verfügung. Im Notfall schließt eine normale Thrombinzeit bzw. ein normalwertiger Anti-Faktor-Xa-Test das Vorhandensein wirksamer Konzentrationen von Dabigatran bzw. Faktor-Xa-Inhibtoren im Blut aus. Die neuen oralen Antikoagulanzien werden sowohl in der Thromboseprophylaxe als auch in der (längerfristigen) gerinnungshemmenden Therapie, beispielsweise bei Vorhofflimmern oder nach tiefer Beinvenenthrombose, eingesetzt. Bei Dabigatran liegen Prophylaxedosis (1-mal 220 mg) und therapeutische Dosis (2-mal 110 bis 2-mal 150 mg) recht eng beisammen, bei den Faktor-Xa-Inhibitoren Rivaroxaban und Apixaban entspricht die therapeutische Dosis in etwa dem Doppelten der Prophylaxedosis (Rivaroxaban: Thromboseprophylaxe 1-mal 10 mg, Vorhofflimmern 1-mal 20 mg, Therapie der venösen Thrombose initial 2-mal 15 mg, dann 1-mal 20 mg; Apixaban: Prophylaxedosis 2-mal 2,5 mg, Antikoaglation bei Vorhofflimmern 2-mal 5 mg). Content Type Journal ArticleCategory SchwerpunktPages 1-7DOI 10.1007/s00059-012-3616-yAuthors C.-E. Dempfle, IMD Gerinnungspraxis Mannheim, Belchenstr. 1-5, 68163 Mannheim, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Rolle der neuen oralen Antikoagulanzien im Vergleich zu V... Zusammenfassung Die standardisierte, gleichbleibende Tagesdosis, das Fehlen eines engmaschigen Monitorings sowie die geringere Anzahl von Interaktionen machen die Therapie mit den neuen oralen Antikoagulanzien einfacher und praktikabler im Vergleich zur Standardtherapie mit Vitamin-K-Antagonisten. Dabei sind die bisher geprüften Substanzen bei Patienten mit Vorhofflimmern den Vitamin-K-Antagonisten therapeutisch zumindest ebenbürtig und haben ein geringeres Risiko für schwere und tödliche Blutungen. Die neuen Substanzen sind als Medikamente deutlich teurer als die alten, können jedoch nach Studienlage bei breiterer Akzeptanz das Auftreten von Schlaganfällen und deren Folgekosten voraussichtlich reduzieren. Content Type Journal ArticleCategory SchwerpunktPages 1-9DOI 10.1007/s00059-012-3619-8Authors A. Osterspey, Gemeinschaftspraxis für Herz- und Kreislaufkrankheiten, am St. Elisabeth-Krankenhaus Hohenlind, Werthmannstr. 1b, 50935 Köln, DeutschlandA. Krome, Gemeinschaftspraxis für Herz- und Kreislaufkrankheiten, am St. Elisabeth-Krankenhaus Hohenlind, Werthmannstr. 1b, 50935 Köln, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Interventioneller Vorhofohrverschluss Zusammenfassung Als mögliche Alternative zu einer dauerhaften oralen Antikoagulation mit Vitamin-K-Antagonisten bei Patienten mit Vorhofflimmern hat sich der interventionelle Verschluss des linken Vorhofohrs als nicht unterlegen in Bezug auf die neurologische Ereignisrate gezeigt. Gerade im Hinblick auf die neuen Möglichkeiten, direkte orale Faktor-II- oder Faktor-Xa-Inhibitoren zur Schlaganfallprophylaxe einsetzen zu können, ist eine individuelle Entscheidung, die das jeweilige Blutungs- und Schlaganfallrisiko mit dem periinterventionellen Risiko abwägt, erforderlich. Hier können etablierte Risiko-Scores hilfreich sein. Content Type Journal ArticleCategory SchwerpunktPages 1-5DOI 10.1007/s00059-012-3621-1Authors B. Plicht, Westdeutsches Herzzentrum Essen, Klinik für Kardiologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandP. Kahlert, Westdeutsches Herzzentrum Essen, Klinik für Kardiologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandR. Erbel, Westdeutsches Herzzentrum Essen, Klinik für Kardiologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandT.F.M. Konorza, Westdeutsches Herzzentrum Essen, Klinik für Kardiologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Rolle der Vitamin-K-Antagonisten aus Sicht des Hepatologen Zusammenfassung Vitamin-K-Antagonisten greifen in den hepatischen Vitamin-K-Metabolismus ein. Sie werden im klinischen Alltag als orale Antikoagulanzien zur Prophylaxe thrombembolischer Ereignisse verwendet. Die bekanntesten Komplikationen sind Blutungskomplikationen und die cumarininduzierte Hautnekrose. Es finden sich zunehmend Fälle hepatischer Komplikationen, die von einer milden Hepatopathie bis hin zum akuten Leberversagen mit signifikanter Mortalität reichen können. Die Hepatotoxizität tritt in der Regel mit einer Latenz von mehreren Monaten auf. Neben unspezifischen Symptomen zeigt sich häufig ein schmerzloser Ikterus. Laborchemisch zeigen sich sowohl Transaminasen als auch Cholestaseparameter erhöht. Hepatische Nebenwirkungen sind insgesamt selten, sollten jedoch bei Anstieg der Leberwerte unter Therapie mit Cumarinderivaten in Betracht gezogen werden. Eine Hepatopathie macht das Absetzen des Vitamin-K-Antagonisten notwendig, und alternative Therapieformen müssen erwogen werden. Ein Wechsel auf ein anderes Cumarinderivat muss kritisch hinterfragt werden, da Kreuzreaktivitäten beschrieben sind. Content Type Journal ArticleCategory SchwerpunktPages 1-7DOI 10.1007/s00059-012-3620-2Authors G. Kneiseler, Klinik für Gastroenterologie und Hepatologie, Zentrum für Innere Medizin, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandA. Canbay, Klinik für Gastroenterologie und Hepatologie, Zentrum für Innere Medizin, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandG. Gerken, Klinik für Gastroenterologie und Hepatologie, Zentrum für Innere Medizin, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Neue Antikoagulanzien bei Vorhofflimmern Zusammenfassung Die neuen Antikoagulanzien Rivaroxaban und Dabigatran wurden vor Kurzem zur Prophylaxe kardioembolischer Komplikationen bei Vorhofflimmern zugelassen. Weitere Substanzen werden demnächst folgen. Die neuen Antikoagulanzien unterscheiden sich in wesentlichen Punkten von den Vitamin-K-Antagonisten: Ihre Wirksamkeit tritt schneller ein, die inter- und intraindividuellen Schwankungen sind wesentlich geringer, sie haben eine deutlich kürzere Halbwertszeit und zeigen eine geringe Arzneimittelinteraktion. Im Alltag sind daher kein Monitoring und keine Dosisanpassung erforderlich. Rivaroxaban und Dabigatran können fast alle Gerinnungstests beeinflussen. Daher müssen das Antikoagulans und der Zeitpunkt der letzten Einnahme bei der Interpretation von Gerinnungsbefunden berücksichtigt werden. Zum Monitoring von Rivaroxaban und Dabigatran sollten Testsysteme verwendet werden, die eine möglichst lineare Dosis-Wirkungs-Beziehung zeigen. Für den direkten Faktor-Xa (FXa)-Inhibitor Rivaroxaban ist die Bestimmung der Anti-FXa-Einheiten und der Thromboplastinzeit (TPZ), gemessen in Sekunden, möglich; für den Thrombininhibitor Dabigatran sind die Thrombinzeit und die aktivierte partielle Thromboplastinzeit (APTT) geeignete Testparameter. Optimierte Gerinnungstests stehen inzwischen für beide Präparate zur Verfügung. Der Umkehrschluss, nämlich vom Ausmaß eines veränderten Gerinnungstests auf die Wirksamkeit einer Antikoagulation zu schließen, ist aktuell mit keinem Testsystem möglich. Content Type Journal ArticleCategory SchwerpunktPages 1-6DOI 10.1007/s00059-012-3618-9Authors K. Madlener, Hämostaseologie und Transfusionsmedizin, Kerckhoff-Klinik, Benekestr. 2-8, 61231 Bad Nauheim, DeutschlandC. Hamm, Kardiologie, Kerckhoff-Klinik und Medizinische Klinik I, Kardiologie/Angiologie, Universitätsklinikum Gießen-Marburg, Marburg, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Neue Antikoagulanzien zur Schlaganfallprävention bei Vor... Zusammenfassung Patienten mit Vorhofflimmern haben ein hohes Schlaganfallrisiko. Dieses Risiko kann durch Vitamin-K-Antagonisten wie Phenprocoumon oder Warfarin sowohl in der Primär- als auch in der Sekundärprävention, verglichen mit Placebo, um 60–70% reduziert werden. Vitamin-K-Antagonisten haben allerdings eine Vielzahl von Problemen in der praktischen Anwendung, was die relativ geringe Einnahmefrequenz bei Patienten mit Vorhofflimmern erklärt. Neue orale Antikoagulanzien wie direkte Thrombininhibitoren (Dabigatran) oder direkte Faktor-Xa-Hemmer wie Rivaroxaban und Apixaban zeigten eine im Vergleich zu Warfarin mindestens ebenbürtige wenn nicht höhere Wirksamkeit und zum Teil auch eine niedrigere Inzidenz an schwerwiegenden Blutungskomplikationen. Die neuen Substanzen sind sowohl in der Sekundär- als auch in der Primärprävention von Schlaganfällen bei Patienten mit Vorhofflimmern wirksam. Apixaban ist auch deutlich wirksamer als Azetylsalizylsäure bei Patienten, die für eine Behandlung mit Warfarin nicht geeignet sind, bei vergleichbarer Rate an schwerwiegenden Blutungskomplikationen. Content Type Journal ArticleCategory SchwerpunktPages 1-8DOI 10.1007/s00059-012-3617-xAuthors H.C. Diener, Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, DeutschlandK. Hajjar, Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, DeutschlandB. Frank, Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, DeutschlandM. Perrey, Klinik für Kardiologie, Universitätsklinikum Essen, Essen, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937
- Besonderheiten der Infarkttherapie bei Diabetes Zusammenfassung Die Therapie des akuten Myokardinfarkts (STEMI und NSTEMI) bei Diabetes unterscheidet sich im Prinzip nicht von der beim Nichtdiabetiker. Wegen der höheren Mortalität sollten allerdings beim Diabetiker zeitgerecht Reperfusionsmaßnahmen – in der Regel die direkte PCI – und eine konsequente medikamentöse Begleittherapie entsprechend der aktuellen Leitlinien mit Thrombozytenaggregationshemmern, ACE-Hemmstoffen und Betarezeptorenblockern erfolgen. Als wichtige Besonderheit ist die Gefahr eines Nierenversagens bei vorbestehender diabetischer Nierenschädigung in Folge der Kontrastmittelverabreichung im Rahmen der katheterinterventionellen Revaskularisation zu nennen. Deswegen sollte in der Regel eine Kontrastmittelbegrenzung auf 100 ml erfolgen. Die direkte PCI sollte sich auf das Zielgefäß beschränken. Im Intervall muss über eine endgültige Koronartherapie (PCI/Bypass-Operation) entschieden werden. Bei schwerer koronarer Dreigefäßkrankheit ist bei Diabetikern in der Regel die Bypass-Operation als nachhaltige Maßnahme zu bevorzugen. Nach durchgemachtem Myokardinfarkt ist eine differenzierte diabetologische Stoffwechselführung notwendig. Content Type Journal ArticleCategory CME Zertifizierte FortbildungPages 311-320DOI 10.1007/s00059-012-3612-2Authors W. Motz, Klinik für Kardiologie, Herz- und Diabeteszentrum Mecklenburg-Vorpommern, Greifswalder Str. 11, 17495 Karlsburg, DeutschlandW. Kerner, Klinik für Diabetes und Stoffwechselerkrankungen, Herz- und Diabeteszentrum Mecklenburg-Vorpommern, Karlsburg, Deutschland Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937 Journal Volume Volume 37 Journal Issue Volume 37, Number 3
- Diabetes and the heart—at the edge between upcoming sol... Diabetes and the heart—at the edge between upcoming solutions and newly detected problems Content Type Journal ArticleCategory EditorialPages 243-243DOI 10.1007/s00059-012-3609-xAuthors D. Tschoepe, Heart and Diabetes Center NRW, Ruhr University, Bochum, GermanyR. Dörr, Practice Clinic Heart and Vessels, Dresden, GermanyD. Müller-Wieland, Asklepios Hospital St. Georg, Hamburg, Germany Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937 Journal Volume Volume 37 Journal Issue Volume 37, Number 3
- Comorbidity, hypoglycaemia and appropriate selection of a... Abstract Background Patients with type 2 diabetes and heart failure are considered to be at high risk for hypoglycaemic complications. There is a considerable uncertainty with respect to the appropriate choice of antidiabetic pharmacotherapy in patients with type 2 diabetes and comorbid heart failure. Little is known about comorbidity, hypoglycaemia rates and selected pharmacotherapy in diabetic patients with heart failure in clinical practice. Methods DiaRegis is a prospective registry in Germany including 3,810 patients with type 2 diabetes receiving antidiabetic treatment with oral mono or oral dual combination therapy in 2009/2010. Only patients for which adjustment of pharmacotherapy (including the introduction of insulin and GLP-1 analogues) was deemed necessary were enrolled. We examined the differences in comorbidity, hypoglycaemia and choice of anti-diabetic pharmacotherapy between diabetics with and without clinical heart failure in clinical practice in Germany. Results For 3,746 patients, data on the presence of heart failure were available, median (IQR) age 65.9 (57.6–72.8) years and 46.8% were female. Patients with heart failure (n = 370; 9.9%) were older, had a higher BMI, were less physically active, and had more cardiovascular risk factors and a substantial comorbidity. Glycaemic control was comparable between groups. Of the patients with heart failure, 76.8% received metformin, 32.7% sulfonylureas, 2.2% glucosidase inhibitors, 4.3% glinides, 6.2% glitazones and 7.3% DPP-4 inhibitors at baseline before adjustment of therapy. In multivariate analyses, patients with heart failure received less metformin (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.43–0.79) and sulfonylureas (OR 0.70, 95%CI 0.52–0.95) but not thiazolidinediones (OR 1.22, 95%CI 0.82–1.81) or other antidiabetic drugs. Hypoglycaemia was considerably more frequent in diabetic patients with heart failure than in those without (OR 1.96, 95%CI 1.47–2.61). Conclusion Patients with type 2 diabetes and heart failure had a substantially increased comorbidity burden compared to patients without heart failure. They more often suffered from episodes of hypoglycaemia, especially those requiring medical assistance. The diagnosis of heart failure did not impact the choice of antidiabetic pharmacotherapy in patients with type 2 diabetes. There was no differential use of thiazolidinediones despite evidence discouraging their use in patients with heart failure. Content Type Journal ArticleCategory Main topicPages 294-300DOI 10.1007/s00059-012-3611-3Authors A.K. Gitt, Medizinische Klinik B, Kardiologie, Herzzentrum Ludwigshafen, Ludwigshafen, GermanyP. Bramlage, Institut für Pharmakologie und präventive Medizin, Mahlow, GermanyC. Binz, Medical Department, Bristol-Myers Squibb, Munich, GermanyM. Krekler, Medical Department, Bristol-Myers Squibb, Munich, GermanyE. Deeg, Institut für Herzinfarktforschung Ludwigshafen, Bremserstr. 79, 67063 Ludwigshafen, GermanyD. Tschöpe, Herz- und Diabeteszentrum Nordrhein-Westfalen in Bad Oeynhausen, Universitätsklinik der Ruhr Universität Bochum, Bochum, Germany Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937 Journal Volume Volume 37 Journal Issue Volume 37, Number 3
- Antithrombotic therapy in patients with acute coronary sy... Abstract Acute coronary syndrome (ACS) is associated with high mortality even in the acute phase as well as in the post-acute (chronic) phase. Diabetes mellitus type 2 (DM-2), on the other hand, further increases mortality after ACS. Several new antiplatelet and antithrombotic drugs available for clinical use have also been investigated in patients with DM-2, and the guidelines of the European Society of Cardiology (ESC) were recently adapted. However, in daily clinical practice choosing the most suitable regimen is a challenge in many cases. This review article aims to shed light on and simplify antiplatelet and antithrombotic therapy in ACS patients with DM-2 in order to ease the clinician’s decision-making. Content Type Journal ArticleCategory Main topicPages 264-272DOI 10.1007/s00059-012-3610-4Authors S. Farhan, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Montleartstr. 37, 1160 Vienna, AustriaI. Tentzeris, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Montleartstr. 37, 1160 Vienna, AustriaM.K. Freynhofer, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Montleartstr. 37, 1160 Vienna, AustriaB. Vogel, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Montleartstr. 37, 1160 Vienna, AustriaK. Huber, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Montleartstr. 37, 1160 Vienna, Austria Journal HerzOnline ISSN 1615-6692Print ISSN 0340-9937 Journal Volume Volume 37 Journal Issue Volume 37, Number 3
Angiology
- Admission Hyperglycemia and TIMI Frame Count in Primary P... We evaluated the relationship between admission blood glucose levels and estimated coronary flow by the thrombolysis in myocardial infarction (TIMI) frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The TFC of 121 consecutive patients with STEMI were evaluated after pPCI. Patients with admission glucose levels >198 mg/dL (11 mmol/L) were defined as hyperglycemic. Hyperglycemia was observed in 36 (29.8%) patients. The TFC was significantly higher in patients with hyperglycemia (70.75 [10-96] vs 56.87 [8-100], P = .04). No-reflow frequency was higher in the hyperglycemia group (44.4% vs 23.5%, P = .02). In multivariate linear regression analysis admission glucose was an independent predictor of high TFC (B = 0.21, P = .02). Our findings suggest that admission blood glucose is a predictor of TFC which reflects coronary blood flow.
- Rapamycin Affects Tissue Plasminogen Activator and Plasmi... Although drug-eluting stents (DESs) can decrease the risk of restenosis, this benefit is tempered by a possible increased risk of in-stent thrombosis. We assessed the effects of rapamycin on human umbilical vein endothelial cells (HUVECs) to identify the alterations in gene expression associated with thrombosis. Expression of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) was assessed in HUVECs treated with rapamycin (final concentrations: 1, 10, 100, and 1000 ng/mL) for 24 and 48 hours. Incubation of HUVECs with rapamycin strongly reduced the expression of t-PA in a concentration-dependant manner (P < .05 to < .01). However, the expression of PAI-1 was induced by rapamycin (P < .05 to < .01). The increase in PAI-1 induction was up to 3.3-fold. In conclusion, rapamycin inhibited t-PA and induced PAI-1 expression in HUVECs. This effect may contribute to in-stent thrombosis associated with DESs.
- Rapamycin and Thrombosis
- Body Mass Index and Hypertension Among Chinese Government... Body mass index (BMI) and hypertension have been found to be associated in most studies of diverse populations; however, little information is available on whether the positive relationship is consistent among individuals at work sites. A work site-based screening was performed in 30 682 employees with a mean age of 40.3 years. In crude models, higher BMI quartiles above the lowest quartiles (BMI <20.6 kg/m2) were associated with progressively higher odds ratio (OR) of hypertension with an OR of 2.80 (95% confidence interval [CI]: 2.67-2.93) for the top quartile (BMI ≥24.6 kg/m2). Similar trends were found in fully adjusted models. Moreover, a 1-standard deviation (SD) increase in BMI was associated with a 42% significantly higher (95% CI 38-46) risk of hypertension after adjusting for other factors. Concordant relationships were revealed in all evaluated subgroups, even among those without traditional cardiovascular risk factors.
- Platelet-Activating Factor and Its Basic Metabolic Enzyme... Platelet-activating factor (PAF), a mediator of proatherosclerotic inflammatory processes, is also implicated in endothelial dysfunction during human immunodeficiency virus (HIV) infection. We examined PAF metabolism in blood of naive male patients, 8 with early HIV infection (group A) and 17 just before treatment initiation (group B), versus 18 healthy age-matched males (group C). Statistical analysis was performed with 1-way analysis of variance (ANOVA) criterion and Pearson r test. Higher PAF biosynthesis in patients’ leukocytes versus group C was accompanied by an increase in lipoprotein-associated phospholipase A2 (Lp-PLA2) activity that degrades PAF. Moreover, PAF synthesis was higher and Lp-PLA2 activity was lower in group B compared to group A. Lipoprotein-associated phospholipase A2 was positively correlated with viral load and negatively correlated with CD4 cell counts in group B. The activities of PAF-basic biosynthetic enzymes in patients’ leukocytes were also negatively correlated with CD4 cell counts. The observed continuous increase in PAF biosynthesis during HIV infection progress seems to amplify the risk of AIDS manifestations and/or cardiovascular complications in HIV-infected patients, while a subsequent increase in Lp-PLA2 activity seems to be a host response.
- The Acute Effects of Passive Smoking on Mean Platelet Vol... Mean platelet volume (MPV) is an indicator of platelet activation. We investigated the acute effect of passive smoking on MPV in healthy volunteers. Healthy nonsmoker volunteers (n = 90) spent 120 minutes in a smoke-free room. Then they were exposed to passive smoking in 3 groups consisting of 30 volunteers each in group A (carbon monoxide [CO] <7.5 ppm), group B (CO = 7.5-15 ppm), and group C (CO > 15 ppm) for 120 minutes in a smoking room. Mean platelet volume did not change in group A and in the smoke-free room. Mean platelet volume increased significantly at the 60th minute and continued to increase at the 90th and 120th minute in group B. Mean platelet volume increased significantly at the 30th minute and continued to increase at the 60th, 90th, and 120th minute in group C. In conclusion, acute exposure to passive smoking affected MPV according to the duration and intensity of smoke.
- Long-Term Impact of Multifactorial Treatment on New-Onset... This post hoc analysis of the Assessing The Treatment Effect in Metabolic Syndrome Without Perceptible diabeTes (ATTEMPT) study assesses the 31/2 year incidence of new-onset diabetes (NOD) and related cardiovascular disease (CVD) events in patients with metabolic syndrome (MetS), after multifactorial (lifestyle and drug, including atorvastatin) intervention. Patients were randomized to group A (low-density lipoprotein cholesterol [LDL-C] target <100 mg/dL) and group B (<130 mg/dL). The incidence of NOD during the 42-month follow-up was very low, 0.83 to 1.00/100 patient-years in patients with MetS and MetS with impaired fasting glucose, respectively. Older age, increased waist circumference, and persistent MetS were determinants of NOD. One CVD nonfatal event occurred in the 28 patients with NOD. Our findings suggest that treating the characteristics of MetS is achievable and beneficial. New-onset diabetes incidence and CVD events were negligible and not different from what is expected in the general population.
- The Utility of Collaborative Biobanks for Cardiovascular ... Differences between animal and human atherosclerosis have led to the requirement for clinical data, imaging information and biological material from large numbers of patients and healthy persons. Where such "biobanks" exist, they have been fruitful sources for genomewide association, diagnostic accuracy, ethnicity, and risk stratification cohort studies. In addition once established, they attract funding for future projects. Biobanks require a network of medical contributors, secure storage facilities, bioinformatics expertise, database managers, and ethical working practices to function optimally. There is the opportunity for collaboration between individual biobanks to further amplify the advantages afforded.
- Chest Radiography as a Method of Screening for Occult Can... The occurrence of neoplasms in patients with idiopathic deep vein thrombosis (DVT) may result in a significant reduction in survival rates. The aim of our study was to assess the use of chest X-rays (CXRs) as a screening method of intrathoracic neoplasms in patients who with idiopathic DVT. In observational, cross-sectional study, the medical records of 99 patients with idiopathic DVT, who were submitted to CXR (during the hospital stay or within 30 days after discharge), were investigated. Of these patients, 15.1% had images suggestive of thoracic neoplasias (single or multiple pulmonary nodules and mediastinal widening). Neoplasms were diagnosed in 4 patients in the follow-up with CXR. The CXR is an option of early screening for thoracic neoplasms and other nonmalignant diseases in patients with idiopathic DVT.
- Prevalence and Predictors of Coexistent Silent Atheroscle... Although patients with abdominal aortic aneurysm (AAA) often have other cardiovascular diseases (CVDs), the exact prevalence remains unclear. We aimed to determine the prevalence and predictors of coexistent silent atherosclerotic cardiovascular diseases (SACVDs) in patients with AAA without a history of CVD. Consecutive 157 patients with AAA (mean age, 73 years), without any previous history of CVD, were included. Silent myocardial ischemia (SMI), cerebrovascular disease (CeVD), peripheral artery disease (PAD), and thoracic aortic aneurysm (TAA) without symptoms coexisted in 29.3%, 25.5%, 15.9%, and 8.3%, respectively. The significant predictors of SMI were diabetes mellitus (P = .025) and male sex (P = .048). The significant predictor of silent CeVD was older age (P = .039). The borderline predictors of asymptomatic PAD and TAA were diabetes mellitus (P = .056) and AAA size (P = .053), respectively. Even with no previous symptomatic CVD, patients with AAA have high prevalence of coexistent SACVD.
Scandinavian Cardiovascular Journal
- Temporary emergency pacingan orphan in district hospitals
- Diet and risk of coronary heart disease
- Temporary cardiac pacemaker treatment in five Norwegian r...
- Paroxysmal atrial fibrillation with silent episodes: Inte...
- Validity of the diagnoses atrial fibrillation and atrial ...
- Association between psychological measures and brain natr...
- Aerobic interval training compensates age related decline...
- Surgical treatment of acute pulmonary embolisma 12-year r...
- Lack of C4d deposition may reveal susceptibility for asce...
- Inhalation of hydrogen gas protects against myocardial st...
American Heart Hospital Journal
- Accountability and Transparency in Medical Publishing: Po...
- An Affordable Physician- and Consumer-Friendly Health Car... Winter issues of The American Heart Hospital Journal traditionally focus on health care policy issues. As health care reform in the United States is a topic of major importance in the upcoming presidential election, we invited Dr Regina E. Herzlinger, the Nancy R. McPherson Professor of Business Administration at Harvard University and a noted expert in the field, to provide an analysis of the major proposals currently under debate by the candidates. We invite your comments in the coming months as the field of candidates narrows and the focus on reform sharpens.—Sylvan Lee Weinberg, Editor in Chief
- W. Proctor Harvey, MD
- Specialized Centers and Systems for Heart Attack Care Evidence from randomized controlled clinical trials and registries suggest that primary percutaneous coronary intervention provides superior clinical outcomes when compared with fibrinolytic therapy for the treatment of ST segment elevation myocardial infarction (STEMI). However, the delivery of expert and timely primary percutaneous coronary intervention to the majority of patients with STEMI is extremely challenging. This objective has fueled the concept of regional centers of excellence for the care of patients with STEMI as well as regional STEMI networks similar to those currently available for trauma or stroke victims. This article reviews the rationale behind, as well as the issues inherent to, the development of systems of care for STEMI patients.
- Drug-Eluting Stents for Left Main Coronary Artery Stenosi... The use of coronary stents for the treatment of left main coronary artery (LMCA) stenosis is feasible and is associated with a high rate of procedural success and low rates of early and late complications, such as death, myocardial infarction, and stent thrombosis, in low-risk patient populations. Patients at high risk for coronary artery bypass grafting (CABG), however, have reduced event-free survival after stenting. Compared with bare-metal stents for LMCA disease, the subsequent rate of target lesion revascularization appears to be diminished by use of drug-eluting stents (DESs), with similar or enhanced survival and freedom from myocardial infarction. Intravascular ultrasonographic guidance during the procedure is strongly encouraged to assess the lesion, select an appropriate stenting technique, and achieve optimal stent placement. Results of prospective randomized trials comparing the use of DESs with CABG may be needed to ascertain whether DESs could be a reasonable alternative for patients with LMCA disease.
- In New York State, Do More Percutaneous Coronary Interven... Surgeons allege that fewer coronary artery bypass graft (CABG) operations are being performed because cardiologists are performing more percutaneous coronary intervention (PCI) procedures for monetary gain. The authors reviewed publicly accessible databases from New York State, California, Canada, and Europe for 1997 and 2003. In New York State, the number of CABGs performed fell by one-third. Patient demographics, however, remained unchanged. In contrast, while the number of PCIs substantially increased, the percentage of 3-vessel PCIs remained unchanged. In California, the rate of CABG production (per million population) fell by one-quarter, but it increased in Canada and Europe. In contrast, the rate of PCI production increased in all locations. The performance of fewer CABG procedures in America cannot be entirely explained by cardiologists' increasingly self-referring patients with coronary artery disease for PCI.
- Clinical Correlates of Very High Brain Natriuretic Peptid... While low brain natriuretic peptide (BNP) values have been shown to improve diagnostic accuracy by excluding congestive heart failure in acute dyspnea, the meaning of excessively elevated BNP is not clear. This is a retrospective analysis of clinical, echocardiographic, and laboratory data in patients with BNP values >2500 ng/L. Sixty-seven patients (36 men) with a median age of 79 years were included. The median BNP level was 3118 ng/L (2506–5000 ng/L). Forty-six percent of the patients had no dyspnea or New York Heart Association class II dyspnea. Most patients had impaired renal function. BNP value did not correlate with ejection fraction (r=0.2; P=.15) and weakly correlated with left ventricular end-diastolic diameter index (r=0.26; P=.02). Very high BNP values only poorly correlated with dyspnea and traditional echocardiographic markers of congestive heart failure. The clinical usefulness of very high BNP values is questionable and needs evaluation in a prospective trial.
- Differences in Echocardiographic Indices Between Patients... Partial interatrial block (IAB) (P wave ≥110 ms) is a marker of left atrial abnormality. A similar association among patients with advanced IAB (biphasic P waves ≥110 ms in leads II, III, and aVF) is unknown. The authors screened 27 consecutive patients for advanced IAB with transthoracic echocardiograms (TTEs). Of those, 19 who had repeat TTEs after 2 years formed our study cohort. The authors used 44 consecutive controls with partial IAB who had been similarly screened and had follow-up TTEs 2 years apart. TTE parameters were comparable at baseline between groups but were expectedly different on follow-up. When change (delta value) in these indices was compared, however, only left atrial dimension remained significant (advanced 0.07±0.06 mm vs partial IAB 0.03±0.06 mm; P=.03). Further study over a longer duration is warranted to ascertain if advanced IAB patients would benefit from follow-up noninvasive cardiac imaging for appropriate risk stratification.
- The Prevalence of Brugada ECG in Adult Patients in a Larg... The prevalence of Brugada ECG in the United States is controversial and has not been studied in the western United States. The goal of this study is to evaluate the prevalence of Brugada syndrome appearing on ECGs in a large university hospital located in California. A total of 1348 ECGs performed at a university hospital in southern California in 1995 were randomly selected and reviewed for fulfilling 1 of the 3 types of Brugada criteria. Patients' baseline data were recorded, including age, sex, and race. Only 2 (0.14%) ECGs were consistent with 1 of the 3 types of Brugada syndrome. Both were classified as type 2. One of the patients was an Asian woman and the second was a Hispanic man. The mean age of study population was 52.7±16.2 years and consisted of 55% Caucasian patients followed by 20.8% Hispanic patients. The incidence of Brugada is rare among adult patients at a university hospital in the western United States.
- William Osler, Maude Abbott, Paul Dudley White, and Helen... In 1965, Helen Taussig traced the evolution of knowledge of congenital heart disease (CHD) during the 20th century, beginning with the William Osler-Maude Abbott lineage at McGill University in Montreal, Canada. Osler encouraged Abbott in her CHD pathologic observations. Abbott's London Exhibit (1934) preceded her classic text Atlas of Congenital Cardiac Disease (1936). Taussig's friendship with Abbott (1935) began in Boston; Abbott brought Taussig to meet Paul Dudley White whose text Heart Disease (1931) featured Abbott's work. Taussig visited Abbott (Montreal 1938). Abbott's statistical approach was based on post-mortem malformations; Taussig's concern was why CHD babies died. Abbott (1927) suggested surgery for a patent ductus arteriosus; Taussig conceived of creating a patent ductus arteriosus shunt to improve lung blood flow in cyanotic “blue babies”. Surgeon Alfred Blalock and Taussig collaborated with the blue baby shunt operations (1944–1945), opening the field of cardiac surgery in cyanotic babies. Taussig's Congenital Malformations of the Heart text came 2 years later. Sequential contributions by Osler, Abbott, White, and Taussig were landmarks in the evolution of knowledge of CHD in North America.
Annals of Pediatric Cardiology
- Clinical errors Shyam S KothariAnnals of Pediatric Cardiology 2012 5(1):1-2
- Congenital mitral valve lesions : Correlation between mor... Bo Remenyi, Tom L GentlesAnnals of Pediatric Cardiology 2012 5(1):3-12Congenital malformations of the mitral valve are often complex and affect multiple segments of the valve apparatus. They may occur in isolation or in association with other congenital heart defects. The majority of mitral valve malformations are not simply classified, and descriptive terms with historical significance (parachute, mitral, or arcade) often lack the specificity that cardiac surgeons demand as part of preoperative echocardiographic morphological assessment. This paper examines the strengths and limitations of commonly used descriptions and classification systems of congenitally malformed mitral valves. It correlates pathological, surgical, and echocardiographic findings. Finally, it makes recommendations for the systematic evaluation of the congenitally malformed mitral valve using segmental echocardiographic analysis to assist precise communication and optimal surgical management.
- Mitral valve operations at a high-volume pediatric heart ... Christopher W Baird, Patrick O Myers, Gerald Marx, Pedro J del NidoAnnals of Pediatric Cardiology 2012 5(1):13-20Mitral valve disease is quite variable and can occur as an isolated defect or in association with other complex left sided lesions. These lesions are often best described with detailed pre-operative imaging studies to define the valve anatomy and to access associated left heart disease. Depending on the type of mitral valve disease, various surgical repair techniques have led to improved survival in the recent era. We describe lesion specific approach to mitral valve repair and results.
- Impact of congenital heart disease on brain development i... Moustafa M Abdel Raheem, Walid A MohamedAnnals of Pediatric Cardiology 2012 5(1):21-26Objective: To assess brain development and brain injury in neonates with cyanotic and acyanotic congenital heart disease (CHD). Methods: The study included 52 term infants with CHD who were divided into two groups: Cyanotic (n=21) and acyanotic (n=31). Fifteen healthy neonates of matched age and sex were enrolled in the study as controls. Three-dimensional proton magnetic resonance spectroscopic imaging and diffusion tensor imaging were used to assess brain development and injury. We calculated the ratio of N-acetylaspartate (NAA) to choline (which increases with maturation), average diffusivity (which decreases with maturation), fractional anisotropy of white matter (which increases with maturation), and the ratio of lactate to choline (which increases with brain injury). Results: As compared with control neonates, those with CHD had significant decrease in NAA/choline ratio (P<0.001), significant increase in lactate/choline ratio (P<0.0001), significant increase in average diffusivity (P<0.0001), and significant decrease of white matter fractional anisotropy (P<0.001). Neonates with cyanotic CHD had significant less brain development and more brain injury than those with acyanotic CHD (P<0.05). Conclusions: Newborn infants with cyanotic and acyanotic CHD are at high risk of brain injury and impaired brain maturity.
- The Contegra conduit: Late outcomes in right ventricular ... Anthony A Holmes, Steve Co, Derek G Human, Jacques G LeBlanc, Andrew IM CampbellAnnals of Pediatric Cardiology 2012 5(1):27-33Objectives: To report the clinical outcomes (early death, late death, and rate of reintervention) and performance of the Contegra conduit as a right ventricle outflow tract implant and to determine the risk factors for early reintervention. Methods: Forty-nine Contegra conduits were implanted between January 2002 and June 2009. Data collection was retrospective. The mean age and follow-up duration of Contegra recipients was 3.5 ± 4.6 years and 4.2 ± 2.0 years, respectively. Results: There were three deaths (two early, one late), giving a survival rate of 93.9%. The rate of conduit-related reintervention was 19.6% and was most often due to distal conduit stenosis. Age at implantation of <3 months, receipt of a conduit of 12-16 mm diameter, and a diagnosis of truncus arteriosus were each significant contributors to the rate of reintervention. Conclusion: The Contegra is a cost-effective and readily available solution. However, there is a limited range of larger calibers, which means that the homograft conduit (>22 mm) remains the first choice of implant in older children. The rates of reintervention are significantly higher with a diagnosis of truncus arteriosus, age at implantation of <3 months, and implantation of conduits sized 12-16 mm.
- The Contegra bovine jugular valved conduit: Living up to ... Krishna S IyerAnnals of Pediatric Cardiology 2012 5(1):34-35
- Pulmonary artery banding in the current era: Is it still ... Maziar Gholampour Dehaki, Ali Sadeghpour Tabaee, Changiz Azadi Ahmadabadi, Alireza Alizadeh Ghavidel, Gholamreza OmraAnnals of Pediatric Cardiology 2012 5(1):36-39Background: The objective of this study was to assess the results of the pulmonary artery (PA) banding in patients with congenital heart defects (CHD) and pulmonary hypertension (PH) in the current era. Methods: We analyzed data from 305 patients who underwent PA banding between April 2005 and April 2010 at our centre. All patients were approached through a left thoracotomy. Twenty percent of patients underwent PA banding based on Trusler's rule (Group 1), 55% of them underwent PA banding based on PA pressure measurement (Group 2), and the rest of them (25%) based on surgeon experience (Group 3). The follow-up period was 39 ± 20 month and 75% of patients (230 cases) had definitive repair at mean interval 23 ± 10 months. Results: The rate of anatomically and functionally effectiveness of PA banding in all groups was high (97% and 92%, respectively). There were no significant differences in anatomically and functionally efficacy rate between all groups (P=0.77, P=0.728, respectively). There was PA bifurcation stenosis in six cases (2%), and pulmonary valve injury in one case (0.3%). The mortality rate in PA banding was 2% and in definitive repair was 3%. Conclusions:We believe that PA banding still plays a role in management of patients with CHD, particularly for infants with medical problems such as sepsis, low body weight, intracranial hemorrhage and associated non cardiac anomalies. PA banding can be done safely with low morbidity and mortality.
- Pulmonary artery banding: Rationale and possible indicati... Rajesh SharmaAnnals of Pediatric Cardiology 2012 5(1):40-43
- Neonatal pulmonary artery thrombosis Mangesh Jadhav, Ashish Sapre, Swati Garekar, Snehal KulkarniAnnals of Pediatric Cardiology 2012 5(1):44-46Pulmonary artery thrombosis in neonates is a rare entity. We describe two neonates with this diagnosis; their presentation, evaluation, and management. These cases highlight the importance of this differential diagnosis when evaluating the cyanotic neonate.
- "Vanishing" pulmonary valve stenosis Nofil I Arain, James H Moller, Lee A Pyles, Shanthi SivanandamAnnals of Pediatric Cardiology 2012 5(1):47-50Objective: Both spontaneous resolution and progression of mild pulmonary valve stenosis (PS) have been reported. We reviewed characteristics of the pulmonary valve (PV) to determine factors that could influence resolution of mild PS. Methods: Fifteen asymptomatic pediatric patients with spontaneous resolution of isolated mild PS were retrospectively reviewed. Results: There was no correlation between the PV gradient, clinical presentation, age at diagnosis, or PV morphology. The PV annulus was small at initial presentation, which normalized at follow up. When corrected for the body surface area (z-score), the PV annulus was normal in all patients, including at initial evaluation. Conclusions: Based on our observation, neither age at diagnosis, nor PV-morphology-influenced resolution of mild PS. The variable clinical presentation makes it difficult to categorize and observe mild PS by auscultation alone. The PV annulus z-score could be a useful adjunct to determine the course and serial observation of mild PS.
The Journal of Clinical Hypertension
- Relationship of Resistant Hypertension and Treatment Outc... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.Resistant hypertension (RH) affects 8% to 30% of hypertensive patients. Blood pressure (BP) reflects the interaction between vascular compliance, resistance to flow, intravascular volume, and cardiac contractility. The relationship of RH with total arterial compliance index (TACI) has not been adequately explored. The RH period prevalence (RH at baseline or follow-up) was determined in a hypertensive cohort (N=156) and compared across quartiles of TACI. Age- and sex-adjusted systolic BP, diastolic BP, and antihypertensive therapeutic intensity score (TIS) were also determined at the time of first BP control. The cohort was 85.3% African American and 67.3% female. Median follow-up was 7 months. The prevalence of RH at baseline was 14.7% while the period prevalence was 43.6%. The period prevalence of RH by ascending quartile for TACI was 66%, 36.8%, 40%, and 30.8% (P=.008). The average BP and antihypertensive TIS at first BP control across TACI quartiles was 122.3/73.4 mm Hg (2.26), 120.7/72.5 mm Hg (1.88), 122.4/75.3 mm Hg (1.71), and 120.0/79.4 mm Hg (1.64) (P=.62, P=.03, P=.13). Low TACI was linked to higher RH prevalence and antihypertensive TIS at first attainment of goal BP according to the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. TACI provides prognostic information that is clinically and perhaps pathophysiologically relevant in RH.
- Aggressive Blood Pressure–Lowering Therapy Guided by Ho... J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.The authors tested the hypothesis that an aggressive antihypertensive treatment is beneficial in protecting against target organ damage (TOD) in patients with type 2 diabetes/prediabetes. The authors enrolled 60 patients with uncontrolled hypertension and diabetes/prediabetes and performed clinic, home, and ambulatory blood pressure (BP) monitoring. Irbesartan, amlodipine, and indapamide were used according to a titration schedule from step 1 to 5 for target home BP level ≤125/75 mm Hg. The flow-mediated vasodilation (FMD), radial augmentation index (AI), pulse wave velocity (PWV), and urinary albumin excretion ratio (UACR), as a surrogate marker of TOD, were measured at baseline and 6 months. Compared with baseline, clinic, home, and ambulatory BP measures were significantly lower in the sixth month. FMD was increased significantly and AI, PWV, and UACR were reduced by the treatment. The extent of the changes in PWV and UACR were associated with the changes in all BP measures, but only the change in home morning BP was associated with the change in FMD. The change in AI was not associated with the change in BP levels, but was associated with the change in PWV. A very aggressive antihypertensive therapy guided by home morning BP was effective for surrogate end points in patients with diabetes/prediabetes.
- Are Sleep Symptoms Predictors of Resistant Hypertension i... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.The aim of this study was to test the association of self-reported sleep symptoms to those identified with severe hypertension in a nationally representative sample of adults. Self-reported and study-measured health and sleep characteristics were collected by the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008. Of 10,526 individuals with completed sleep surveys participating in the study, the authors identified 379 patients with severe hypertension defined as those treated with ≥3 antihypertensive medications including a diuretic; 110 of these had resistant hypertension (RHTN) despite therapy, while 269 were controlled for severe hypertension (CSHTN). Patients with RHTN were more likely to be married, less educated, smoke, and self-report unsatisfactory health and diabetes when compared with patients with CSHTN. Multivariate analyses showed that poorly controlled diabetes (glycated hemoglobin >7%) was the strongest predictor of RHTN (odds ratio, 3.0; 95% confidence interval, 1.2–7.9). Unsatisfactory health (odds ratio, 1.7; 95% confidence interval, 1.7–2.7) was also associated with RHTN. Poorly controlled diabetes and self-reported unsatisfactory heath showed significant association with RHTN. Contrary to expectations, there was no significant association between self-reported snoring/snorting and RHTN, when other factors were examined. The association between poorly controlled diabetes and RHTN warrants further emphasis on strict control of diabetes in these individuals.
- Dietary Supplements and Hypertension: Potential Benefits ... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.Dietary supplements (DSs) are used extensively in the general population and many are promoted for the natural treatment and management of hypertension. Patients with hypertension often choose to use these products either in addition to or instead of pharmacologic antihypertensive agents. Because of the frequent use of DS, both consumers and health care providers should be aware of the considerable issues surrounding these products and factors influencing both efficacy and safety. In this review of the many DSs promoted for the management of hypertension, 4 products with evidence of possible benefits (coenzyme Q10, fish oil, garlic, vitamin C) and 4 that were consistently associated with increasing blood pressure were found (ephedra, Siberian ginseng, bitter orange, licorice). The goals and objectives of this review are to discuss the regulation of DS, evaluate the efficacy of particular DS in the treatment of hypertension, and highlight DS that may potentially increase blood pressure.
- Prognostic Impact of Baseline Low Blood Pressure in Hyper... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.The authors’ aim was to investigate the prognostic value of first-visit systolic and diastolic blood pressure (SBP/DBP) in hypertensive patients with stable coronary artery disease (sCAD) in conditions of contemporary daily clinical practice. From February 1, 2000, to January 31, 2004, 690 consecutive hypertensive patients with sCAD (mean age 68±10 years, 65% male) were prospectively followed in the outpatient cardiology clinic for major events (acute coronary syndrome, revascularization, stroke, heart failure, or death) and associations with baseline SBP/DBP were investigated. At first visit, median SBP/SDP were 130/75 mm Hg (interquartile range, 25–75; 120–140/70–80 mm Hg). After 25 months of follow-up (median), 19 patients died (2.8%); 10 from cardiovascular causes (1.5%), 87 patients experienced a coronary event (13%), and 130 patients (19%) a major event. After adjusting for baseline variables, DBP <75 mm Hg or SBP <130 mm Hg resulted in independent predictors of major events (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.07–2.16, P=.02; HR, 1.68; 95% CI, 1.18–2.40, P=.004, respectively), coronary events (HR, 1.78; 95% CI, 1.15–2.75, P=.009; HR, 1.84; 95% CI, 1.20–2.83, P=.005, respectively), and cardiovascular mortality (HR, 7.02; 95% CI, 1.26–39.04, P=.03; HR, 9.26; 95% CI, 1.33–64.32, P=.02, respectively). In this study, a low first-visit SBP or DBP was associated with an adverse prognosis in hypertensive patients with sCAD of contemporary daily clinical practice.
- Primary Aldosteronism in a Patient Who Exhibited Heart Fa...
- Antihypertensive Drug Use By Children: Are the Drugs Labe... J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.As a result of the Food and Drug Administration (FDA) Modernization Act and the Best Pharmaceuticals for Children Act, the number of medications with FDA-approved pediatric labeling has increased. To assess the success of these initiatives, we examined whether antihypertensive drugs used by children with hypertension in 2008 had FDA-approved pediatric labeling and indications. Using a nationwide commercial insurer database, 2915 children with primary (n=2607) and secondary (n=308) hypertension were identified. Drug user rate and days of supply were calculated from pharmacy claims. Drugs were categorized based on pediatric labeling and indication and whether they were recommended for pediatric use. Antihypertensive drugs were used by 889 (34%) children with primary hypertension and 200 children (65%) with secondary hypertension. User rates were 44.3% in hypertensive children younger than 6 years, 30.9% in those 6 years to older than 12 years, and 38.1% in those 12 years to older than 18 years. Seven percent of drugs were neither labeled for pediatric use nor considered recommended for use in children. In children younger than 6 years, 29% of drugs used were not indicated for use in that age group. Despite recent legislative initiatives, many drugs used by hypertensive children still lack pediatric labeling. Additional efforts are needed to close the gap between the availability of drugs that are labeled and indicated for pediatric use and actual drug usage in children.
- Pediatric Ambulatory Blood Pressure Monitoring: Indicatio... J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc.The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient’s BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.
- The Present and Future of the American Society of Hyperte...
- Correlation of Blood Pressure Readings From 6-Hour Interv... J Clin Hypertens (Greenwich). 2012;00:000–000. ©2012 Wiley Periodicals, Inc.Shorter-interval (6-hour) ambulatory blood pressure monitoring (ABPM) has been shown to correlate well with 24-hour ABPM in adults, but this has not been studied in children. The authors selected 131 patients aged 9 to 18 who underwent 24-ABPM from 2000–2008. Six-hour intervals beginning at different start times were compared with the daytime and 24-hour period, with subset analysis for normotensive and hypertensive patients. Concordance correlation coefficients (CCCs) were used to assess for agreement. Among normotensive patients, the mean difference between daytime and 6-hour intervals ranged from −0.1 mm Hg to 0.0 mm Hg for diastolic blood pressure (DBP) and −1.1 mm Hg to 0.6 mm Hg for systolic blood pressure (SBP) with CCCs of 0.88 to 0.93 for DBP and 0.93 to 0.96 for SBP. For hypertensive patients, mean difference ranged from −0.6 to 1.3 mm Hg for DBP and −0.8 to 1.1 mm Hg for SBP with CCCs of 0.89 to 0.98 for DBP and 0.86 to 0.95 for SBP. Shorter-interval monitoring correlates significantly with full daytime monitoring in children, allowing for assessment of blood pressure with improved convenience.
Journal of Cardiac Surgery
- Inflammatory Pseudotumor Arising from the Right Ventricul... Abstract Inflammatory pseudotumor (also known as inflammatory myofibroblastic tumor) is an uncommon spindle cell lesion that was initially recognized in the lung and is now known to occur in virtually every major organ of the body. We report a case of a seven-year-old male who had an inflammatory pseudotumor of the right ventricular outflow tract involving the pulmonary valve causing pulmonary stenosis.(J Card Surg 2012;**:1-3)
- Primary Cardiac T Cell Lymphoma Abstract We report a case of primary cardiac T-cell lymphoma. The diagnosis and management of this unusual primary tumor is reviewed.(J Card Surg 2012;**:1-3)
- Response
- Letter to Editor (J Card Surg 2012;xx:1-2)
- Efficacy of Fibrinogen/Thrombin-Coated Equine Collagen Pa... Abstract We report the use of fibrinogen/thrombin-coated equine collagen patch (Tachosil®) as a sealant agent in six patients who underwent heart surgery for congenital heart disease (CHD) and developed an intraoperative lymphatic leakage detected at the time of surgery. The use of fibrinogen/thrombin-coated equine collagen patch proved to be safe and effective in preventing the development of postoperative chylothorax. (J Card Surg 2012;**:1-2)
- Cardiac Surgery in Patients with Fabry's Disease: Review ... Abstract Fabry's disease is a rare but important cause of structural cardiac disease that may influence cardiac surgical decision making. Herein we present a case of mitral valve repair in a patient with Fabry's disease and review the cardiac-related literature on this lysosomal storage disease.(J Card Surg 2012;**:1-3)
- Right Ventricular Blood Cyst Causing Outflow Tract Obstru... Abstract Blood cysts are benign intracardiac masses that are well described in infants. We present a rare adult presentation of a blood cyst tethered to the right ventricular wall and the tricuspid valve causing right ventricular outflow obstruction. Multimodality imaging approach was found to be of great importance in the diagnosis and treatment of this patient. (J Card Surg 2012;**:1-2)
- Unprotected Left Main Coronary Artery Disease—Coronary ... doi: 10.1111/j.1540-8191.2012.01452.x(J Card Surg 2012;**:1-2)
- Percutaneous Mitral Valve Repair in Patients with Prior C... Abstract Background and aim of the study: The safety of percutaneous mitral valve repair with the MitraClip system has been documented. However, few data are available on high-risk patients not amenable to surgery. The aim of this study was to evaluate the outcomes of patients with prior cardiac surgery undergoing MitraClip therapy (Abbott, Abbott Park, Chicago, IL, USA) for severe mitral regurgitation. Methods: We reported two cases of percutaneous treatment of severe mitral regurgitation performed in patients who had previously undergone cardiac surgery with the implantation of mechanical prosthetic aortic valve. Results: In both the reported cases a sustained reduction in mitral regurgitation severity was obtained at two-year follow-up, with a relevant improvement in terms of clinical status and quality of life. Conclusions: Percutaneous mitral valve repair using the MitraClip system represents a viable treatment choice for severe mitral regurgitation in high-risk patients who have previously undergone cardiac surgery. (J Card Surg 2012;27:295-298)
- Modified Anastomosis for Repair of Supracardiac Total Ano... Abstract Recurrent pulmonary venous obstruction after repair of total anomalous pulmonary venous connection (TAPVC) is usually restricted to the anastomosis between the pulmonary venous confluence and the left atrium. We describe a modified technique for repair of supracardiac TAPVC in infants. An L-shaped incision of left atrium is utilized and the right-sided anastomosis is enlarged by using autologous pericardium to create a large and tension-free anastomosis. (J Card Surg 2012;XX:1-3)
Journal of Cardiopulmonary Rehabilitation and Prevention
- Long-term Efficacy of Pulmonary Rehabilitation: A STATE-O... PURPOSE: While the short-term efficacy of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) is well documented, less is known about its sustainability and long-term effects in non-COPD patients, as well as secondary effects on exacerbation rates and the use of health care resources. METHODS: We conducted a MEDLINE literature search on studies of pulmonary rehabilitation from the years 2000 to 2010. For each study, design, modalities, and outcomes were tabulated. RESULTS: Design, group size, and duration of followup varied considerably between studies. Fifteen studies assessed physical performance, quality of life, or dyspnea in patients with COPD up to 24 months after rehabilitation. Six studies conducted followup evaluations in patients with interstitial lung disease, and 1 study considered asthma. Exacerbation rates and the use of health care resources were assessed in 20 studies in COPD and in 1 study in asthma. Results indicated the maintenance of the primary effects up to 1 year after pulmonary rehabilitation in COPD, while such effects were less pronounced in patients with interstitial lung disease. Secondary improvements regarding exacerbation rates and the use of health care resources were not consistent throughout studies and diseases. CONCLUSIONS: Pulmonary rehabilitation has positive short- and long-term functional effects in COPD and more recent research supports improvements of exacerbation rates and the use of health care resources as secondary outcomes of pulmonary rehabilitation. Additional research on long-term efficacy regarding secondary effects and non-COPD patients is essential.
- Can Individuals Participating in Cardiac Rehabilitation A... PURPOSE: Cardiac rehabilitation (CR) has been recommended to provide exercise guidance poststroke. However, it has not been established whether minimal exercise training levels, sufficient for obtaining health benefits, can be attained in CR. Therefore, we assessed the ability of stroke patients to achieve recommended exercise levels during a single standard CR session following completion of CR. METHODS: Sixteen patients (10 males and 6 females) with mild/moderate motor impairments who had completed CR participated in the study. Resting metabolic rate and oxygen uptake during 30 minutes each of aerobic and resistance training (AT, RT, respectively) were assessed by ambulatory oxygen monitor. Obtained values were compared with recommended minimal levels, that is, 20 or more minutes of exercise at 40% or more of peak oxygen uptake ( O2peak), 30 or more minutes of exercise at 3 or more metabolic equivalents (METs) (multiples of resting metabolic rate), and an energy expenditure of approximately 200 kcal per session. RESULTS: Mean time sustaining 40% or more of O2peak was 47.6 ± 9 minutes, exceeding the minimal target of 20 minutes (P < .001). Time sustaining 3 or more METs was 30.8 ± 12.2 minutes, matching the target of 30 minutes (P = .8). Total energy expenditure (252 ± 49.9 kcal) was significantly greater than the target value of 200 kcal (P = .001). CONCLUSIONS: Chronic stroke patients with mild/moderate motor impairments are able to meet or exceed minimal recommended exercise target levels for intensity, duration, and energy expenditure during a typical exercise session consisting of 30 minutes of AT combined with 30 minutes of RT after completing CR. These data contribute to the evidence promoting the efficacy and feasibility of CR for people following stroke.
- Perceptions of Cardiac Specialists and Rehabilitation Pro... BACKGROUND: Access to cardiac rehabilitation (CR) remains at approximately 30%, despite a national target of 70%. This study evaluated cardiac specialist and CR program perceptions of CR access and referral strategies. METHODS: Postal and online surveys of Canadian CR specialists and CR programs were administered. Responses were received from 71 of 765 CR specialists (9.3%) and 92 of 149 CR programs (61.7%). Respondents rated perceptions on 5-point Likert scales. RESULTS: Specialists rated patient access to CR as moderate (2.9 ± 1.4). While they reported that they refer 65.9% of their patients, they most frequently do not refer because their patients report disinterest (23.4%) or geographic barriers to access (23.4%). Cardiac rehabilitation programs reported having capacity to serve a median of 275 patients annually, yet reportedly serving up to 350. The most commonly used methods of referral included discharge order sets (over 60%) and allied health care provider support. Electronic referral was perceived to be highly effective (4.1 ± 1.0) yet the least frequently used. Cardiac rehabilitation programs perceived more patients are accessing CR because of these referral strategies, but increased patients strain program resources. CONCLUSIONS: Some of the least frequently used referral strategies were perceived as, and are also empirically demonstrated to be, most effective. Broader implementation of these strategies, while better-resourcing CR programs, may improve the continuum of care for cardiac patients.
- Patients With Heart Failure in the “Intermediate Range... PURPOSE: While patients with heart failure who achieve a peak oxygen uptake (peak O2) of 10 mL·kg−1·min−1 or less are often considered for intensive surveillance or intervention, those achieving 14 mL·kg−1·min−1 or more are generally considered to be at lower risk. Among patients in the “intermediate” range of 10.1 to 13.9 mL·kg−1·min−1, optimally stratifying risk remains a challenge. METHODS: Patients with heart failure (N = 1167) referred for cardiopulmonary exercise testing were observed for 21 ± 13 months. Patients were classified into 3 groups of peak o2 (≤10, 10.1–13.9, and ≥14 mL·kg−1·min−1). The ability of heart rate recovery at 1 minute (HRR1) and the minute ventilation/carbon dioxide output ( E/ co2) slope to complement peak o2 in predicting cardiovascular mortality were determined. RESULTS: Peak o2, HRR1 (34) were independent predictors of mortality (hazard ratio 1.6, 95% CI: 1.2–2.29, P = .006; hazard ratio 1.7, 95% CI: 1.1–2.5, P = .008; and hazard ratio 2.4, 95% CI: 1.6–3.4, P < .001, respectively). Compared with those achieving a peak o2 ≥ 14 mL·kg−1·min−1, patients within the intermediate range with either an abnormal E/ co2 slope or HRR1 had a nearly 2-fold higher risk of cardiac mortality. Those with both an abnormal HRR1 and E/ co2 slope had a higher mortality risk than those with a peak o2 ≤ 10 mL·kg−1·min−1. Survival was not different between those with a peak o2 ≤ 10 mL·kg−1·min−1 and those in the intermediate range with either an abnormal HRR1 or E/ co2 slope. CONCLUSIONS: HRR1 and the E/ co2 slope effectively stratify patients with peak o2 within the intermediate range into distinct groups at high and low risk.
- Effects of Sauna Alone Versus Postexercise Sauna Baths on... PURPOSE: We measured the effects of sauna bathing alone or a 30-minute exercise session followed by sauna bathing on short-term heart rate variability (HRV) in subjects with untreated hypertension. METHODS: Ten patients with untreated hypertension (age 59 ± 10 years) were randomly assigned to (1) a control resting session, (2) two 8-minute sauna-only sessions (S), or (3) a 30-minute aerobic exercise session at 75% of maximal heart rate followed by a sauna session (ES). Spectral analysis of HRV was measured with a Polar S810 heart rate monitor at baseline, during the sauna session, and 15 and 120 minutes after the sauna session (T15 and T120). A Fast Fourier Transformation was used to quantify the power spectral density of the low-frequency (LF) and high-frequency (HF) bands. RESULTS: For S and ES conditions, LF (NU, normalized unit) and LF/HF were significantly higher (P < .05 and P < .01) in the first and second sauna sessions, and HF (NU) was significantly lower (P < .05, first sauna). At baseline and T15 for S and ES versus control, LF (NU) and LF/HF were significantly higher (P < .05), and HF (NU) was significantly lower (P < .05), without any effect of the 30-minute exercise session. CONCLUSIONS: A single sauna session induced a significant alteration of autonomic cardiovascular control in patients with untreated hypertension, with an increased sympathetic and decreased parasympathetic drive. These alterations were normalized within 15 to 120 minutes after sauna bathing. Additional studies are required to document long-term effects of chronic sauna bathing on autonomic control in patients with hypertension.
- Effect of Exercise Training in Patients With Chronic Obst... PURPOSE: Exercise training in patients with chronic obstructive pulmonary disease (COPD) can be challenging because whole-body exercise often elicits disabling symptoms of dyspnea before the exercising muscles reach their critical limits. The extent that this factor limits training has not been totally defined. The purpose of this study was to compare the response to training of patients with moderate to severe COPD with that achieved by healthy elderly subjects who were exercising using an identical program. METHODS: Eight healthy subjects and 20 patients with COPD (forced expiratory volume in 1 second 42 ± 13% predicted) exercised 3 times a week for 8 weeks. Outcome measures included 6-minute walk distance, maximal exercise capacity (Wmax) during an incremental cycle ergometer test, and submaximal constant workload (60%-70% of subject Wmax) exercise time. RESULTS: Six-minute walk distance and Wmax increased after training to a significantly greater extent in the healthy controls compared with the patients with COPD; 65 ± 24 versus 32 ± 50 m, P = .03; and 25.1±13.9 versus 11.5±13.1 watts, P = .025, respectively. However, these differences disappeared when data were expressed as percent improvement, 12.1 ± 5.3% versus 10.0 ± 15.8%, and 25.6 ± 13.5% versus 23.1 ± 33.3%. Improvement in submaximal constant workload exercise time after training was similar in healthy controls 21.6 ± 6.1 versus patients with COPD 18.8 ± 11.2 minutes. CONCLUSIONS: Patients with COPD can show similar relative improvements in exercise capacity compared with healthy elderly subjects. The difference in absolute values reflects, at least in part, the greater baseline exercise capacity.
- Early Rehabilitation Exercise Program for Inpatients Duri... PURPOSE: To determine whether an early rehabilitation program was safe and feasible for patients during an acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: In this phase 1 randomized controlled trial, patients with an acute exacerbation of COPD admitted to the hospital were randomly allocated to a low-intensity exercise group, a moderate- to high-intensity exercise group, or a control group, who received routine physical therapy. In addition to routine physical therapy, patients in the exercise group had to participate in an exercise program. The program consisted of twice-daily aerobic and resistance exercise sessions. Primary outcomes were the number and classification of adverse events and program adherence. RESULTS: In 174 exercise sessions, there was 1 serious adverse event of arrhythmia in the low-intensity exercise group that resolved within 1 hour. There were 12 other minor adverse events involving 5 patients with no significant differences between groups. Patients completed an average of 80% of their scheduled sessions with no significant between-group differences. The exercise groups improved significantly in walking distance; however, no significant between-group differences were observed. CONCLUSIONS: There was preliminary evidence that it was safe and feasible to implement an exercise program for patients during an acute exacerbation of COPD. Additional studies with larger sample sizes are required to accurately evaluate program effectiveness.
- Selected Abstracts From Recent Publications in Cardiopulm... No abstract available
Vascular and Endovascular Surgery current issue
- Preoperative Cardiac Evaluation of the Vascular Surgery P... The morbidity and mortality associated with vascular surgery procedures are largely the results of cardiac events. National guidelines have been regularly proposed and updated by the American College of Cardiology (ACC)/American Heart Association (AHA) to ensure optimal perioperative management and risk stratification. Controversy remains between experts and other cardiology societies regarding several patient care issues including revascularization before surgery, timing of β-blocker therapy, and the administration of antiplatelet therapy. Several landmark articles recently published have helped to modify the guidelines in the hope of improving vascular patient outcomes. In this review, we searched all recent available literature pertaining to perioperative cardiac evaluation before major vascular surgery. We propose an algorithm for preoperative cardiac evaluation, which is a modification to the AHA recommendations. Incorporated in this algorithm are recent published pivotal articles that can help in guiding physicians caring for the vascular patient requiring major operative or endovascular interventions.
- The Use of Antithrombotic Therapies in Reducing Synthetic... Background. Thrombosis of synthetic small-diameter bypass grafts remains a major problem. The aim of this article is to review the antithrombotic strategies that have been used in an attempt to reduce graft thrombogenicity. Methods. A PubMed/MEDLINE search was performed using the search terms "vascular graft thrombosis," "small-diameter graft thrombosis," "synthetic graft thrombosis" combined with "antithrombotic," "antiplatelet," "anticoagulant," "Dacron," "PTFE," and "polyurethane." Results. The majority of studies on antithrombotic therapies have used either in vitro models or in vivo animal experiments. Many of the therapies used in these settings do show antithrombotic efficacy against synthetic graft materials. There is however, a distinct lack of human in vivo studies to further delineate the performance and limitations of therapies displaying good antithrombotic characteristics. Conclusion. Very few antithrombotic therapies have translated into clinical use. More human in vivo studies are required to assess the efficacy and safety of such therapies.
- Anemia is Associated With Mortality Following Endovascula... Aim: The aim of this study was to compare midterm mortality between anemic and nonanemic patients undergoing endovascular repair of abdominal aortic aneurysm and to assess a correlation with markers of inflammation. Methods: Anemia was defined as hemoglobin <13 (men) and <12 g/dL (women). The impact of anemia and inflammatory markers on mortality was assessed using Kaplan-Meier curves and Cox regression. Results: A total of 224 patients (12 females [5.36%]; age: 69.73 ± 8.72 years) were included; 102 (45.53%) were anemic. Median follow-up was 17 months (interquartile range: 7-25 months). Nine patients died (1.79%; 8 anemic vs 1 nonanemic). Survival was lower for patients with anemia (log-rank, P = .01). White blood cell count and C-reactive protein (CRP) differed significantly (P < .001 and P = .01). Anemia and CRP were associated with decreased survival (Cox regression, P = .01, hazard ratio [HR]: 0.35, 95% confidence interval: 0.14-0.84 and P = .002, HR: 1.18, 95% CI: 1.06-1.31). Conclusion: Patients with anemia had decreased survival over the midterm; inflammatory markers were higher among this group.
- Comparison of Embolic Load in Femoropopliteal Interventio... Purpose: To compare the incidence of distal emboli occurring during percutaneous transluminal angioplasty (PTA) and primary stent on the superficial femoral artery (SFA) Methods: A total of 50 consecutive patients were entered in a prospective, randomized trial. Inclusion criteria were the presence of symptomatic limb ischemia due to stenosis or occlusion of the SFA. An embolic protection device was placed in the popliteal artery. The patients were then randomly assigned to undergo primary stent implantation or PTA. The filters were retrieved and sent for histologic examination. Results: Stenting in the SFA produced more emboli (1.44 mm3) than PTA (0.772 mm3), P = .031. Reanalyzing the patients according to actual treatment performed, volume of debris in the stent group was 1.271 mm3 and in the PTA group was 0.191 mm3, P = .00087. Conclusion: Volume of embolized material during endovascular interventions in the SFA-above-knee popliteal artery is higher when a stent is used.
- Buttock Claudication After Interventional Occlusion of th... Background. Interventional occlusion of the hypogastric artery (HA) can be used for endovascular aneurysm repair (EVAR) in the iliac arteries. Most frequent ischemic complication is buttock claudication (BC). Aim. To investigate the frequency and progression of BC after interventional occlusion of the HA prior to EVAR. Methods. A retrospective analysis was performed in patients with EVAR and occlusion of the HA between September 2004 and August 2010. Acute and persistent BC symptoms were assessed. Results. Fifty-four catheter occlusions of the HA were performed. In 10 cases, claudication could not be evaluated. During a mean follow-up of 17 months, 23 occlusions (52.3%) of the HA showed BC, in 52% symptoms were persistent. Of the 5 patients, 3 patients who underwent bilateral occlusion had BC and in 2 cases, persistent in the follow-up. Conclusion. Buttock claudication after occlusion of the HA prior to EVAR is a frequent complication, which often persists during follow-up. Alternatives that maintain pelvic perfusion should be considered.
- C-Reactive Protein and the Framingham Coronary Risk Score... Objective: To investigate the relationship between serum C-reactive protein (CRP) levels and the calculated 10-year Framingham risk score (FRS) in patients newly diagnosed with intermittent claudication. Methods: Serum CRP levels were measured in 90 patients newly diagnosed with intermittent claudication over a 12-month period. In all, 76 patients (53 males [70%], mean age 63.3 ± 9.3) were included in the analysis. Results: Log-transformed CRP levels significantly correlated with total FRS (r = .34, P = .002). Participants were divided into 4 groups according to log-CRP levels. Analysis of variance showed a statistically significant difference between the 4 groups in terms of mean FRS, P = .003. Post hoc comparisons indicated that group 1 was significantly different from group 4, P = .002. Analysis of covariance showed a significant difference between the 4 groups of log-CRP levels in terms of mean FRS, P = .008. Conclusion: There is an increased 10-year risk of coronary heart disease associated with increased plasma concentration of CRP in patients newly diagnosed with intermittent claudication.
- External Iliac Artery Stenting: High Incidence of Concomi... Objectives: To review immediate results, patency rates, hemodynamic success, and incidence of concomitant procedures with external iliac artery stenting (EIAS). Methods: Demographic features, category and clinical grade, Trans-Atlantic Inter-Society Consensus II classification lesion type, pre- and postprocedure ankle–brachial indices, and primary patency were compared between group 1 (EIAS without distal revascularization) and group 2 (EIAS with concomitant distal revascularization). Results: No mortality and a 100% immediate technical success rate was recorded in group 1 (n = 12) and group 2 (n = 24). Eleven patients (30.6%) also had stenting of the adjacent common iliac artery. Two thirds of group 2 patients required concomitant femoral or distal revascularization. Conclusions: No difference in stent patency rates was found between patients in group 1 versus group 2. Patients requiring EIAS tend to have more diffuse arterial disease necessitating complicated open reconstruction and/or distal revascularization, as well as more proximal iliac stenting.
- Treatment of Type II Endoleaks With Ethylene-Vinyl-Alcoho... We report our single-center experience in treating 101 type II endoleaks with ethylene-vinyl-alcohol copolymer (EVOH, Onyx). In all, 65 endoleaks were embolized transarterially, and 36 were treated through a translumbar approach. Since the first transarterial embolization, when we began attempts to treat all patients initially via common femoral access, 58 (65.9%) of 88 patients were successfully embolized transarterially. All endoleaks in the translumbar group were successfully treated. At a median follow-up length of 15 weeks, a decrease or stabilization in aneurysm size was observed in 39 (73.6%) of the 53 endoleaks that had adequate follow-up computed tomography imaging. The overall residual endoleak rate was 34.0%. There was no difference in efficacy when comparing transarterial and translumbar approaches. We demonstrate that in most cases, transarterial access of the endoleak nidus is feasible, and controlled embolization is possible using EVOH. Furthermore, EVOH appears effective in long-term stabilization of aneurysm size and in preventing residual endoleaks.
- Aortic Aneurysmal Repair With Surtureless Visceral Revasc... This article details a novel technique in the treatment of a symptomatic thoracoabdominal aneurysm (TAA) involving the visceral segment and an infrarenal abdominal aortic aneurysm. The patient was treated in a 2-staged hybrid approach combining an endovascular repair of the infrarenal segment, followed by open TAA repair. The large visceral arteries were revascularized using expanded polytetrafluoroethylene GORE Hybrid Vascular Graft (GHVG) and a Gradual Funneling Technique with Dacron graft. This method assured a complete hemostatic seal and minimized visceral ischemic time. To our knowledge, this is the first case of sutureless visceral artery revascularization using GHVG reported in the literature.
- Endovascular Management of Vascular Complications in Panc... Vascular complications after pancreatic transplantation carry a high rate of graft loss. Endovascular management of these complications is confined to stent placement for iliac artery inflow disease and embolization for arteriovenous fistulae (AVFs), pseudoaneurysms, or active bleeding. The current study describes the endovascular management of pancreatic transplant venous thrombosis (N = 1), arterial stenosis (N = 5), thrombosis (N = 3), pseudoaneurysms (N = 1), and AVF (N = 2). In addition, embolization of nonfunctioning grafts is described as an endovascular alternative to pancreatectomy.
JACC Cardiovascular Imaging
- Impact of Aortic Regurgitation After Transcatheter Aortic... Objectives Understanding the severity of aortic regurgitation (AR) after transcatheter aortic valve implantation, its impact on left ventricular (LV) structure and function, and the structural factors associated with worsening AR could lead to improvements in patient selection, implantation technique, and valve design. Background Initial studies in patients at high risk of surgical aortic valve replacement have reported both central valvular and paravalvular AR after transcatheter aortic valve implantation. Methods Transthoracic echocardiograms were quantified from 95 patients in the REVIVAL (TRanscatheter EndoVascular Implantation of VALves) trial. Transthoracic echocardiograms were obtained before implantation of the Edwards-Sapien valve (Edwards Lifesciences, Irvine, California) and thereafter at selected intervals. Measurements included LV internal diameters and volumes, ejection fraction, aortic valve area, and the degree of aortic regurgitation. Measures of degree of native leaflet mobility, thickness, and calcification, as well as left ventricular outflow tract, aortic annulus, and aortic root diameters were also made. Results Eighty-four patients remained after 11 were excluded; 26 (29.8%) died over a period of 3 years. At 24 h post-implantation, 75% had some degree of AR, mostly paravalvular. By 1 year, the mean AR grade increased slightly, but not significantly (1.1 ± 0.8 to 1.3 ± 0.9), and all measures of LV structure and function improved (LV ejection fraction, 50.7 ± 16.1% to 59.4 ± 14.0%). Native aortic leaflet calcification and annulus diameter correlated significantly with the severity of AR at 1 year (p < 0.05). Conclusions AR after transcatheter aortic valve implantation is frequent but is rarely more than mild. Although AR progresses, it is not associated with a harmful impact on LV structure and function over the first year. Native valve calcification and aortic annulus diameter influence the degree of AR at 6 months.
- Direct Assessment of Normal Mechanical Mitral Valve Orifi...
- Image Quality and Radiation Exposure With Prospectively E... Objectives The purpose of this study was to evaluate image quality and radiation dose using a prospectively electrocardiogram (ECG)–triggered axial scan protocol compared with standard retrospective ECG-gated helical scanning for coronary computed tomography angiography. Background Concerns have been raised regarding radiation exposure during coronary computed tomography angiography. Although the use of prospectively ECG-triggered axial scan protocols may effectively lower radiation dose compared with helical scanning, it is unknown whether image quality is maintained in a clinical setting. Methods In a prospective, multicenter, multivendor trial, 400 patients with low and stable heart rates were randomized to either an axial or a helical coronary computed tomography angiography scan protocol. The primary endpoint was to demonstrate noninferiority in image quality with the axial scan protocol, which was assessed on a 4-point scale (1 = nondiagnostic, 4 = excellent image quality). Secondary endpoints included radiation dose and the rate of downstream testing during 30-day follow-up. Results Image quality in patients scanned with the axial scan protocol (score 3.36 ± 0.59) was not inferior compared with helical scan protocols (3.37 ± 0.59) (p for noninferiority <0.004). Axial scanning was associated with a 69% reduction in radiation exposure (dose-length product [estimated effective dose] 252 ± 147 mGy · cm [3.5 ± 2.1 mSv] vs. 802 ± 419 mGy · cm [11.2 ± 5.9 mSv] for axial vs. helical scan protocols, p < 0.001). The rate of downstream testing did not differ (13.8% vs. 15.9% for axial vs. helical scan protocols, p = 0.555). Conclusions In patients with stable and low heart rates, the prospectively ECG-triggered axial scan protocol maintained image quality but reduced radiation exposure by 69% compared with helical scanning. Axial computed tomography data acquisition should be strongly recommended in suitable patients to avoid unnecessarily high radiation exposure. (Prospective Randomized Trial on Radiation Dose Estimates of CT Angiography in Patients Scanned With a Sequential Scan Protocol [PROTECTION-III]; NCT00612092)
- CMR Imaging Assessing Viability in Patients With Chronic ... Objectives The purpose of this study was to compare the diagnostic accuracy of cardiac magnetic resonance (CMR) assessing myocardial viability in patients with chronic left ventricular (LV) dysfunction due to coronary artery disease using 3 techniques: 1) end-diastolic wall thickness (EDWT); 2) low-dose dobutamine (LDD); and 3) contrast delayed enhancement (DE). Background CMR has been proposed to assess myocardial viability over the past decade. However, the best CMR strategy to evaluate patients being contemplated for revascularization has not yet been determined. Some centers advocate DE CMR due to its high sensitivity to identify scar, whereas others favor the use of LDD CMR for its ability to identify contractile reserve. Methods A systematic review of MEDLINE, Cochrane, and Embase for all the prospective trials assessing myocardial viability in subjects with chronic LV dysfunction using CMR was performed using a standard approach for meta-analysis for diagnostic tests and a bivariate analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results A total of 24 studies of CMR evaluating myocardial viability with 698 patients fulfilled the inclusion criteria. Eleven studies used DE, 9 studies used LDD, and 4 studies used EDWT. Our meta-analysis indicates that among CMR methods, DE CMR provides the highest sensitivity as well as the highest NPV (95% and 90%, respectively) for predicting improved segmental LV contractile function after revascularization, followed by EDWT CMR, whereas LDD CMR demonstrated the lowest sensitivity/NPV among all modalities. On the other hand, LDD CMR offered the highest specificity and PPV (91% and 93%, respectively), followed by DE CMR, whereas EDWT showed the lowest of these parameters. Conclusions DE CMR provides the highest sensitivity and NPV, whereas LDD CMR provides the best specificity and PPV. In light of these findings, integrating these 2 methods should provide increased accuracy in evaluating patients with chronic LV dysfunction being considered for revascularization.
- Myocardial Viability: Dead or Alive Is Not the Question!
- Diagnostic Performance of CMR Imaging Compared With EMB i... Objectives The goal of this study was to assess the diagnostic performance of cardiac magnetic resonance (CMR) compared with endomyocardial biopsy in patients with suspected acute myocarditis (AMC) and chronic myocarditis (CMC). Background Several studies have reported an encouraging diagnostic performance of CMR in myocarditis. However, the comparison of CMR with clinical data only and the use of preselected patient populations are important limitations of the majority of these reports. Methods One hundred thirty-two consecutive patients with suspected AMC (defined by symptoms ≤14 days; n = 70) and CMC (defined by symptoms >14 days; n = 62) were included. Patients underwent cardiac catheterization with left ventricular endomyocardial biopsy and CMR, including T2-weighted imaging for assessment of edema, T1-weighted imaging before and after contrast administration for evaluation of hyperemia, and assessment of late gadolinium enhancement. CMR results were considered to be consistent with the diagnosis of myocarditis if 2 of 3 CMR techniques were positive. Results Within the total population, myocarditis was the most common diagnosis on endomyocardial biopsy analysis (62.9%). Viral genomes were detected in 30.3% (40 of 132) of patients within the total patient population and significantly more often in patients with AMC than CMC (40.0% vs. 19.4%; p = 0.013). For the overall cohort of patients with either suspected AMC or CMC, the diagnostic sensitivity, specificity, and accuracy of CMR were 76%, 54%, and 68%, respectively. The best diagnostic performance was observed in patients with suspected AMC (sensitivity, 81%; specificity, 71%; and accuracy, 79%). In contrast, diagnostic performance of CMR in suspected CMC was found to be unsatisfactory (sensitivity, 63%; specificity, 40%; and accuracy, 52%). Conclusions The results of this study underline the usefulness of CMR in patients with suspected AMC. In contrast, the diagnostic performance of CMR in patients with suspected CMC might not be sufficient to guide clinical management.
- CMR in Myocarditis: Valuable Tool, Room for Improvement
- Feasibility of [18F]-2-Fluoro-A85380-PET Imaging of Human... Objectives The aim of this feasibility study was to evaluate [18F]-2-Fluoro-A85380 for in vivo imaging of arterial nicotinic acetylcholine receptors (nAChRs) in humans. Furthermore, potentially different vascular uptake patterns of this new tracer were evaluated in healthy volunteers and in patients with neurodegenerative disorders. Background [18F]-2-Fluoro-A85380 was developed for in vivo positron emission tomography (PET) imaging of nAChR subunits in the human brain. These nAChRs are also found in arteries and seem to mediate the deleterious effects of nicotine as a part of tobacco smoke in the vasculature. It has been previously shown that uptake patterns of the radiotracer in the brain differs in patients with neurodegenerative disorders compared with healthy controls. Methods [18F]-2-Fluoro-A85380 uptake was quantified in the ascending and descending aorta, the aortic arch, and the carotids in 5 healthy volunteers and in 6 patients with either Parkinson's disease or multiple system atrophy, respectively, as the maximum target-to-background ratio. The maximal standardized uptake value values, the single hottest segment, and the percent active segments of the [18F]-2-Fluoro-A85380 uptake in the arteries were also assessed. Results [18F]-2-Fluoro-A85380 uptake was clearly visualized and maximum target-to-background ratio uptake values corrected for the background activity of the tracer showed specific tracer uptake in the arterial walls. Significantly higher uptake values were found in the descending aorta. Comparison between volunteers and patients revealed significant differences, with lower [18F]-2-Fluoro-A85380 uptake in the patient group when comparing single arterial territories but not when all arterial territories were pooled together. Conclusions [18F]-2-Fluoro-A85380 can provide specific information on the nAChR distribution in human arteries. Vascular nAChR density seems to be lower in patients with Parkinson's disease or multiple system atrophy. Once confirmed in larger study populations and in the experimental setting, this approach might provide insights into the pathogenic role of nAChRs in the human vasculature.
- Imaging Vascular Nicotine Receptors: A New Window Onto Va...
- High Platelet Reactivity on Clopidogrel Therapy Correlate... Objectives This study sought to evaluate the relationship between platelet reactivity and atherosclerotic burden in patients undergoing percutaneous coronary intervention (PCI) with pre-intervention volumetric intravascular ultrasound (IVUS) imaging. Background Atherosclerosis progresses by the pathologic sequence of subclinical plaque rupture, thrombosis, and healing. In this setting, increased platelet reactivity may lead to more extensive arterial thrombosis at the time of plaque rupture, leading to a more rapid progression of the disease. Alternatively, abnormal vessel wall biology with advanced atherosclerosis is known to enhance platelet reactivity. Therefore, it is possible that by either mechanism, increased platelet reactivity may be associated with greater atherosclerotic burden. Methods This study included patients who underwent PCI with pre-intervention IVUS imaging and platelet reactivity functional assay (P2Y12 reaction units) performed >16 h after PCI, after the stabilization of clopidogrel therapy (administered before PCI). Platelet reactivity >230 P2Y12 reaction units defined high on-treatment platelet reactivity (HPR). Results Among 335 patients (mean age 65.0 years, 71% men), there were 109 patients with HPR (32.5%) and 226 without HPR (67.5%), with HPR being associated with diabetes and chronic renal insufficiency. By IVUS analysis, patients with HPR had significantly greater target lesion calcium lengths, calcium arcs, and calcium indexes. Furthermore, patients with HPR tended to have longer lesions and greater volumetric dimensions, indicating higher plaque volume, larger total vessel volume, and also greater luminal volume, despite similar plaque burden. By multivariate analysis controlling for baseline clinical variables, HPR was the single consistent predictor of all IVUS parameters examined, including plaque volume, calcium length, and calcium arc. Conclusions Increased platelet reactivity on clopidogrel treatment, defined as >230 P2Y12 reaction units, is associated with greater coronary artery atherosclerotic disease burden and plaque calcification.
Journal of Cardiovascular Computed Tomography
- Journal introduction Do you track your performance for appropriateness of cardiac CT indications? The most recent criteria, published in late 2010, provide a comprehensive list of potential indications for cardiac CT, rating the indications as appropriate, of uncertain appropriateness, or inappropriate. Created from a blend of evidence and expert input, they provide a pathway to selecting the right test for the right patient at the right time. Appropriateness of imaging represents the leading edge of ensuring quality, evidenced by its consideration as a quality metric among accrediting organizations. This issue of the Journal includes 2 evaluations of the 2010 criteria, showing the effect of the update by keeping up with science and practice through broader coverage of the indications and a large shift toward appropriateness. These studies provide an initial benchmark on the performance of the cardiac CT appropriateness use criteria (AUC); how do you stack up?
- Cardiac CT in women: Clinical application and considerat... Abstract: Cardiac computed tomography (CT) has special considerations and applications in women for the evaluation of coronary heart disease (CHD). Unique aspects of cardiovascular disease (CVD) in women include atypical symptoms and a later presentation of CHD. Disparities exist in mortality trends of CVD between men and women along with a lack of patient awareness of CVD as a significant cause of mortality for women. Differences have also become evident among plaque characteristics between the 2 sexes, with a relative increased prevalence of noncalcified plaque in women. Traditional risk prediction models, such as the Framingham Risk Score (FRS), have limitations in this population. Coronary calcium scanning contributes significantly to the accuracy of CHD detection on top of traditional CV risk factors in asymptomatic women. Coronary CT angiography has proven accurate for the diagnosis of significant CHD as well as cost effective in the evaluation of symptomatic women. The safety issue of radiation exposure with cardiac CT warrants special consideration for women. Concern for radiation-related cancer risks and organ-specific dose delivered to the breast is being addressed by radiation-reducing techniques. Future technologic advances in CT may allow for simultaneous screening for CHD and other disease processes, such as osteoporosis, breast cancer, and visceral adiposity in one routine test.
- Dual-source computed tomography angiography for diagnosis... Background: Development of an accurate test for noninvasive assessment of coronary arteries has been highly desirable.Objectives: We performed a systematic review of diagnostic accuracy of the dual-source computed tomography (DSCT) in the diagnosis of coronary artery disease (CAD).Methods: Eight medical databases were searched for articles published from January 2005 through March 2011. Studies compared DSCT coronary angiography (DSCT-CA) and invasive coronary angiography, as the reference standard, in consecutive patients with suspected or known CAD, and relevant data were extracted by 2 independent reviewers. Summary diagnostic accuracies were calculated, and the effect of covariates on the diagnostic performance was evaluated by meta-regression.Results: Twenty-five studies were included. In per-patient analysis (n = 2303), pooled sensitivity was 99% [95% confidence interval (CI), 97%–99%] with specificity of 89% (95% CI, 84%–92%). The summary positive (+LR) and negative (−LR) likelihood ratios were 8.6 (95% CI, 6.4–11.6) and 0.02 (95% CI, 0.01–0.03), respectively. In per-segment analysis (n = 32,615), pooled sensitivity was 94% (95% CI, 92%–96%) with specificity of 97% (95% CI, 96%–-98%). Summary +LR and −LR were 30.2 (95% CI, 22.1–43.5) and 0.06 (95% CI, 0.04–0.08), respectively.Conclusions: DSCT-CA seems to be robust to elevate heart rates while maintaining a high level of diagnostic performance.
- Influence of heart rate and phase of the cardiac cycle on... Background: Coronary CT angiography allows visualization of the coronary arteries. However, motion artifact can impair delineation of the coronary artery lumen and detection of coronary artery stenoses.Objective: We investigated the influence of heart rate and the segment of the cardiac cycle during which images are reconstructed on the occurrence of motion artifacts.Methods: We evaluated coronary CT angiography datasets obtained by 64-slice dual-source CT in 100 consecutive patients. Data were reconstructed at 13 time instants during the cardiac cycle and evaluated for the presence of motion artifact.Results: Mean heart rate was 66±14 beats/min. Overall, 98 of 100 patients had evaluable datasets. For heart rates ≤60 beats/min, optimal image quality was uniformly found during late diastole (100% of cases with evaluable image quality during a time window between 65% and 75% of the cardiac cycle). With increasing heart rates, images reconstructed during late systole more frequently provided best image quality. However, image reconstruction could not be restricted to a systolic time period. To achieve evaluable image quality in 95% of cases, data acquired between 25% and 75% of the cardiac cycle had to be available for patients with heart rates >60 beats/min.Conclusion: Dual-source CT provides high image quality across a wide range of heart rates. Although data acquisition may be limited to diastole for patients with heart rates ≤60 beats/min, the availability of data acquired both during systole and diastole is necessary for patients with higher heart rates.
- Comparison of cardiac computed tomography examination app... Background: The 2006 Cardiac CT Appropriate Use Criteria (AUC) were recently revised in 2010. In addition to rating an expanded number of indications, the new criteria adjusted the appropriateness of existing indications to reflect changes in clinical practice and new evidence since 2006.Objective: We sought to determine how the appropriateness of cardiac CT examinations performed at a tertiary-care hospital changed under the revised criteria compared with the original AUC.Methods: Data were collected from the medical records and personal interview of 267 consecutive patients referred for cardiac CT in 2008. With the use of the 2010 and 2006 AUCs, two physicians designated each examination’s indication as appropriate, inappropriate, uncertain, or “not classified” if examination indication could not be assigned.Results: With the use the new 2010 AUC, a highly significant change was observed in the classification of examination appropriateness (P < 0.001), with 40% of examinations changing appropriateness level compared with the 2006 AUC. Under the 2010 AUC, there were an increased proportion of both appropriate examinations (59% vs. 45%; P < 0.001) and inappropriate examinations (15% vs. 10%; P < 0.001), and approximately the same proportion with uncertain appropriateness (13% vs. 16%; P = 0.33). Consequently, the proportion of examinations that were not classified was significantly reduced under the 2010 AUC (29% vs. 13%; P < 0.001).Conclusion: The revision of the AUC for cardiac CT had a significant effect on examination appropriateness. In comparison to the 2006 AUC, the 2010 AUC provided improved clarification of examination appropriateness. This shift was because of the inclusion of many previously unaddressed indications and the designation of more examinations as either appropriate or inappropriate.
- Prospective evaluation of the updated 2010 ACCF Cardiac C... Background: The cardiac CT Appropriate Use Criteria (AUC) were updated in 2010 to reflect technical advances, evolving expert consensus, and rapidly expanding clinical evidence.Objective: We evaluated the effect of the AUC update on their clinical performance, including the completeness and distribution of appropriateness ratings and test outcomes among a consecutive series of patients referred for CT angiography (CTA).Methods: The 2006 and 2010 criteria were prospectively applied at the point of service to a consecutive series of patients referred for CTA at a single center (n = 1216). Patient interview and review of available health records were used to determine the CTA indication. The proportions of patients within categories of appropriate (A), uncertain (U), inappropriate (I), and not covered were described and compared between the 2006 and 2010 criteria.Results: The 2010 criteria significantly reduced the proportion of uncertain (30.5%–11.4%), inappropriate (16.0%–12.9%), and no covered (12.1%–4.7%; P < 0.001) indications, while increasing the proportion of appropriate tests from 41.4% to 71%. By the 2010 criteria, appropriate indications were more likely to lead to the detection of coronary artery stenosis (11.5% vs 6.7%; P = 0.03) and complete examinations (95.0% vs 90.8%; P = 0.03).Conclusion: The 2010 cardiac CT AUC update lead to more complete classification and to large shifts in the appropriateness ratings, underscoring the importance of ensuring the periodic revision of AUCs for evolving imaging technologies such that they perform optimally as quality measurement and reimbursement tools.
- Low radiation coronary calcium scoring by dual-source CT ... Background: Reducing tube voltage from 120 kV to 100 kV during noncontrast CT for the detection of coronary artery calcium reduces patient radiation exposure.Objective: We investigated whether coronary calcium scoring by multidetector row CT can be performed at reduced tube current, resulting in lower radiation dose to the patient.Methods: Sixty-six outpatients were scanned on the same visit by dual-source CT (DSCT) with a standard protocol (120 kVp, 150 mAs), followed by a scan with reduced tube current: 85 mAs for patients with body mass index (BMI) ≤ 30 kg/m2 and weight ≤ 85 kg, and 120 mAs for patients with BMI > 30 kg/m2 or weight > 85 kg. Low-dose scans were scored by an experienced reader blinded to the standard scan.Results: Agatston scores (ASs) and calcium volume for standard versus low-dose scans were 236 ± 581 versus 234 ± 586 (P = 0.65, NS), and 189 ± 460 mm3 versus 184 ± 455 mm3 with excellent correlation (r = 1.0, P < 0.0001), and no significant difference (P = 0.14, NS). Effective radiation dose for the low-dose protocol (1.0 ± 0.2 mSv) was significantly lower than for the standard protocol (1.7 ± 0.2 mSv; P < 0.0001). Image noise was higher for the low-dose scan (18.8 ± 5.5 HU vs 15.2 ± 4.8 HU; P < 0.0001), but both were within target limits.Conclusion: Noncontrast CT for measurement of coronary artery calcium with lower tube current optimized for patient body size is equivalent to standard methods at 40% lower radiation dose, indicating that radiation dose can be lowered for coronary calcium scanning.
- Left ventricular thrombus attenuation characterization in... Background: Because of their similar visual appearance, differentiation of left ventricular thrombotic material and myocardial wall can be difficult in contrast-enhanced coronary computed tomography (CT) angiography.Objective: We identified typical thrombi attenuation of left ventricular thrombi with the use of CT measurement.Methods: Over a time period of 6 years, we retrospectively identified 31 patients who showed a left ventricular thrombus in CT angiography datasets. Patients underwent routine contrast cardiac CT to investigate coronary artery disease. CT attenuation of each thrombus was assessed in the 4-chamber view. CT densities were also determined in the ascending aorta, left ventricle, and myocardial wall both in the mid-septal and mid-lateral segments. The mean CT attenuation of thrombi and the difference between attenuation in thrombi, left ventricular cavity, and myocardial wall were determined. The ratio of attenuation values in thrombus versus aorta and myocardium versus aorta were also determined.Results: Mean (±SD) CT attenuation of all left ventricular thrombi in 31 patients was 43.2 ± 15.3 HU (range, 25–80 HU). Mean CT densities of septal and lateral myocardial wall were 102.9 ± 23.1 HU (range, 63-155 HU) and 99.3 ± 28.7 HU (range, 72-191 HU), respectively, and were thus significantly higher than the CT attenuation of thrombi (P < 0.001). A threshold of 65 HU yielded a sensitivity, specificity, and positive and negative predictive values of 94%, 97%, 94%, and 97%, respectively, to differentiate thrombus from the myocardial wall. The mean ratio between CT attenuation of thrombus and CT attenuation within the ascending aorta was 0.11 ± 0.05 (range, 0.04–0.23), which was significantly lower compared with the mean ratio between CT attenuation of the myocardial wall and the CT attenuation within the ascending aorta.Conclusion: CT attenuation within left ventricular thrombi was significantly lower than myocardial attenuation in CT angiography datasets. Assessment of CT attenuation may contribute to the differentiation of thrombi.
- Atrial isomerism: A pictorial review Abstract: This review describes the broad spectrum of findings found in atrial isomerism, suggesting a sequential approach to image evaluation, and illustrates the most common situs disorders, for example, polysplenia and asplenia.
- Primary cardiac lymphoma diagnosed by multiphase-gated ca... Abstract: We present a case of a primary cardiac B-cell lymphoma where a multiphase-gated cardiac CT exam helped to successfully guide trans-sternal needle biopsy to establish a tissue diagnosis.
Journal of Cardiac Surgery
- Inflammatory Pseudotumor Arising from the Right Ventricul... Abstract Inflammatory pseudotumor (also known as inflammatory myofibroblastic tumor) is an uncommon spindle cell lesion that was initially recognized in the lung and is now known to occur in virtually every major organ of the body. We report a case of a seven-year-old male who had an inflammatory pseudotumor of the right ventricular outflow tract involving the pulmonary valve causing pulmonary stenosis.(J Card Surg 2012;**:1-3)
- Primary Cardiac T Cell Lymphoma Abstract We report a case of primary cardiac T-cell lymphoma. The diagnosis and management of this unusual primary tumor is reviewed.(J Card Surg 2012;**:1-3)
- Response
- Letter to Editor (J Card Surg 2012;xx:1-2)
- Efficacy of Fibrinogen/Thrombin-Coated Equine Collagen Pa... Abstract We report the use of fibrinogen/thrombin-coated equine collagen patch (Tachosil®) as a sealant agent in six patients who underwent heart surgery for congenital heart disease (CHD) and developed an intraoperative lymphatic leakage detected at the time of surgery. The use of fibrinogen/thrombin-coated equine collagen patch proved to be safe and effective in preventing the development of postoperative chylothorax. (J Card Surg 2012;**:1-2)
- Cardiac Surgery in Patients with Fabry's Disease: Review ... Abstract Fabry's disease is a rare but important cause of structural cardiac disease that may influence cardiac surgical decision making. Herein we present a case of mitral valve repair in a patient with Fabry's disease and review the cardiac-related literature on this lysosomal storage disease.(J Card Surg 2012;**:1-3)
- Right Ventricular Blood Cyst Causing Outflow Tract Obstru... Abstract Blood cysts are benign intracardiac masses that are well described in infants. We present a rare adult presentation of a blood cyst tethered to the right ventricular wall and the tricuspid valve causing right ventricular outflow obstruction. Multimodality imaging approach was found to be of great importance in the diagnosis and treatment of this patient. (J Card Surg 2012;**:1-2)
- Unprotected Left Main Coronary Artery Disease—Coronary ... doi: 10.1111/j.1540-8191.2012.01452.x(J Card Surg 2012;**:1-2)
- Percutaneous Mitral Valve Repair in Patients with Prior C... Abstract Background and aim of the study: The safety of percutaneous mitral valve repair with the MitraClip system has been documented. However, few data are available on high-risk patients not amenable to surgery. The aim of this study was to evaluate the outcomes of patients with prior cardiac surgery undergoing MitraClip therapy (Abbott, Abbott Park, Chicago, IL, USA) for severe mitral regurgitation. Methods: We reported two cases of percutaneous treatment of severe mitral regurgitation performed in patients who had previously undergone cardiac surgery with the implantation of mechanical prosthetic aortic valve. Results: In both the reported cases a sustained reduction in mitral regurgitation severity was obtained at two-year follow-up, with a relevant improvement in terms of clinical status and quality of life. Conclusions: Percutaneous mitral valve repair using the MitraClip system represents a viable treatment choice for severe mitral regurgitation in high-risk patients who have previously undergone cardiac surgery. (J Card Surg 2012;27:295-298)
- Modified Anastomosis for Repair of Supracardiac Total Ano... Abstract Recurrent pulmonary venous obstruction after repair of total anomalous pulmonary venous connection (TAPVC) is usually restricted to the anastomosis between the pulmonary venous confluence and the left atrium. We describe a modified technique for repair of supracardiac TAPVC in infants. An L-shaped incision of left atrium is utilized and the right-sided anastomosis is enlarged by using autologous pericardium to create a large and tension-free anastomosis. (J Card Surg 2012;XX:1-3)
Cardiovascular Pathology
- Histological correlate of a cardiac magnetic resonance im... Abstract: Background: Microvascular obstruction after reperfusion therapy of acute myocardial infarction is reported as an adverse promoter of left ventricular remodeling and is an important target to prevent deterioration into heart failure. In this study, we illustrate the early onset of a magnetic resonance imaged microvascular obstruction in a porcine model of acute myocardial infarction with the exact histological correlate.Methods: Occlusion of the left anterior descending coronary artery followed by 3-h reperfusion was performed in 10 pigs. Microvascular obstruction was assessed by contrast-enhanced magnetic resonance imaging (MRI). After sacrifice, serial sectioned slices of the hearts matching the MRI were stained with Triphenyl tetrazolium chloride (TTC). Biopsies were fixed, embedded in paraffin, and stained for hematoxylin–eosin.Results: Microvascular obstruction was defined with MRI as a hypoenhanced no-reflow area within the hyperenhanced infarct region. Erythrocyte plugging was consistently observed in the no-reflow area and was completely absent in the adjacent hyperenhanced infarct region.Conclusion: This model of acute ischemia–reperfusion contributes to the histological comprehension of contrast-enhanced MRI during the early stages of myocardial infarction.
- Granulation tissue is altered after intramyocardial and i... Abstract: Background: Bone marrow-derived mononuclear cell (BMMC) treatment in acute myocardial infarction (AMI) has been shown to have a beneficial effect. Our objective was to study in detail the histopathological process after the cell therapy after intramyocardial (IM) or intracoronary (IC) administration of BMMCs following experimental AMI.Methods: Twenty-fours pigs were randomized to the IM group (n=8), the IC group (n=8), and the control group (n=8).After 90 min of transient occlusion of the circumflex coronary artery, BMMCs were injected either intramyocardially or by a transfemoral catheter into the circumflex coronary artery. Echocardiography was performed preoperatively, postoperatively, and after a 21-day recovery period. The heart biopsies were examined histopathologically. Volumetric ex vivo CT scan was performed to evaluate calcification of the infarcted myocardium.Results: The ejection fraction (EF) showed significant recovery in the IM group compared to the control group at Day 21 (P=.05). Despite beneficial histological changes in the infarction site in the IC group, compared to the control group, EF failed to recover. Reduction of collagen density that depicts scar formation was seen in both cell therapy groups compared to the control (P<.001). The number of mitotic cells was higher in the control group compared to the cell therapy groups (P<.001). The IC and IM groups differed significantly from each other in muscle-specific actin staining (P<.001) and smooth muscle actin staining (P<.004). The IM therapy group showed higher density for both stainings. Additionally, macrophage density was higher in the IC group compared to the IM and control groups (P<.002). Both cell therapy regimens substantially diminished tissue calcification; due to the large variation, the effect was not statistically significant.Conclusion: BMMC therapy launches cellular changes that affect mostly the repair process in the granulation tissue. The cell transplantation method might have some effect on the magnitude of the effect.
- Acute myocardial infarction induces bilateral stellate ga... Abstract: Introduction: Myocardial infarction (MI) results in cardiac nerve sprouting in the myocardium. Whether or not similar neural remodeling occurs in the stellate ganglia (SGs) is unknown. We aimed to test the hypothesis that MI induces bilateral SG nerve sprouting.Methods: Acute MI was created by coronary artery ligation in rabbits (n=12). Serum nerve growth factor (NGF) level was measured by enzyme-linked immunosorbent assay. The hearts and bilateral SGs were harvested for immunohistochemistry after 1 week in six rabbits and after 1 month in six rabbits. Immunostaining for tyrosine hydroxylase (TH), growth-associated protein 43 (GAP43), choline acetyltransferase (ChAT), and synaptophysin (SYN) was performed to determine the magnitude of nerve sprouting. Tissues from six normal rabbits were used as controls. Nerve density was determined by computerized morphometry.Results: Myocardial infarction results in increased serum NGF levels at 1 week (1519.8±632.2 ng/ml) that persist up to 1 month (1361.2±176.3 ng/ml) as compared to controls (89.6±34.9 ng/ml) (P=.0002 and P=.0001, respectively). Immunostaining demonstrated nerve sprouting and hyperinnervation in both SGs after MI. The nerve densities (μm2/ganglion cell) in SG 1 week after MI and 1 month after MI and those in control groups, respectively, were as follows: GAP43: 278±96, 225±39, and 149±57 (P=.01); SYN: 244±152, 268±115, and 102±60 (P=.02); TH: 233±71, 180±50, and 135±68 (P=.047); ChAT: 244±100, 208±46, and 130±41 μm2/cell (P=.01).Conclusions: Myocardial infarction increases serum NGF levels and induces nerve sprouting and hyperinnervation in bilateral SGs for at least 1 month after MI. The hyperinnervation includes both adrenergic axons and cholinergic axons in the SG.
- Degeneration of sensory afferent nerves enhances pulmonar... Abstract: Background: Evidence suggests proinflammatory changes in the lungs during acute myocardial infarction and a participation of neural mechanisms and substance P in the pathology. This study was undertaken to investigate the role and the mechanisms by which sensory afferent degeneration at neonatal stages exacerbates the pulmonary inflammatory responses to acute myocardial infarction in the adult rats.Methods: The degeneration of capsaicin-sensitive afferent nerves was induced by administration of capsaicin to neonatal rats. The pulmonary inflammatory changes following coronary artery occlusion (CAO) were assessed by the analysis of the infiltration of neutrophils and tissue morphology in the lungs.Results: Significant increases in the pulmonary infiltration of neutrophils, up to 240% and 218% of the sham controls at 3 and 6 h, respectively, after CAO (P<.05) and marked pulmonary edema were observed. Degeneration of capsaicin-sensitive afferent nerves or antagonism of endogenous neurokinin (NK)-1 receptor exacerbated the pulmonary infiltration of neutrophils (up to 214% and 254% of the controls, respectively) and pulmonary tissue edema following the CAO.Conclusion: The findings indicate that degeneration of sensory afferent nerves enhances the pulmonary inflammatory changes in acute myocardial infarction, in which the endogenous NK may play a role.
- Characterizing the inflammatory reaction in explanted Med... Abstract: Background: The Medtronic Freestyle valve is a stentless porcine valve with reportedly excellent clinical and hemodynamic results, but little has been reported about its long-term pathology.Methods: Seventeen Freestyle valves were explanted (from 2003 to 2009) and reviewed to assess reasons for bioprosthesis failure. All valves were examined in detail, using histochemistry and immunohistochemistry to identify morphological changes, as well as cellular and humoral responses.Results: One Freestyle valve, explanted for mitral valve endocarditis on the fifth postoperative day, was excluded from analysis. The average implant duration was 71.1±35.2 months. Six valves were explanted for infective endocarditis, six for aortic insufficiency, and four for aortic stenosis. Calcification was seen in 11 explants, pannus in 15, thrombus in 12, cusp tears in 9, and 10 explants showed needle tract-like injuries. A chronic inflammatory reaction involving the xenograft arterial wall was seen in 15 of 16 valves. The cells were composed of macrophages and lymphocytes, including T cells (CD8 positive) and B cells. Significant damage to the porcine aortic wall was seen in 15 cases, and cusp myocardial shelf damage in 7 cases. All cases stained positively for IgG and C4dpar.Conclusions: The porcine aortic tissue showed T cell-mediated rejection and significant aortic medial damage, consistent with dilatation of the porcine aortic root. The demonstration of IgG suggests the likelihood of humoral rejection, in addition to cellular rejection. One of the underlying possibilities is that the porcine aortic tissues are inadequately fixed, hence the retained antigenicity.
- Juxtaposition of the atrial appendages Abstract: Juxtaposition of the atrial appendages is a rare congenital cardiac malformation, with the appendages both located on the left or right side of the great arteries. It is usually associated with cyanotic congenital heart disease.The aim of this report is to illustrate the anatomical features of normal and juxtaposed atrial appendages, with a review of the associated anomalies.In the Anatomical Collection of Congenital Heart Disease of the University of Padua, consisting in 1,526 specimens, we found 17 (1.1%) cases of atrial appendages juxtaposition with left juxtaposition in 15 (88%) and right juxtaposition in 2 (12%). Complete form was present in 11 cases and partial form in 6.In left juxtaposition, the situs was solitus in all, and the most frequent anomalies were complete transposition of great arteries in 9 (60%) and tricuspid atresia in 5 (33%); anomalies of position of the heart in the thorax (dextro-mesocardia) were present in 46% of cases, hypoplastic right ventricle in 73%, abnormal relation of the great arteries and subaortic or bilateral infundibulum in all.In right atrial juxtaposition, the atrial situs was solitus with mitral and pulmonary atresia in one case and left isomerism with aortic atresia and double-inlet right ventricle in the other.In describing this malformation, we propose to maintain the use of a positional definition using the terms right and left juxtaposition to describe the presence of both the appendages on the right or on the left side of the great arteries, respectively. The use of a morphological definition should be added in cases of situs inversus or isomerism, with description of the morphology of the appendage located in the wrong position.
- Atypical cardiac myxomas: a clinicopathologic analysis an... Abstract: Introduction: Myxomas are the most common among the primary cardiac neoplasms, seen mainly in adult population, and are typically attached to the interatrial septum, on the left side. Myxomas arising from other sites are designated as “atypical myxomas.” In this article, we describe the clinicopathologic features of 28 such lesions, resected in 20 patients.Methods: A 15-year study (1995–2009) of all cardiac myxomas, received as surgical excisions in our institution, was performed. Atypical myxomas were selected on the basis of their atypical sites of origin, and a systematic review and comparison of their clinicopathologic features with all typical myxomas excised during the same period were done.Results: Among a total of 84 patients who had undergone cardiac myxoma excisions in this 15-year duration, 64 patients had typical myxomas, while atypical myxomas (30 tumors) were diagnosed in 20 patients (23.8%). None of them had a family history of similar symptoms. There were six children. In the atypical subset, there were 12 males and eight females; the mean age of diagnosis was 33.7 years. This demography differed from the typical myxoma group where there were more females than males and the mean age of diagnosis being 40.8 years. The symptoms of dyspnea, episodic chest pain, and palpitation were common in both cohorts of patients, and all showed a mass lesion with varying degrees of valvular regurgitation and obstruction on echocardiography. Five of the 20 patients with atypical myxomas had multifocal or multicentric tumors. Grossly, like typical myxomas, the atypical ones also exhibited solid and papillary patterns with the usual histological features. Four patients had recurrence of the disease.Conclusions: Atypical myxomas are rare lesions having clinical and pathological features, not entirely different from those of typical myxomas. With the advent of modern diagnostics, it is now imperative to do genetic studies and screen the relatives of patients having atypical myxomas to rule out additional occult familial cases as they are now known to occur more in this “atypical” group.
- Variable phenotype in murine transverse aortic constriction Abstract: Background: In mice, transverse aortic constriction (TAC) is variably characterized as a model of pressure overload-induced hypertrophy (left ventricular [LV] hypertrophy, or LVH) or heart failure (HF). While commonly used, variability in the TAC model is poorly defined. The objectives of this study were to characterize the variability in the TAC model and to define a simple, noninvasive method of prospectively identifying mice with HF versus compensated LVH after TAC.Methods: Eight-week-old male C57BL/6J mice underwent TAC or sham and then echocardiography at 3 weeks post-TAC. A group of sham and TAC mice were euthanized after the 3-week echocardiogram, while the remainder underwent repeat echocardiography and were euthanized at 9 weeks post-TAC. The presence of TAC was assessed with two-dimensional echocardiography, anatomic aortic m-mode and color flow, and pulsed-wave Doppler examination of the transverse aorta (TA) and by LV systolic pressure (LVP). Trans-TAC pressure gradient was assessed invasively in a subset of mice. HF was defined as lung/body weight>upper limit in sham-operated mice.Results: As compared with sham, TAC mice had higher TA velocity, LVP and LV weight, and lower ejection fraction (EF) at 3 or 9 weeks post-TAC. Only a subset of TAC mice (28%) developed HF. As compared with compensated LVH, HF mice were characterized by similar TA velocity and higher percent TA stenosis, but lower LVP, higher LV weight, larger LV cavity, lower EF and stress-corrected midwall fiber shortening, and more fibrosis. Both EF and LV mass measured by echocardiography at 3 weeks post-TAC were predictive of the presence of HF at 3 or 9 weeks post-TAC.Conclusions: In wild-type mice, TAC produces a variable cardiac phenotype. Marked abnormalities in LV mass and EF at echocardiography 3 weeks post-TAC identify mice with HF at autopsy. These data are relevant to appropriate design and interpretation of murine studies.
- Age is a risk factor for maladaptive changes of the pulmo... Abstract: Introduction: Pulmonary artery root does not adapt properly when exposed to increased pressure stress, with progressive dilatation. The aim of this study was to evaluate, in an animal model, the histologic changes of the pulmonary root wall under increased pressure load.Methods and Results: To increase the systolic pressure in the pulmonary root, a banding of the pulmonary artery (PAB) was performed in 10 adult Sprague–Dawley rats and in 10 weanlings, using 7 adults and 8 weanlings as controls. We analyzed the structural changes of the pulmonary artery root after 30 days of increased pressure load.The mean pressure gradient across the banded pulmonary trunk was 53.57 ± 10 mmHg in the adult rats and 86.73 ± 15 mmHg in the weanlings. The pulmonary artery wall was significantly thicker in both age groups of PAB rats when compared to age-matched controls, showing also architectural structural changes, as a higher degree of mucoid degeneration, medionecrosis, and fibrosis as well as elastic fibers fragmentation. The apoptotic index was also increased in both PAB age groups. We also confirmed the physiologic higher degree of elastic fibers disarray in adult rats when compared to weanlings.Conclusions: The pulmonary artery wall seems to present maladaptive architectural changes in the media when exposed to systemic pressure. The PAB-related increase of the apoptotic index seems to reflect an accelerated involution of the pulmonary root's media. The physiologic higher degree of elastic fibers disarray in adult rats can possibly influence the worst adaptation of the pulmonary arterial wall to a systemic pressure load.
- Elevated cyclic stretch and serotonin result in altered a... Abstract: Introduction: Serotonin/5-hydroxytryptamine (5-HT) has been implicated in valve disease and in the modulation of valve mechanical properties. Several 5-HT receptor subtypes are also known to be mechanosensitive in other cell types, but this has not been studied in the context of the valve. In this study, we sought to understand the effects of elevated 5-HT levels and stretch overload on aortic valve remodeling and the dominant 5-HT receptor subtype that regulates these processes.Methods and results: Collagen biosynthesis and tissue mechanical properties of porcine aortic valve cusps were evaluated after 10% (physiologic) and 15% (pathologic) dynamic stretch. These studies were performed in normal medium or medium supplemented with 5-HT (1, 10, 100 μM) in the absence and presence of 5-HT2A or 5-HT2B receptor antagonists. Fresh valves served as controls. Valve collagen content was maximal at the 10-μM 5-HT concentration for both 10% and 15% stretch. The 5-HT2A receptor antagonist reduced collagen synthesis, cell proliferation, and hsp47 expression under elevated and normal stretch, whereas the 5-HT2B receptor antagonist was effective only at normal stretch. The pretransition stiffness of the valve cusps was also increased in response to 5-HT via a stretch-sensitive 5-HT2A mechanism, with the post-transition stiffness unaltered.Conclusions: Combined elevated stretch and 5-HT resulted in increased valve collagen biosynthesis, cell proliferation, and tissue stiffness. These responses were inhibited by a 5-HT2A antagonist. This strongly suggests that the 5-HT2A receptor subtype is sensitive to elevated stretch.
Heart, Lung and Circulation
- Editorial Board
- Cardiac Surgery in Patients with a History of Malignancy:... Background: Little is known about the outcome of cardiac surgery in patients with a prior history of malignancy. Our aim was to investigate in our unit the population of patients with a known malignancy and compare their outcomes to a matched population without malignancy.Methods: We identified all patients who underwent cardiac surgery at the Alfred Hospital between February 2002 and December 2009 with malignancy. Cases were matched to 216 controls based on age, gender, major medical comorbidities and type of surgery. A univariate analysis was performed with Fishers exact test and χ2 test.Results: 83/4474 patients were identified with malignancy. Sixty-four (77%) were male. Mean age of the patients with malignancy was 66.7 years, and 67.4 in the control group. 68.7% had a solid organ tumour, and 31.3% had a haematological malignancy. There were no significant between-group differences in hospital or 30-day mortality. However, there were significantly higher rates of transfusion (79.5% vs 49%, p<0.0001), reintubation (8.4% vs 0.9%, p=0.0009), pneumonia (14.5% vs 6%, p=0.035), septicaemia (8.4% vs 1.9%, p=0.018), arrhythmias (42.2% vs. 33.8%, p=0.047) and anticoagulant complications (7.2% vs 0%, p=0.008) in patients with malignancies.Conclusion: Patients who present for cardiac surgery having had prior treatment for cancer are at particular risk for complications. However, these patients can be operated upon with acceptable risk. There is no difference in the short term mortality. Therefore, for selected patients who are undergoing curative treatment for their malignancy, or are in remission, cardiac surgery is not contraindicated.
- The Acute Haemodynamic Effect of Nebulised Frusemide in S... Purpose: To assess the acute haemodynamic effects of nebulised frusemide in a stable advanced heart failure population.Procedure: In this randomised, double blind, placebo controlled trial, people with stable, advanced heart failure undergoing right heart catheterisation were randomised to receive either 40mg (4ml) of nebulised frusemide or 4ml of normal saline. Following inhalation of the study medication, subjects’ pulmonary pressures were recorded every 15min for 1h.Findings: There were no significant changes in the weighted average time course data of the subjects (n=32) in either group over the study period, in particular no differences were observed in haemodynamic parameters between the two groups. Weighted average pulmonary capillary wedge pressure after 60min in the frusemide group was 22.5 (SD 6.5) mmHg (n=14) compared to the placebo group's 24.0 (SD 7.3) mmHg (n=18), p=0.55. The frusemide group had a significantly greater change in the median volume of urine in the bladder over the study period (186ml IQR 137.8–260.8) compared to the placebo group (76ml IQR 39.0–148.0) p=0.02.Conclusion: This study showed that nebulised frusemide had no significant clinical effect on the haemodynamic characteristics of the subjects.
- The Use of Computerised Simulators for Training of Transt... Background: Echocardiography is the commonest form of non-invasive cardiac imaging but due to its methodology, it is operator dependent. Numerous advances in technology have resulted in the development of interactive programs and simulators to teach trainees the skills to perform particular procedures, including transthoracic and transoesophageal echocardiography.Methods: Forty trainee sonographers assessed a computerised mannequin echocardiographic simulator and were taught how to obtain an apical two-chamber (A2C) view and image the superior vena cava (SVC). Forty-two attendees at a TOE simulator workshop assessed its utility and commented on perceived future use, using defined criteria.Results: One hundred percent and 88% of sonographers found the simulator useful in obtaining the SVC or A2C view respectively. All users found it easy to use and the majority found it helped with image acquisition and interpretation. Attendees of the TOE training day assessed the simulator with 100% finding it easy to use, as well as the augmented reality graphics benefiting image acquisition. Ninety percent felt that it was realistic.Conclusions: This study revealed that both trainee sonographers and TOE proceduralists found the simulation process was realistic, helped in image acquisition and improved assessment of spatial relationships. Echocardiographic simulators may play an important role in the future training of echocardiographic skills.
- Occlusion of Both Caval Veins by an Endovascular Occluder Minimally invasive surgery (MIS) for redo mitral/tricuspidal surgery is going to increase, offering good results for early and late mortality and morbidity. In a case of redo surgery through a right thoracotomy (RT), when tricuspid surgery is planned, the superior (SVC) and inferior caval veins (IVC) are usually isolated and snared in order to prevent air embolism and significant blood regurgitation. We describe our experience in eight redo patients, operated for combined mitral/tricuspid or isolated tricuspid surgery, where the endovascular occlusion of the SVC and IVC was obtained by means of an endovascular occluder (Equalizer).
- Textiloma mimicking a pericardial hydatid cyst: A case re... Textiloma is unusual and uncommon diagnosis which is rarely considered. We report the case of a 13 year-old patient with Holt-Oram syndrome. He was operated on in 2006 for ostium secundum atrial septal defect. The postoperative course was uneventful until 2010 when the child presented paroxysmal dyspnoea. Investigations revealed para-cardiac mass which was thought to be a hydatid cyst, but operative findings showed textiloma.
- Prevalence of Bacteria in the Circulation of Cardiovascul... Cardiovascular diseases (CVDs) have a complex aetiology determined by risk factors, which include genetic and environmental factors. Chronic infection and inflammation is reported to be a pathogenic determinant for the development of CVDs. Here, we report the prevalence of bacterial pathogens in the circulation of CVD patients in Madurai, India. Blood culturing was performed using BD BACTEC automated culture system and organisms were identified by16S rRNA gene sequence analysis. From a total of 133 samples screened, 47 samples showed culture positive which indicates a high level of bacteraemia in CVD patients. From the 47 samples that showed growth, we have identified 57 bacterial isolates comprising 35 different species. Coagulase negative Staphylococci (CoNS) was the most predominant group of bacteria and other notable bacterial species isolated in this study are discussed.
- Multimodality Imaging of the Mitral Paravalvular Abscess ... Paravalvular complications may occur in patients with infective endocarditis. Paravalvular abscess formation rarely occurs and if so it generally involves the aortic valve. Herein we present a case of left ventriculo-atrial fistula formation through mitral paravalvular abscess cavity shown by multimodality imaging including two- and real-time three-dimensional transoesophageal echocardiography (RT 3-D TEE), cardiac magnetic resonance imaging (CMRI), multislice computed tomography (MSCT) and ventriculography in a patient with a mechanical prosthetic mitral valve. This is the first case in the literature of a mechanical prosthetic mitral valve complicated by a left ventriculo-atrial fistula formation in a healed abscess cavity that is demonstrated with RT-3D TEE, cardiac MRI and MSCT.
- Right atrial mass after open heart surgery: tumour or thr... Detection of a rapidly growing mass in the right atrium during routine inter-echocardiogram follow-up period in two patients after corrective open-heart surgery raises concerns about nature of the mass and the probable cause. One turned out to be an atrial myxoma that grew rapidly over a eight month period and the other a well encapsulate thrombus in a fully anticoagulated patient. Preoperative transthoracic echocardiogram had reported both the cases to be a myxoma. This article highlights the importance of considering rare causes in the face of a seemingly obvious diagnosis and possible use of imaging modalities in the management of these cases.
- Anterior Mediastinal Lymphangioma in an Infant: Diagnosis... Cystic lymphangioma is a rare lesion of the mediastinum. We present a patient with an antenatally detected mediastinal mass that appeared to regress during foetal life and was not demonstrated on early postnatal imaging. Acute severe respiratory distress at two months of age precipitated surgery with subsequent diagnosis of lymphangioma.
Journal of Clinical Lipidology
- Editorial Board
- Table of Contents
- From the Editor Medications that lower low-density lipoprotein (LDL) cholesterol and non–high-density lipoprotein (non-HDL) cholesterol have provided convincing proof that the latter are causative particles in the arteriosclerotic process. The mechanism of action of the most effective medications depends on lowering the cholesterol content of the liver and stimulating the expression of LDL receptors. However, there are certain conditions in which these medications are not effective, most notably, in patients with little ability to synthesize or deliver fully functional LDL receptors to the cell membranes. Such patients are not sufficiently responsive to statins, bile acid binding resins, ezetimibe, or any other current medications. The research into mechanisms that reduce apolipoprotein B synthesis show promise for improved therapy in this circumstance. These include the antisense oligonucleotides, like mipomersen, but none of these are yet fully documented by adequate clinical trials. It is estimated that 0.2% of most populations have either homozygous familial hypercholesterolemia (same genetic defect in both chromosomes) or compound heterozygous familial hypercholesterolemia (different defects existing in the two alleles). Rarely, other genetic defects may cause dysfunction of the LDL receptor and lead to high LDL values. Unfortunately, these disorders produce arteriosclerosis in very young children and without effective treatment, all the consequences of this process are seen in youth and early middle age.
- News from the NLA Submit your research for presentation as a poster during the NLA Annual Scientific Sessions in Scottsdale, AZ. The deadline for poster abstract submissions is April 2, 2012. All accepted poster abstracts will be published in the May/June 2012 issue of the Journal of Clinical Lipidology. In addition to posters being displayed at the meeting during the designated hours, selected abstract submissions will be identified for an oral presentation session on Saturday, June 2.
- The use of lipopheresis in the practice of clinical lipid... W. Virgil Brown, MD: In this issue of the Journal, I have invited three clinical lipidologists who are treating patients with very high LDL concentrations using devices that physically remove apolipoprotein B (apoB)-containing lipoproteins from the blood. We have discussed the clinical use of these methods that trap lipoproteins in physical systems while directly connected to the vasculature. Although extremely efficacious in the short term, they require repeated use to achieve the longer-term effects necessary to successfully reduce vascular disease risk. The several methods in this arena have become known as lipopheresis or lipoprotein apheresis. Dr. Robert Brook, from the University of Michigan, Dr. Linda Hemphill, from Harvard, and Dr. Patrick Moriarty, from the University of Kansas, have agreed to answer my questions regarding the appropriate applications of these procedures.
- Polish Lipid Association – A strong response to the pro... As a group, lipid disorders constitute one of the most important and common risk factors for atherosclerotic disease. According to the cardiovascular continuum theory, lipid disorders promote the development of atherosclerosis and its clinical sequelae, including acute coronary syndromes (ACS), ischemic stroke, peripheral arterial disease, heart failure, and sudden cardiac death. Despite the introduction of very effective lipid-modifying drugs, hyperlipidemia is still poorly controlled and treated worldwide.
- Genotype–phenotype correlation related to lipid profile... Background: Beta-thalassemia is commonly associated with lipid abnormalities. The aim of this study was to search for links between these lipid alterations and different types of β-thalassemia mutations.Methods: The study, conducted from 2009 to 2010, included 100 patients with thalassemia major (TM) and 100 with thalassemia intermedia (TI). The control group was selected from 100 age- and sex-matched healthy individuals with normal hematologic indices. Serum lipid profiles, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG), were determined and their relationship with different covariates, including different β-globin gene mutations, was analyzed.Results: Patients with TI had significantly lower values for TC, LDL-C, HDL-C, and LDL-C/HDL-C ratio compared with TM patients and controls (P < .001). TG was greater in TM compared with TI patients (P = .001) and healthy individuals (P = .007). Hemoglobin was positively associated with TC (P < .001), LDL-C (P = .004), and HDL-C (P = .01) in TM patients. Splenectomy correlated with greater TC (P = .006) and LDL-C (P = .01) in TI patients, but only with greater LDL-C in TM patients (P = .02). The average amounts of TC and LDL-C were lower in persons with the β0/β0 mutation compared with the β+/β+ group.Conclusion: Lower amounts of TG, TC, LDL-C, and HDL-C were seen in TI patients compared with TM patients and healthy individuals. The severity of the genotype (ie, β0 type mutations compared with β+ type mutations) affected the degree of reduction in serum lipids.
- Difference between calculated and direct-measured low-den... Objective: We evaluated factors that caused differences between calculated low-density lipoprotein cholesterol (C-LDL-C) and direct-measured LDL-C (D-LDL-C) and compared them in subjects with diabetes mellitus (DM) or taking lipid-lowering medications.Methods: 21,452 subjects (9,177 women, 12,275 men; 8.1% with DM and 8.5% on lipid-lowering medications) were included in the analysis. Participants were classified into 3 groups, i.e., group 1: the subjects without DM and not on lipid-modifying drugs (n = 18,287), group 2: without DM and on lipid-modifying drugs (n = 1,423), and group 3: with DM (n = 1,742). LDL-C concentrations were either directly measured by a homogenous method or calculated by Friedewald formula.Results: There was a significant correlation between C-LDL-C and D-LDL-C (r = 0.966, P < .001). The absolute values of the differences between two LDL-C values were 7.0 ± 6.2 mg/dl and 6.6 ± 7.3% (6.6 ± 5.9 mg/dl and 6.0 ± 6.5%, 8.8 ± 6.7 mg/dl and 9.1 ± 9.7%, and 10.1 ± 7.3 mg/dl and 10.7 ± 10.1% in group 1, 2, and 3 respectively, P < .001). The subjects with the absolute value of the differences of LDL-C ≥10% was 20.2% (17.3%, 31.3%, and 41.1% in group 1, 2, and 3 respectively, P < .001). In the multiple logistic regression analysis, high triglyceride (≥150 mg/dl), low high-density lipoprotein cholesterol (HDL-C) (<40 mg/dl), male gender, obesity (body mass index ≥25 kg/m2), DM and taking lipid-lowering drugs were significant associated with high LDL-differences (the absolute value of the differences ≥10% or ≥10 mg/dl).Conclusion: D-LDL-C was generally higher by 5 mg/dl or 5% than C-LDL-C. The differences C-LDL-C and D-LDL-C were higher in subjects with DM and on lipid-lowering medications. Male gender, high triglyceride, low HDL-C, and obesity were also associated with the greater differences between C-LDL-C and D-LDL-C.
- A systematic review on evidence of the effectiveness and... Abstract: Niacin is a uniquely efficacious therapy in the treatment of dyslipidemia because of its broad spectrum of beneficial effects on every aspect of the lipid profile and because it has been shown to reduce both total mortality and coronary death. However, niacin therapy is hindered by its side-effect profile, which appears to be dependent on its formulation with immediate-release niacin, associated with a greater incidence of flushing, and sustained-release niacin, associated with greater liver function test (LFT) abnormalities and hepatotoxicity. One such sustained-release niacin nutritional supplement formulation, Endur-acin (Endurance Products Company, Tigard, OR), claims to have clinical evidence to support its use in the treatment of dyslipidemias, which prompted us to systematically review the literature. We identified four published papers in which the authors reported the results of two separate clinical trials and one pharmacokinetic study that fulfilled the inclusion criteria and were included in this review. Endur-acin significantly reduced total cholesterol, low-density lipoprotein cholesterol, and total cholesterol/high-density lipoprotein cholesterol ratio with mean reductions up to 19%, 26%, and 20%, respectively, at a dose of 2000 mg/day. Less-impressive benefits were also seen with high-density lipoprotein cholesterol (+10%) and serum triglycerides (−23%). Mean LFT elevations of up to 1.6-fold were seen at the 2000 mg per day dose, however, not exceeding three times the upper limit of normal, with abnormal results occurring at similar frequency in placebo and one patient experiencing marked gastrointestinal symptoms and a hepatitis-like syndrome with reversible elevated LFT. Short-term randomized controlled trials suggest Endur-acin is effective in modifying serum lipids, although study limitations prevent a comprehensive evaluation of safety.
- Lipid levels in obese and nonobese subjects as predictors... Background: Dyslipidemia in the overweight/obese patient often is associated with impaired glucose metabolism. The authors of large clinical trials in different ethnic groups highlighted the correlation between glycemia and lipid profile, although the effect of abdominal adiposity was not explored.Objective: To evaluate the relationship of visceral adiposity and lipid profile with fasting (FPG) and postload glucose (2hPG) in subjects without known diabetes (DM2).Methods: A total of 3030 subjects were divided in three groups: obese subjects (OB; n = 490), nonobese subjects with an increased waist circumference (NOB/W+; n = 500), and nonobese subjects without an increased waist circumference (NOB/W−; n = 2040). We performed a linear regression analysis among lipid fractions and fasting and 2hPG in the three groups, with or without diagnosis of DM2 after 2hPG.Results: Our data confirmed the significant association (P < .01) of high triglycerides and low high-density lipoprotein cholesterol (HDL-C) with fasting and 2hPG in all three groups such as for non-HDL cholesterol, whereas total cholesterol (TC) showed a significant correlation only with fasting glucose in OB and NOB/W+ subjects (P < .01). The analysis with or without DM2 demonstrated no difference in the statistical significance, although a better correlation in subjects without DM2 was observed. In addition, for each quartile of TC a significant trend (P < .01) in prevalence of fasting hyperglycemia in obese and in NOB/W+ patients was observed.Conclusion: This study suggests that triglycerides and HDL-C, together with non-HDL cholesterol, are associated with impaired fasting and 2hPG and that high total cholesterol levels are associated with abnormalities of fasting glucose metabolism only in patients with elevated waist circumference.
Vascular Medicine
- Imbalanced matrix metalloproteinase-9 and tissue inhibito... The pathogenic mechanisms of thromboangiitis obliterans (TAO) are not entirely known and the imbalance of matrix metalloproteinases (MMPs) plays a role in vascular diseases. We evaluated the MMP-2 and MMP-9 circulating levels and their endogenous tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) in TAO patients with clinical manifestations. The study included 20 TAO patients (n = 10 female, n = 10 male) aged 38–59 years under clinical follow-up. The patients were classified into two groups: (1) TAO former smokers (n = 11) and (2) TAO active smokers (n = 9); the control group included normal volunteer non-smokers (n = 10) and active smokers without peripheral artery disease (n = 10). Patient plasma samples were used to analyze MMP-2 and MMP-9 levels using zymography, and TIMP-1 and TIMP-2 concentrations were determined by enzyme-linked immunosorbent assays. The analysis of MMP-2/TIMP-2 and MMP-9/TIMP-1 ratios (which were used as indices of net MMP-2 and MMP-9 activity, respectively) showed significantly higher MMP-9/TIMP-1 ratios in TAO patients (p < 0.05). We found no significant differences in MMP-2/TIMP-2 ratios (p > 0.05). We found higher MMP-9 levels and decreased levels of TIMP-1 in the TAO groups (active smokers and former smokers), especially in active smokers compared with the other groups (all p < 0.05). MMP-2 and TIMP-2 were not significantly different in patients with TAO as compared to the control group (p > 0.05). In conclusion, our results showed increased MMP-9 and reduced TIMP-1 activity in TAO patients, especially in active smokers compared with non-TAO patients. These data suggest that smoke compounds could activate MMP-9 production or inhibit TIMP-1 activity.
- Reproducibility of different methods to measure the endot... This study compares the reliability and reproducibility of flow-mediated dilatation (FMD) and peripheral arterial tonometry (PAT) to assess endothelial function. Eighteen volunteers with coronary heart disease underwent simultaneous testing of FMD by means of brachial artery ultrasound scanning and PAT with the EndoPAT 2000. The subjects underwent both tests twice with an interval of 30 minutes and the same protocol was repeated 2 days later. The within-day variability was lower for the FMD measurements than for the PAT measurements (10% versus 18%; p < 0.05). The between-day variability was similar (11%). A significant correlation was found between PAT and FMD (r = 0.57, p < 0.001). The typical errors of measurements for FMD were lower than those for PAT. In conclusion, in this study, FMD demonstrated the best reliability for the within- and between-day and separate day measurements when compared to PAT.
- Insulin resistance and incident peripheral artery disease... Type 2 diabetes is a risk factor for peripheral artery disease (PAD), and insulin resistance is a key feature of diabetes and pre-diabetes. No longitudinal epidemiological study has examined the relation between insulin resistance and PAD. Our study analyzed the association of quartiles of the homeostatic model of insulin resistance (HOMA-IR) and the development of PAD defined by two methods. PAD was first defined as the development of an abnormal ankle–brachial index (ABI) (dichotomous outcome) after 6 years of follow-up. PAD was alternatively defined as the development of clinical PAD (time-to-event analysis). The study samples included adults over the age of 65 years who were enrolled in the Cardiovascular Health Study, had fasting measurements of insulin and glucose, had ABI measurements, and were not receiving treatment for diabetes. Multivariable models were adjusted for potential confounders, including age, sex, field center and cohort, body mass index (BMI), smoking status, alcohol use, and exercise intensity. Additional models adjusted for potential mediators, including blood pressure, lipids, kidney function, and prevalent vascular disease. In the ABI analysis (n = 2108), multivariable adjusted models demonstrated a positive relation between HOMA-IR and incident PAD (odds ratio = 1.80 comparing the 4th versus 1st quartile of HOMA-IR, 95% confidence interval [CI] 1.20–2.71). In the clinical PAD analysis (n = 4208), we found a similar relation (hazard ratio = 2.30 comparing the 4th versus 1st quartile of HOMA-IR, 95% CI 1.15–4.58). As expected, further adjustment for potential mediators led to some attenuation of effect estimates. In conclusion, insulin resistance is associated with a higher risk of PAD in older adults.
- Alteration in angiogenic and anti-angiogenic forms of vas... The aims of this study were twofold: (1) to identify whether peripheral artery disease (PAD) patients had increased muscle concentration of angiogenic VEGF-A, anti-angiogenic VEGF165b or VEGF receptor 1 (VEGF-R1) when compared with control subjects, and (2) to evaluate whether exercise training in PAD patients was associated with changes in muscle concentration of VEGF-A, VEGF165b or VEGF-R1. At baseline, 22 PAD and 30 control subjects underwent gastrocnemius muscle biopsy. Twelve PAD patients were treated with supervised exercise training (SET) and underwent muscle biopsy after 3 weeks and 12 weeks of training and had sufficient tissue to measure VEGF-A, VEGF165b and VEGF-R1 concentrations in skeletal muscle lysates by ELISA. Muscle concentrations of VEGF-A and VEGF165b were similar in PAD patients versus controls at baseline. At both time points after the start of SET, VEGF-A levels decreased and there was a trend towards increased VEGF165b concentrations. At baseline, VEGF-R1 concentrations were lower in PAD patients when compared with controls but did not change after SET. Skeletal muscle concentrations of VEGF-A are not different in PAD patients when compared with controls at baseline. SET is associated with a significant reduction in VEGF-A levels and a trend towards increased VEGF165b levels. These somewhat unexpected findings suggest that further investigation into the mechanism of vascular responses to exercise training in PAD patients is warranted.
- Effect of sulfasalazine on inflammation and endothelial f... Inflammation is critical for atherosclerosis development and may be a target for risk-reduction therapy. In experimental studies, activation of the inflammatory regulator, nuclear factor kappa B (NFlB), contributes to endothelial activation and reduced nitric oxide production. We treated patients with coronary artery disease with sulfasalazine, an inhibitor of NFB, and placebo in a randomized, double-blind, crossover study design. Brachial artery flow-mediated dilation (FMD) and digital vascular function were measured at baseline and after each 6-week treatment period. Of the 53 patients enrolled in the crossover study, 32 (age 60 ± 10, 22% female) completed all the visits, with a high rate of study withdrawal due to gastrointestinal side effects. In a subset of 10 participants, we compared the effects of 4 days of sulfasalazine treatment (n = 5) to no treatment (n = 5) on NFB-regulated gene expression in peripheral blood mononuclear cells. Tumor necrosis factor α-stimulated expression of CD69 and NFlB subunit p50 was significantly blunted after 4 days of sulfasalazine treatment but not after no treatment. However, FMD and digital vasodilator response did not significantly change from baseline with long-term sulfasalazine treatment. Short-term sulfasalazine inhibited NFlB activity; however, long-term treatment was poorly tolerated and did not improve endothelial function. Our findings suggest that sulfasalazine therapy is not the optimal anti-inflammatory treatment for reversing endothelial dysfunction in cardiovascular disease. Further studies are warranted to investigate the potential for NFlB inhibition to reduce cardiovascular risk.
- Hypothenar hammer syndrome: A case and brief review Hypothenar hammer syndrome is an uncommon cause of upper-extremity ischemia that is often overlooked in the absence of a thorough occupational and recreational history. Importantly, it is a reversible cause of hand ischemia that, if missed, can lead to significant morbidity and even amputation. The occupational ramifications and quality of life of those affected can be significant. Its relative rarity, set against the ubiquitous use of the hand as a ‘hammer’ is noteworthy. Several other causes of hand ischemia can present similarly; therefore, consideration of other etiologies must be thoroughly investigated. Key distinguishing clinical features, in addition to a detailed occupational and recreational history, may include characteristic sparing of the thumb, the absence of a hyperemic phase in ‘Raynaud’s phenomenon’, and a positive Allen’s sign. Both non-invasive and invasive diagnostic studies, including bilateral upper-limb segmental pulse volume recordings (PVR), arterial duplex examination, and upper-extremity angiography, are complementary to a thorough history and physical examination. Optimal management strategies are not well defined because of its rarity and resultant lack of quality, evidence-based data. Though most cases can be successfully managed non-operatively, micrographic arterial reconstruction may be limb saving in severe or recalcitrant cases. Newer, experimental strategies including selective sympathetic blockage using botulinum toxin A have been reported in a few recalcitrant cases. The brief case description illustrates the typical presentation and potential treatment strategies employed in a difficult case. A review of relevant literature is also presented.
- The relation between atherosclerosis and the occurrence o... Old and frail patients undergoing vascular surgery seem at great risk of developing postoperative delirium (POD). The aim of this review was to identify risk factors for the development of POD in vascular surgery patients. Different aetiological factors have been identified, such as increased age, excessive blood transfusion, preoperative cognitive impairment and depression. Mounting evidence supports a role for inflammation and tobacco exposure in the development of POD. Vascular surgery patients differ from the general surgical population because they suffer from both loco-regional and systemic atherosclerosis. Although current scientific evidence cannot fully link both entities, evidence is growing that suggests a relationship between systemic and cerebrovascular atherosclerosis and the development of POD.
- Agenesis of the left pulmonary artery accompanied by righ...
- A case of Bockenheimer's syndrome (genuine diffuse phlebe...
Nutrition, Metabolism & Cardiovascular Diseases
- Editorial Board
- Effect of soy isoflavones on blood pressure: A meta-analy... Abstract: Background and aim: The effect of soy isoflavones on blood pressure is controversial. The objective of this study was to evaluate the effect of dietary soy isoflavones on blood pressure.Methods and Results: Trials were searched in PubMed, the Cochrane Library, Embase and references cited in related reviews and studies. A total of eleven trials were reviewed. Meta-analysis results showed a mean decrease of 2.5 mm Hg (95% CIs, − 5.35 to 0.34 mm Hg; P = 0.08) for systolic blood pressure and 1.5 mm Hg (95% CIs, − 3.09 to 0.17 mm Hg; P = 0.08) for diastolic blood pressure in the soy isoflavones-treated group compared to placebo. Meta-regression and subgroup analyses indicated that blood pressure status was a significant predictor of heterogeneity for the effect of soy isoflavones on blood pressure. Subgroup analysis of hypertensive subjects revealed that a greater blood pressure reduction was identified in the soy isoflavone-treated group compared to placebo (5 trials; SBP: − 5.94, 95% CIs [− 10.55, − 1.34] mm Hg, P = 0.01; DBP: − 3.35, 95% CIs [- 6.52, − 0.19] mm Hg, P = 0.04). In contrast, treatment with soy isoflavones did not lead to a significant reduction in blood pressure in normotensive subjects (6 trials; SBP: 0.29, 95% CIs [- 2.39, 2.97] mm Hg, P = 0.83; DBP: − 0.43, 95% CIs [- 1.66, 0.81] mm Hg, P = 0.50).Conclusion: Soy isoflavones had an effect of lowering blood pressure in hypertensive subjects, but not in normotensive subjects. Larger trials need to be carried out to confirm the present findings.
- Gut–liver axis: The impact of gut microbiota on non alc... Abstract: Aim: To examine the impact of gut microbiota on non alcoholic fatty liver disease (NAFLD) pathogenesis.Data synthesis: Emerging evidence suggests a strong interaction between gut microbiota and liver. Receiving approximately 70% of its blood supply from the intestine, the liver represents the first line of defence against gut-derived antigens. Intestinal bacteria play a key role in the maintenance of gut–liver axis health. Disturbances in the homeostasis between bacteria- and host-derived signals at the epithelial level lead to a break in intestinal barrier function and may foster “bacterial translocation”, defined as the migration of bacteria or bacterial products from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. While the full repertoire of gut-derived microbial products that reach the liver in health and disease has yet to be explored, the levels of bacterial lipopolysaccharide, a component of the outer membrane of Gram-negative bacteria, are increased in the portal and/or systemic circulation in several types of chronic liver diseases. Derangement of the gut flora, particularly small intestinal bacterial overgrowth, occurs in a large percentage (20–75%) of patients with chronic liver disease. In addition, evidence implicating the gut–liver axis in the pathogenesis of metabolic liver disorders has accumulated over the past ten years.Conclusions: Complex metabolic diseases are the product of multiple perturbations under the influence of triggering factors such as gut microbiota and diet, thus, modulation of the gut microbiota may represent a new way to treat or prevent NAFLD.
- A derangement of the maternal lipid profile is associated... Abstract: Background and aims: Maternal hyperglycaemia and hyperhomocysteinaemia are risk factors for congenital heart disease (CHD). These metabolic derangements and deranged lipid levels are associated with adult cardiovascular disease. We examined whether maternal lipid levels are associated with the risk of CHD offspring.Methods and Results: From 2003 onwards, a case-control study was conducted. Participants were mothers of children with (n = 261) and without (n = 325) CHD. At around 16 months after the index-pregnancy, maternal lipid levels were determined. Maternal characteristics and lipid levels were compared by Student’s t-test. In a multivariable logistic regression model, risk estimates were calculated for associations between CHD and lipid levels. Adjustments were made for maternal age, diabetes, ethnicity, body mass index (BMI), parity, periconception folic acid use and total homocysteine levels. Outcome measures are presented in (geometric) means (p5–p95) and odds ratios (ORs) with 95% confidence intervals (CIs).Case mothers showed higher cholesterol (4.9 vs. 4.7 mmol l−1, P < 0.05), low-density lipoprotein (LDL)-cholesterol (3.2 vs. 3.0 mmol l−1, P < 0.05), apolipoprotein B (84.0 vs. 80.0 mg dl−1, P < 0.01) and homocysteine (10.8 vs. 10.2 μmol l−1, P < 0.05) than controls. LDL-cholesterol above 3.3 mmol l−1 (OR 1.6 (95%CI, 1.1–2.3)) and apolipoprotein B above 85.0 mg dl−1 were associated with an almost twofold increased CHD risk (OR 1.8 (95%CI, 1.2–2.6)). This was supported by elevated CHD risks per unit standard deviation increase in cholesterol (OR 1.2 (95% CI 1.03–1.5)), LDL-cholesterol (OR 1.3 (95%CI, 1.1–1.6) and apolipoprotein B (OR 1.3 (95% CI 1.1–1.6)). Apolipoprotein B was most strongly associated with CHD risk.Conclusion: A mildly deranged maternal lipid profile is associated with an increased risk of CHD offspring.
- Receptor identification and physiological characterisatio... Abstract: Background and aims: The anorexigenic glucagon-like peptide (GLP)-2 is produced by intestinal L cells and released in response to food intake. It affects intestinal function involving G-protein-coupled receptors. To verify whether GLP-2 acts as a cardiac modulator in mammals, we analysed, in the rat heart, the expression of GLP-2 receptors and the myocardial and coronary responses to GLP-2.Methods and results: GLP-2 receptors were detected on ventricular extracts by quantitative real-time polymerase chain reaction (Q-RT-PCR) and Western blotting. Cardiac GLP-2 effects were analysed on Langendorff perfused hearts. Intracellular GLP-2 signalling was investigated on Langendorff perfused hearts and by Western blotting and enzyme-linked immunosorbent assay (ELISA) on ventricular extracts.By immunoblotting and Q-RT-PCR, we revealed the expression of ventricular GLP-2 receptors. Perfusion analyses showed that GLP-2 induces positive inotropism at low concentration (10–12 mol l−1), and negative inotropism and lusitropism from 10 to 10 mol l−1. It dose-dependently constricts coronaries. The negative effects of GLP-2 were independent from GLP-1 receptors, being unaffected by exendin-3 (9–39) amide. GLP-2-dependent negative action involves Gi/o proteins, associates with a reduction of intracellular cyclic adenosine monophosphate (cAMP), an increase in extracellular signal regulated kinases 1 and 2 (ERK1/2) and a decrease in phospholamban phosphorylation, but is independent from endothelial nitric oxide synthase (eNOS) and protein kinase G (PKG). Finally, GLP-2 competitively antagonised β-adrenergic stimulation.Conclusions: For the first time, to our knowledge, we found that: (1) the rat heart expresses functional GLP-2 receptors; (2) GLP-2 acts on both myocardium and coronaries, negatively modulating both basal and β-adrenergic stimulated cardiac performance; and (3) GLP-2 effects are mediated by G-proteins and involve ERK1/2.
- The beta-1 adrenergic antagonist, atenolol, decreases acy... Abstract: Background and aims: Atenolol is a beta-1 adrenergic antagonist commonly prescribed for the treatment of systemic hypertension or coronary artery disease yet its use in individuals with type 2 diabetes mellitus (T2DM) is controversial due to potentially negative side effects on insulin resistance. Non-esterified fatty acid (NEFA) metabolism is altered in T2DM especially under conditions of metabolic stress such as exercise or the postprandial state. We evaluated atenolol effects on circulating NEFA and related hormones in men with T2DM during acute cardiorespiratory exercise in both the fasting and postprandial state, including the adipokine acylation stimulating protein (ASP) which stimulates adipose tissue NEFA uptake.Methods and results: Ten men with T2DM underwent four 1-h exercise sessions at 60% of their maximal oxygen uptake (VO2max) under the following conditions: 1) fasting (F), and 2) 2 h postprandial (PP) without medication; and 3) fasting (F-Atenolol), and 4) 2 h postprandial (PP-Atenolol) after a one-week treatment with atenolol. Results were tested for the effects of atenolol via two-way ANOVA for the F vs F-Atenolol and PP vs PP-Atenolol states separately. Atenolol treatment decreased fasting and postprandial glycerol (p < 0.0001) and NEFA (p < 0.0001), postprandial epinephrine (p = 0.048), postprandial cortisol (p = 0.02), postprandial ASP (p = 0.04) and postprandial dopamine (p < 0.004).Conclusion: Atenolol alters fatty acid metabolism and associated metabolic hormones including ASP during exercise in men with T2DM and its effects are more apparent during conditions of stress such as the postprandial state, acute exercise and obesity.
- Genetic and environmental relationships between Framingha... Abstract: Background and aims: We examined heritability and bivariate analyses for the Framingham Risk Score (FRS) and adiposity measures among Koreans.Methods and results: We analysed the data from 2496 participants (962 men, 1534 women, age 30–74 years), including 1320 non-twin family members, 468 monozygotic (MZ) and 120 dizygotic (DZ) twin pairs, collected from the Healthy Twin study of Korea. Adiposity measurements comprised BMI, waist circumference (WC), waist-to-hip ratio and waist-to-height ratio (WHTR). Analyses were conducted using the Sequential Oligogenic Linkage Analysis Routines (SOLAR) package software. The co-twin control analyses shows that estimates of within-pair regression coefficients in the relationship between adiposity traits and FRS were attenuated for MZ twin pairs, relative to DZ twin pairs (0.11–0.26 vs. 0.60–0.71). The heritability estimate for FRS was 0.37, and the estimates for adiposity traits ranged from 0.45 to 0.63 (P 0.05) to 0.46 (for WC, P < 0.001). The common environmental correlations between FRS and each of the adiposity traits ranged from 0.43 to 0.66 (P < 0.001).Conclusions: FRS and each of the obesity traits shared common genetic and environmental relationships. These findings support a pleiotropic action between genes associated with adiposity traits and FRS and a need of further investigations for identifying specific common environmental factors.
- Metabolic syndrome and coronary heart disease among Spani... Abstract: Background and aims: In Spain, the incidence of coronary heart disease is below that expected based on the burden of classic cardiovascular risk factors present in the population. Whether the risk associated with metabolic syndrome is lower in Spain deserves to be investigated. This study evaluates the association of incident clinical coronary heart disease with metabolic syndrome and each of its individual defining components in a sample of Spanish working males.Methods and results: Among the workers of a factory (MESYAS registry), 208 incident cases of coronary heart disease (between 1981 and 2005) were age-matched with 2080 healthy workers visited in 2004–2005. Metabolic syndrome was characterized using modified criteria of the joint consensus definition (2009). Metabolic syndrome was strongly associated with coronary heart disease (OR = 4.03; 95% CI: 2.98, 5.45) and the risk seemed to be fully explained by metabolic syndrome components (OR = 0.84, p = 0.54 after adjustment). Odds ratios for the independent effects of the diagnostic criteria were: hypertriglyceridemia (OR = 3.39, p < 0.001), hyperglycemia (OR = 2.70, p < 0.001), low HDL cholesterol (OR = 2.35, p < 0.001), hypertension (OR = 1.49, p = 0.016) and overweight (OR = 1.07, p = 0.678). Young workers showed a higher risk associated with metabolic syndrome.Conclusion: The risk associated with metabolic syndrome is fully explained by its components considered independently. The risk of coronary heart disease in a Spanish male working population is considerably increased among those with metabolic syndrome, by a factor similar to that described for other countries. Public health measures to prevent a rise in the prevalence of metabolic syndrome are advisable to minimize cardiovascular disease rate in Spain.
- Gender differences in copper, zinc and selenium status in... Abstract: Background and aims: The European ‘IMMIDIET’ study was designed to evaluate the effect of genetic and dietary habit interactions on cardiovascular disease risk factors in non-diabetic subjects. Copper, zinc and selenium are involved in redox balance and modifications of their homeostasis could be associated with metabolic syndrome. Because few studies have dealt with trace element status in metabolic syndrome with conflicting results, we aimed at investigating the relationships between plasma copper, zinc and selenium concentrations and metabolic syndrome in the IMMIDIET population.Methods and results: Male–female couples born and living in Abruzzo, Italy (n = 271); Limburg, Belgium (n = 267), southwest part of London, England (n = 263) and 205 Italian–Belgian mixed couples living in Belgium were enrolled. Data on medical history, hypertension and blood lipid profile, medication use, smoking and alcohol habits, physical activity and socioeconomic status were collected using a standardised questionnaire. Anthropometric, blood pressure, glucose, insulin, lipid profile and copper, zinc and selenium measurements were performed. Participants were classified in two groups according to the presence of metabolic syndrome (Yes/No).Comparison between these two groups, performed separately in men and women, indicated no association in men whereas, in women, metabolic syndrome was associated with higher plasma selenium concentrations (odds ratio (OR) = 1.55(1.28–1.89)); this association remained significant after adjustment for age, group, social status, physical activity, energy intake, alcohol consumption, smoking and hormonal status (OR = 1.33 (1.06–1.67)).Conclusion: Our results indicate gender differences in the association between plasma selenium concentration and metabolic syndrome without diabetes and may suggest a sub-clinical deleterious effect of high selenium status in women.
- The role of serum adipocyte fatty acid-binding protein on... Abstract: Background and aim: Adipocyte fatty acid-binding protein (FABP4) is abundantly expressed in adipocytes and plays a role in glucose homeostasis. We analysed the relationship between serum FABP4 levels and the progression of metabolic syndrome in healthy adults.Methodsand results: A total of 465 subjects were selected from participants in a medical check-up programme at a Health Promotion Center. Baseline serum FABP4 levels were measured, and the subjects were evaluated for the presence of metabolic syndrome (MetS) according to the recommendations of the American Heart Association/National Heart, Lung, and Blood Institute. The subjects were re-evaluated 4 years later.Baseline FABP4 concentrations were significantly higher in subjects with MetS than in those without MetS (P<0.001). At the 4-year follow-up, subjects in the highest FABP4 tertile at baseline exhibited higher values for body mass index, fat mass and percent body fat, as well as blood pressure, fasting glucose, total cholesterol, triglycerides, low-density lipoprotein (LDL)-cholesterol, insulin, homeostasis model assessment of insulin resistance, monocyte chemoattractant protein-1 and tumor necrosis factor-α levels (all P<0.05). The subjects with higher FABP4 levels had lower HDL-cholesterol concentrations (P<0.05). After adjustment for age, sex, change in percent body fat and baseline values for other metabolic and inflammatory parameters, FABP4 levels at baseline were shown to be strongly associated with the development of MetS by year 4 (odds ratio (OR), 5.75; 95% confidence interval (CI), 2.71–12.23 for highest tertile vs. lowest tertile, P<0.001)Conclusion: Baseline serum FABP4 levels appear to be a significant predictor for the future development of MetS, independent of pro-inflammatory cytokines.
Cardiovascular Engineering (Browse Results)
- Discrete Wavelet-Aided Delineation of PCG Signal Events v... Abstract The aim of this study is to describe a robust unified framework for segmentation of the phonocardiogram (PCG) signal sounds based on the false-alarm probability (FAP) bounded segmentation of a properly calculated detection measure. To this end, first the original PCG signal is appropriately pre-processed and then, a fixed sample size sliding window is moved on the pre-processed signal. In each slid, the area under the excerpted segment is multiplied by its curve-length to generate the Area Curve Length (ACL) metric to be used as the segmentation decision statistic (DS). Afterwards, histogram parameters of the nonlinearly enhanced DS metric are used for regulation of the α-level Neyman-Pearson classifier for FAP-bounded delineation of the PCG events. The proposed method was applied to all 85 records of Nursing Student Heart Sounds database (NSHSDB) including stenosis, insufficiency, regurgitation, gallop, septal defect, split sound, rumble, murmur, clicks, friction rub and snap disorders with different sampling frequencies. Also, the method was applied to the records obtained from an electronic stethoscope board designed for fulfillment of this study in the presence of high-level power-line noise and external disturbing sounds and as the results, no false positive (FP) or false negative (FN) errors were detected. High noise robustness, acceptable detection-segmentation accuracy of PCG events in various cardiac system conditions, and having no parameters dependency to the acquisition sampling frequency can be mentioned as the principal virtues and abilities of the proposed ACL-based PCG events detection-segmentation algorithm. Content Type Journal ArticleCategory Original ResearchPages 218-234DOI 10.1007/s10558-010-9110-3Authors M. R. Homaeinezhad, Department of Mechanical Engineering, K. N. Toosi University of Technology, Tehran, IranS. A. Atyabi, CardioVascular Research Group (CVRG), K. N. Toosi University of Technology, Tehran, IranE. Daneshvar, CardioVascular Research Group (CVRG), K. N. Toosi University of Technology, Tehran, IranA. Ghaffari, Department of Mechanical Engineering, K. N. Toosi University of Technology, Tehran, IranM. Tahmasebi, Cardiovascular Division of Heart Hospital, Holy City Qom, Iran Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Cardiovascular Engineering in the First Decade of the 21s... Cardiovascular Engineering in the First Decade of the 21st Century Content Type Journal ArticleCategory EditorialPages 169-169DOI 10.1007/s10558-010-9115-yAuthors John K-J. Li, Cardiovascular Engineering Lab, Department of Biomedical Engineering, Rutgers University, 599 Taylor Rd, Piscataway, NJ 08854, USA Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Note from the Publisher Note from the Publisher Content Type Journal ArticleCategory NotePages 253-253DOI 10.1007/s10558-010-9114-z Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Afterload Assessment With or Without Central Venous Press... Abstract A clinical comparison, of two methods of afterload assessment, has been made. The first method, systemic vascular resistance index (SVR i ), is based upon the traditional formula for afterload which utilizes central venous pressure (CVP), as well as cardiac index (C i ), and mean arterial blood pressure (MAP). The second method, total systemic vascular resistance index (TSVR i ), also uses MAP and C i . However, TSVR i ignores the contribution of CVP. This preliminary examination, of 10 randomly-selected ICU patients, has shown a high degree of correlation (ranging from 90 to 100%) between SVR i and TSVR i (P < 0.0001). Furthermore, there was also a high degree of correlation (ranging from 94 to 100%) noted between the hour-to-hour change in SVR i with the hour-to-hour change in TSVR i (P < 0.0001). The results, of this pilot study, support the premise that the use of CVP may not always be necessary for afterload evaluation in the clinical setting. Minimally-invasive means of measuring both C i and MAP, without CVP, may be adequate for use in assessing afterload. Content Type Journal ArticleCategory Original PaperPages 246-252DOI 10.1007/s10558-010-9113-0Authors Glen Atlas, Department of Anesthesiology, University of Medicine and Dentistry of NJ, Newark, NJ USAJay Berger, Department of Anesthesiology, University of Medicine and Dentistry of NJ, Newark, NJ USASunil Dhar, Department of Mathematical Sciences, New Jersey Institute of Technology, Newark, NJ USA Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Rapid Noninvasive Continuous Monitoring of Oxygenation in... Abstract The brain is most sensitively dependent on oxygen to maintain its normal function. Methods to assess the degree of its oxygenation have generally been invasive and indirect. Rapid assessment of brain oxygenation is particularly vital during cerebrospinal ischemia and hypoxia. We have developed a noninvasive electro-optical method using pulsed near-infrared (NIR) light to quantify brain oxygenation during ischemia and hypoxia in anesthetized rabbits. Cerebral ischemia was induced through 30–40 s of bi-lateral carotid artery occlusion. Cerebral hypoxia was induced by varying inspired oxygen levels. The NIR light response to the interventions was expressed in terms of relative absorption (RA). Results showed that our pulsed NIR system could rapidly detect sudden alterations in oxygenation and blood flow to the brain. The response patterns during cerebral ischemia and hypoxia were significantly different, although both decreased brain oxygenation. The overall RA response to ischemia was much faster (in seconds) than during hypoxia (in minutes). These different response patterns can serve as early warning signal of low brain oxygenation and to discriminate the cause of the diminished oxygenation. The present pulsed NIR system is capable to provide a rapid, noninvasive and continuous monitoring of such decreases in brain oxygenation. Content Type Journal ArticleCategory Original PaperPages 213-217DOI 10.1007/s10558-010-9116-xAuthors John K-J. Li, Department of Biomedical Engineering, Cardiovascular Engineering Lab, 599 Taylor Rd, Piscataway, NJ 08854, USATijun Wang, Department of Biomedical Engineering, Cardiovascular Engineering Lab, 599 Taylor Rd, Piscataway, NJ 08854, USAHongjun Zhang, Department of Biomedical Engineering, Cardiovascular Engineering Lab, 599 Taylor Rd, Piscataway, NJ 08854, USA Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- On the Mechanics Underlying the Reservoir-Excess Separati... Abstract Several works have separated the pressure waveform p in systemic arteries into reservoir p r and excess p exc components, p = p r + p exc , to improve pulse wave analysis, using windkessel models to calculate the reservoir pressure. However, the mechanics underlying this separation and the physical meaning of p r and p exc have not yet been established. They are studied here using the time-domain, inviscid and linear one-dimensional (1-D) equations of blood flow in elastic vessels. Solution of these equations in a distributed model of the 55 larger human arteries shows that p r calculated using a two-element windkessel model is space-independent and well approximated by the compliance-weighted space-average pressure of the arterial network. When arterial junctions are well-matched for the propagation of forward-travelling waves, p r calculated using a three-element windkessel model is space-dependent in systole and early diastole and is made of all the reflected waves originated at the terminal (peripheral) reflection sites, whereas p exc is the sum of the rest of the waves, which are obtained by propagating the left ventricular flow ejection without any peripheral reflection. In addition, new definitions of the reservoir and excess pressures from simultaneous pressure and flow measurements at an arbitrary location are proposed here. They provide valuable information for pulse wave analysis and overcome the limitations of the current two- and three-element windkessel models to calculate p r . Content Type Journal ArticleCategory Original ResearchPages 176-189DOI 10.1007/s10558-010-9109-9Authors Jordi Alastruey, Departments of Bioengineering and Aeronautics, Imperial College, London, SW7 2AZ UK Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Pulse Pressure, Arterial Compliance and Wave Reflection U... Abstract Similar pulse pressure increases and flow reductions have been reported by many investigators, despite dissimilar forms of arterial loading applied. Increased vascular load is most commonly observed due to mechanical and vasoactive interventions. The present study intended to differentiate the hemodynamic contributions of these two forms of arterial loading at closely matched blood pressure levels. To accomplish this, proximal aortic characteristic impedance (Z o ), total arterial compliance (C), peripheral vascular resistance (R s ) and time-domain resolved forward (P f ) and reflected (P r ) waves were obtained in six anesthetized, thoracotomized and ventilated dogs. Acute loading was accomplished by brief descending thoracic aorta (DTA) occlusion or by intravenous bolus infusion of methoxamine (MTX:5 mg/ml) Systolic pressure increases were matched to a similar extent. Results showed that pulse pressures were drastically increased, reflecting large increases in wave reflections and decreases in arterial compliances. Changes in Z o , R s and C were quantitatively different between the two forms of loading. DTA occlusion primarily increased Z o and R s with a concurrently large reduction in C. MTX infusion significantly increased small vessel R s to the same extent as DTA occlusion, but with a slight decrease in C secondary to an increase in pressure, with Z o unchanged. Examination of dynamic loading showed similar increases in reflection coefficients, but P f and P r were qualitatively different. We conclude that vasoactive methoxamine infusion provides primarily an increased resistive load, while mechanical DTA occlusion provides an increased complex load to the left ventricle. These loads also occur earlier and variably during ventricular ejection. Content Type Journal ArticleCategory Original PaperPages 170-175DOI 10.1007/s10558-010-9107-yAuthors John K-J. Li, Cardiovascular Engineering Lab, Department of Biomedical Engineering, Rutgers University, 599 Taylor Rd, Piscataway, NJ 08854, USAYing Zhu, Cardiovascular Engineering Lab, Department of Biomedical Engineering, Rutgers University, 599 Taylor Rd, Piscataway, NJ 08854, USAPamela S. Geipel, Cardiovascular Engineering Lab, Department of Biomedical Engineering, Rutgers University, 599 Taylor Rd, Piscataway, NJ 08854, USA Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- ECG T-Wave Monitor for Potential Early Detection and Diag... Abstract T-wave abnormalities are gaining significance in the realm of electrocardiogram diagnostics. In particular, T-wave alternans are proving to be powerful predictive indicators of potentially fatal arrhythmias. T-wave morphology monitoring and analysis are the means by which alternans and other abnormalities are detected. We have presented a preliminary design of an analog T-wave monitor to provide a characteristic description of the beat-to-beat T-wave morphology in terms of its maximum leading edge and trailing edge slopes, and its area. Experimental results showed that data from the analog T-wave monitor compared well with those predicted theoretically. Current design of the T-wave monitor, once improved, can find use in the screening, diagnosis, and early detection of T-wave abnormalities in clinical settings. Content Type Journal ArticleCategory Original PaperPages 201-206DOI 10.1007/s10558-010-9106-zAuthors David W. Smith, Cardiovascular Engineering Laboratory, Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USADouglas Nowacki, Cardiovascular Engineering Laboratory, Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USAJohn K-J. Li, Cardiovascular Engineering Laboratory, Department of Biomedical Engineering, Rutgers University, 599 Taylor Road, Piscataway, NJ 08854, USA Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- The Timing of Onset of Mechanical Systole and Diastole in... Abstract Our institution is in development of a low frequency, non-invasive Diastolic Timed Vibrator (DTV) for use in emergency treatment of ST Elevation Myocardial Infarction (STEMI). It is preferable to avoid vibration emissions during the IsoVolumetric Contraction Period (IVCP) and at least the majority of mechanical systole thereafter, as systolic vibration may cause a negative inotropic effect in the ischemic heart. Furthermore diastolic vibration should preferably include the IsoVolumetric Relaxation Period (IVRP) which has been shown in clinical studies to improve cardiac performance and enhance coronary flow. Electrocardiographic (ECG) monitoring can be used to enable diastolic tracking, however, the timing of the phases of the cardiac cycle in relation to the ECG waveform must first be verified. The objective of this study was therefore to determine timing of onset of mechanical systole and diastole in reference to the QRS-T Complex. One hundred and twenty-three adult echocardiographic studies were assessed for the point of mitral and aortic valve closure in relation to the QRS complex and T wave in a representative population. We found that onset of mechanical systole occurred on and usually shortly after the peak of a first dominant QRS complex deflection, and onset of diastole occurred at the earliest on and most commonly beyond the peak or midpoint of the T wave. A DTV should ideally be able to stop vibrating on or before the peak of the first dominant deflection of a QRS complex, and begin vibrating near the peak of the T wave. Given early detection of ventricular depolarization can occur 10–20 ms prior to R wave peak, it is proposed that a DTV should preferably be able to stop vibrating within 10 ms of a triggered stop command. Onset of vibration during peak of T wave could be approximated by a rate adapted Q-T interval regression equation, and then fine tuned by manual adjustment during therapy. Content Type Journal ArticleCategory Original ResearchPages 235-245DOI 10.1007/s10558-010-9108-xAuthors Harjit Gill, Division of Research and Development, Ahof Biophysical Systems Inc., Burnaby, V5C 4G8 CanadaAndrew Hoffmann, Division of Research and Development, Ahof Biophysical Systems Inc., Burnaby, V5C 4G8 Canada Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
- Subthreshold Parameters of Cardiac Tissue in a Bi-Layer C... Abstract Current density threshold and liminal area are subthreshold parameters of the cardiac tissue that indicate its susceptibility to external and internal stimulations. Extensive experimental and theoretical research has been conducted to quantify these two parameters in normal conditions for both animal and human models. Here we employed a 2D numerical model of human cardiac tissue to assess these subthreshold parameters under the pathological conditions of heart failure and fibrosis. Stimuli were applied over an area ranging from 0.04 to 1 mm2 using various pulse durations. The current density threshold decreased with increasing stimulation area or pulse duration. No significant changes were found in both parameters between control conditions and heart failure in the atrial tissue, while in the ventricular tissue, heart failure resulted in significantly reduced excitability with higher stimulation current magnitudes needed for excitation and larger liminal areas. This results from the specific ionic remodeling in ventricular heart failure that affects both subthreshold active currents such as IK1 and connexin 43 conductance. In fibrosis, increased fibroblast to myocyte coupling coefficient had a non-linear influence on current density thresholds, with an initial increase of current magnitude followed by a relaxation phase down to the current magnitude threshold for the control condition with no fibrosis. The results show that subthreshold excitation properties of the myocardium are influenced in a complex, non-linear manner by cardiac pathologies. Such observations may contribute to our understanding of impulse capturing properties, relevant, for example, for the generation of ectopic foci-originated arrhythmias and for the efficient design of cardiac stimulating electrodes. Content Type Journal ArticleCategory Original ResearchPages 190-200DOI 10.1007/s10558-010-9104-1Authors Sharon Zlochiver, Department of Biomedical Engineering, Faculty of Engineering, Tel-Aviv University, 69978 Ramat-Aviv, Tel-Aviv, Israel Journal Cardiovascular EngineeringOnline ISSN 1573-6806Print ISSN 1567-8822 Journal Volume Volume 10 Journal Issue Volume 10, Number 4
Current Opinion in Lipidology
- Editorial introduction No abstract available
- Atypical protein kinase C in cardiometabolic abnormalities Purpose of review: To review the aberrations of insulin signaling to atypical protein kinase C (aPKC) in muscle and liver that generate cardiovascular risk factors, including obesity, hypertriglyceridemia, hypercholesterolemia, insulin resistance and glucose intolerance in type 2 diabetes mellitus (T2DM), and obesity-associated metabolic syndrome (MetSyn). Recent findings: aPKC and Akt mediate the insulin effects on glucose transport in muscle and synthesis of lipids, cytokines and glucose in liver. In T2DM, whereas Akt and aPKC activation are diminished in muscle, and hepatic Akt activation is diminished, hepatic aPKC activation is conserved. Imbalance between muscle and hepatic aPKC activation (and expression of PKC-ι in humans) by insulin results from differential downregulation of insulin receptor substrates that control phosphatidylinositol-3-kinase. Conserved activation of hepatic aPKC in hyperinsulinemic states of T2DM, obesity and MetSyn is problematic, as excessive activation of aPKC-dependent lipogenic, gluconeogenic and proinflammatory pathways increases the cardiovascular risk factors. Indeed, selective inhibition of hepatic aPKC by adenoviral-mediated expression of kinase-inactive aPKC, or newly developed small-molecule biochemicals, dramatically improves abdominal obesity, hepatosteatosis, hypertriglyceridemia, hypercholesterolemia, insulin resistance and glucose intolerance in murine models of obesity and T2DM. Summary: Hepatic aPKC is a unifying target for treating multiple clinical abnormalities that increase the cardiovascular risk in insulin-resistant states of obesity, MetSyn and T2DM.
- The role of cholesterol efflux in mechanisms of endotheli... Purpose of review: HDL and their main apolipoprotein (apo) constituent apoA-I are antiatherogenic. This has been predominantly attributed to the ability of apoA-I/HDL to efflux cholesterol from macrophages within atherosclerotic plaques. It is now emerging that a number of the protective properties of HDL may be due to their effects on the endothelium. Recent findings: In addition to their well characterized anti-inflammatory and antioxidant effects, apoA-I and HDL regulate several other key biological pathways known to preserve endothelial function and promote vascular repair. The ATP-binding cassette (ABC) transporters ABCA1 and ABCG1, and the scavenger receptor B type 1 mediate multiple intracellular signaling pathways as well as the efflux of cholesterol and/or oxysterols in response to apoA-I/HDL. Although cholesterol efflux triggers a host of signaling events in endothelial cells, there is evidence that some of the beneficial actions of HDL may occur independently of efflux. Summary: Current data suggest that in endothelial cells ABCA1 and ABCG1 mediate the activation of intracellular signaling pathways primarily through the efflux of cholesterol and oxysterols to apoA-I/HDL. Interaction between HDL and scavenger receptor B type 1 initiates the greatest number of known signaling pathways and there is evidence that some of these are activated independent of efflux.
- The holy grail of metabolic disease: brown adipose tissue Purpose of review: The finding that brown adipose tissue (BAT) is present in adults brought BAT physiology into the focus of many researchers interested in energy metabolism. Here, we review recent insight into how BAT develops, functions and might help to treat metabolic disorders in humans. Recent findings: BAT is under control of the nervous system, and several pathways have been identified that allow direct manipulation of BAT biology. In addition, some brown adipocytes arise from a distinct subset of white adipocyte precursors and studies were performed that characterize the development of these ‘brite’ adipocytes. Importantly, progress has been made in understanding how BAT takes up and dissipates nutrients that in metabolic disorders are present in excess. Finally, as it seems that BAT activity declines with age and obesity, we review findings that might shed light on how humans could sustain or increase BAT activity, thus preventing or treating obesity, hyperlipidemia and type 2 diabetes. Summary: BAT is a powerful organ that controls the development of metabolic disease. These powers are boosted by mechanisms that turn white into brown fat and enhance lipid flux into BAT. However, in humans, it remains unclear what was the first: metabolic disease or decreased BAT activity.
- Hepatic ABC transporters and triglyceride metabolism Purpose of review: Elevated plasma triglyceride and reduced HDL concentrations are prominent features of metabolic syndrome and type 2 diabetes. Individuals with Tangier disease also have elevated plasma triglyceride concentrations and very low HDL, resulting from mutations in ATP-binding cassette transporter A1 (ABCA1), an integral membrane protein that facilitates nascent HDL particle assembly. Past studies attributed the inverse relationship between plasma HDL and triglyceride to intravascular lipid exchange and catabolic events. However, recent studies also suggest that hepatic signaling and lipid mobilization and secretion may explain how HDL affects plasma triglyceride concentrations. Recent findings: Hepatocyte-specific ABCA1 knockout mice have markedly reduced plasma HDL and a two-fold increase in triglyceride due to failure to assemble nascent HDL particles by hepatocytes, causing increased catabolism of HDL apolipoprotein A-I and increased hepatic production of triglyceride-enriched VLDL. In-vitro studies suggest that nascent HDL particles may induce signaling to decrease triglyceride secretion. Inhibition of microRNA 33 expression in nonhuman primates augments hepatic ABCA1, genes involved in fatty acid oxidation, and decreases expression of lipogenic genes, causing increased plasma HDL and decreased triglyceride levels. Summary: New evidence suggests potential mechanisms by which hepatic ABCA1-mediated nascent HDL formation regulates VLDL–triglyceride production and contributes to the inverse relationship between plasma HDL and triglyceride.
- Parkin in the regulation of fat uptake and mitochondrial ... Purpose of review: Perturbations in fatty acid levels and in regulatory proteins linked to fat and mitochondrial homeostasis are associated with modifying the risk of Parkinson's disease . Findings, that are not surprising, based on the high fat content of the brain, the myriad of neurological functions dependent on polyunsaturated fatty acids and the role of mitochondria in energy supply and stress amelioration. Nevertheless, dissecting out the molecular links between lipid biology, mitochondrial regulation and Parkinson's disease is complicated by the divergent causes underpinning Parkinson's disease pathophysiology. Here, we summarize aspects of fatty acid biology relevant to Parkinson's disease; the known links between the modulation of fat and Parkinson's disease and introduce mechanisms whereby the E3-ubiquitin ligase, Parkin known to be mutated as a genetic predisposing factor in Parkinson's disease, modulates fat uptake and mitochondrial control. Recent findings: Prior evidence supports that Parkin, under mitochondrial stress conditions, plays a pivotal role in the mitophagy mitochondrial housekeeping program. Recent evidence now demonstrates a broader role of Parkin in controlling fat uptake and mitochondrial regulatory programs. Summary: The identification that Parkin has a multifunctional role in modulating cellular fatty acid uptake and mitochondrial biology further strengthens the pathophysiologic link between fat metabolism, mitochondria and Parkinson's disease.
- Apolipoprotein C-III and hepatic triglyceride-rich lipopr... Purpose of review: A strong positive correlation between plasma apolipoprotein (apo) C-III and triglyceride concentrations has been invariably observed in human and animal studies. The hypertriglyceridemic effect of apo C-III has been conventionally explained by its extracellular roles in inhibiting lipolysis catalysed by lipoprotein lipase and attenuating triglyceride-rich lipoprotein clearance through receptor-dependent and/or independent mechanisms. However, recent experimental evidence suggests that apo C-III may also play an intracellular role in promoting hepatic triglyceride-rich lipoprotein production. Recent findings: Kinetic studies with humans and genetically modified mice have shown that apo C-III is linked with increased production of triglyceride-rich lipoproteins, such as very-low-density lipoprotein 1 (VLDL1). Mutational studies on human apo C-III variants (originally identified in humans with hypotriglyceridemia or hyperalphalipoproteinemia) provide the structure–function analysis of human apo C-III, demonstrating that loss-of-function mutations within human apo C-III impair the assembly and secretion of triglyceride-rich VLDL1 under lipid-rich conditions. Summary: The current review summarizes recent experimental evidence for an intrahepatic role of human apo C-III in promoting mobilization and utilization of triglyceride during VLDL1 assembly/secretion. Understanding mechanisms by which hepatic apo C-III expression is regulated under insulin resistance and diabetic conditions will lead to better and more rational strategies for the prevention and treatment of diabetic hypertriglyceridemia that is closely related to premature atherosclerosis.
- Post-transcriptional regulation of lipoprotein receptors ... Purpose of review: The hepatic low-density lipoprotein receptor (LDLR) pathway is essential for clearing circulating LDL and is an important therapeutic target for treating cardiovascular disease. Abundance of the LDLR is subject to both transcriptional and nontranscriptional control. Here, we highlight a new post-transcriptional mechanism for controlling LDLR function via ubiquitination of the receptor by the E3-ubiquitin ligase inducible degrader of the LDLR (IDOL). Recent findings: IDOL is a recently identified transcriptional target of the liver X receptors. Acting as an E3-ubiquitin ligase IDOL promotes ubiquitination of the LDLR, thereby marking it for lysosomal degradation. The determinants required for degradation of the LDLR by IDOL have been largely identified. IDOL also targets two related lipoprotein receptors, the very low-density lipoprotein receptor and apolipoprotein E receptor 2. Despite several similarities, the IDOL, and PCSK9 pathways for controlling LDLR abundance seem independent of each other. Genome-wide association studies have recently identified IDOL as a locus influencing variability in circulating levels of LDL, thereby highlighting the possible role of IDOL in human lipoprotein metabolism. Summary: Transcriptional induction of IDOL by liver X receptor defines a new post-transcriptional pathway for controlling LDLR abundance and LDL uptake independent of sterol regulatory element binding proteins. Targeting IDOL activity may offer a novel therapeutic approach complementary to statins for treating cardiovascular disease.
- MicroRNAs: emerging roles in lipid and lipoprotein metab... Purpose of review: MicroRNAs (miRNAs) regulate gene expression by binding to target mRNAs and control a wide range of biological functions. Recent reports have identified specific miRNAs as major regulators of fatty acid and cholesterol homeostasis. This review examines the biological function of various miRNAs and the emerging evidence linking specific miRNAs to critical pathways in lipid metabolism. Recent findings: Disruption of lipid balance can lead to metabolic disturbances and thus tight regulation is required to maintain lipid homeostasis. Recent studies have shown key roles for miR-33 and miR-122 in regulation of lipid metabolism, and further evidence implicates miR-370 in regulation of miR-122. In addition, miRNAs involved in adipogenesis (miR-378/378* and miR-27) as well as newly discovered miRNAs such as miR-613, miR-302a, and miR-168 have now been implicated in regulation of lipid metabolism. Summary: Growing evidence support key roles for miRNAs in regulating both cholesterol and fatty acid metabolism, leading to considerable interest in miRNAs as potential drug targets to modulate lipid and lipoprotein metabolism. MiRNA-based therapeutics hold considerable promise in the fight to curtail the growing epidemic of obesity and type 2 diabetes and the associated risk of atherosclerosis.
- Connecting mTORC1 signaling to SREBP-1 activation Purpose of review: The implication of the mammalian target of rapamycin (mTOR) complex 1 (mTORC1) in promoting protein synthesis has been well described. Over the past years, several studies revealed that mTORC1 also plays a crucial role in promoting lipid biosynthesis and that such connection could be linked to diseases including obesity, nonalcoholic fatty liver disease (NAFLD), and cancer. Here, we review the mechanisms by which mTORC1 regulates lipid synthesis by focusing on the key signaling events that trigger hepatic de-novo lipogenesis in response to nutrients and insulin. Recent findings: mTORC1 promotes lipid synthesis by activating the transcription factor sterol regulatory element binding protein 1 (SREBP-1). Recent studies indicate that mTORC1 regulates SREBP-1 activation at multiple levels. Although mTORC1 was originally shown to be necessary and sufficient to activate SREBP-1 in vitro, new studies indicate that hyperactivation of mTORC1 is insufficient to trigger SREBP-1 activation and lipid biogenesis in vivo. These findings reveal that the molecular connection between mTORC1 and SREBP-1 is more complex than originally envisioned. Summary: The discovery of a connection between mTORC1 and SREBP-1 opens a new chapter in our understanding of the molecular mechanisms regulating de-novo lipogenesis. A better comprehension of these mechanisms is key for the development of new tools to treat NAFLD and its complications.
Journal of Thrombosis and Thrombolysis
- Incidence of venous thromboembolism among chemotherapy-tr... Abstract Cancer patients, especially those with lung cancer and undergoing chemotherapy, have an elevated risk for venous thromboembolism (VTE). This study assessed incidence, timing, and risk factors for VTE (specifically receipt of chemotherapy), along with the association between VTE and survival among lung cancer patients receiving chemotherapy. Using Florida Medicaid administrative claims data (2000–2008), patients with any diagnosis of primary lung cancer were selected. Patients with recent prior VTE and those enrolled in Medicare or an HMO were excluded. Crude rates of VTE per 100 person years were estimated, and Cox proportional hazards models were developed to assess risk factors for VTE in the lung cancer population, and the association between VTE and survival among patients undergoing chemotherapy. Of 15,749 lung cancer patients, 7,052 (2,242 receiving chemotherapy and 4,810 not receiving chemotherapy) met cohort selection criteria. The incidence of VTE was 10.8 per 100 person-years (PYs) in the chemotherapy cohort and 6.8 per 100 PYs in the non-chemotherapy cohort. Among patients on chemotherapy developing VTE, median time to occurrence was 109 days, with 61 and 82 % of patients experiencing an event within six and 12 months, respectively. In multivariate analyses, the adjusted risk of VTE was 30 % higher among patients undergoing chemotherapy. Comorbidity and the presence of a central venous catheter also were significantly associated with a greater risk of developing VTE. Moreover, patients in the chemotherapy cohort who developed VTE had a significantly faster time-to-death (adjusted hazard ratio [HR] = 1.97; 95 % CI 1.69–2.29).VTE was common among lung cancer patients, especially among patients receiving chemotherapy, with the majority of VTE events occurring within 6 months of initiation of chemotherapy. The presence of a VTE event was significantly associated with an increased risk of mortality. Content Type Journal ArticlePages 1-11DOI 10.1007/s11239-012-0741-7Authors Huan Huang, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USAJonathan R. Korn, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USARajiv Mallick, Daiichi Sankyo, Inc., Two Hilton Court, Parsippany, NJ 07054, USAMark Friedman, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USAChristine Nichols, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USAJoseph Menzin, Boston Health Economics, Inc., 20 Fox Road, Waltham, MA 02451, USA Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Myocardial infarction in two cousins heterozygous for ASN... Abstract Bernard–Soulier Syndrome is characterized by thrombocytopenia with large platelets and defective aggregation to ristocetin. The bleeding tendency is variable but may be severe. The syndrome is due to genetic defects of the GPIb-V-IX complex and it has been maintained to be protective from thrombotic events. Here we present the first two cases of documented M.I. in two cousins, heterozygous for the Arg41His mutation which is responsible for a dominant form of Bernard–Soulier Syndrome. In one of the two patients an aneurysm of the aorta was also present. The patients had a mild bleeding tendency which was severely aggravated by treatment with antiplatelet drugs. These clinical observations are in contrast with experimental studies which demonstrate that Bernard–Soulier-like strains of mice show a decreased thrombus generation in several experimental settings. Content Type Journal ArticlePages 1-5DOI 10.1007/s11239-012-0742-6Authors Antonio Girolami, Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128 Padua, ItalySilvia Vettore, Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128 Padua, ItalyFabrizio Vianello, Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128 Padua, ItalyGiulia Berti de Marinis, Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128 Padua, ItalyFabrizio Fabris, Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128 Padua, Italy Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- The clinical significance of JAK2V617F mutation for Phila... Abstract Polycythemia vera (PV), essential thrombocythemia (ET) and idiopathic myelofibrosis (IMF), collectively known as Philadelphia-negative (Ph-negative) chronic myeloproliferative neoplasms (MPNs), MPNs represent the most common causes of splanchnic vein thrombosis (SVT), including Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT). The JAK2V617F mutation has been demonstrated in most of the Ph-negative chronic MPNs. The study objective was to assess the diagnostic value of JAK2V617F mutation in patients with SVT in a group of 68 patients with SVT (42 PVT,19 BCS, 7 combined PVT and BCS). By DNA-melting curve analysis, the JAK2V617F mutation was detected in 42.1 % of BCS, 38.1 % of PVT and 71.4 % of combined PVT and BCS groups. Thirteen of 15 (86.6 %) SVT patients with overt MPN and 16 of 53 (30.1 %) SVT patients without overt MPN (patients with either normal blood counts or cytopenias), including 6 of 16 with BCS (37.5 %), 7 of 33 with PVT (21.2 %) and 3 of 4 with combined BCS and PVT (75 %) possessed JAK2V617F mutation. A substantial proportion of patients with SVT were recognized as carriers of the JAK2V617F mutation despite the absence of overt signs of MPN. Receiver Operating Characteristic (ROC) curve analysis determined a platelet count of 190,000 mm3 (area under the curve; AUC = 0.724, p = 0.002) and a white blood cell (WBC) count of 8,150 mm3 (AUC = 0.76, p = 0.001) as the best cut-off values for the highest sensitivity and specificity ratios of the JAK2V617F mutation in patients with SVT. A significant positive correlation existed between the JAK2V617F mutational status of SVT patients and the WBC and platelet counts. Our results imply that JAK2V617F mutation screening should be an initial test for MPN in patients with SVT. Content Type Journal ArticlePages 1-9DOI 10.1007/s11239-012-0738-2Authors Ipek Yonal, Division of Hematology, Department of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, TurkeyBinnur Pinarbası, Division of Gastroenterohepatology, Department of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, TurkeyFehmi Hindilerden, Division of Hematology, Department of Internal Medicine, Istanbul Bilim University, Istanbul, TurkeyVeysel Sabri Hancer, Division of Hematology, Department of Internal Medicine, Istanbul Bilim University, Istanbul, TurkeyMeliha Nalcaci, Division of Hematology, Department of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, TurkeySabahattin Kaymakoglu, Division of Gastroenterohepatology, Department of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, TurkeyReyhan Diz-Kucukkaya, Division of Hematology, Department of Internal Medicine, Istanbul Bilim University, Istanbul, Turkey Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Pharmacodynamic effects of cangrelor and clopidogrel: the... Abstract Cangrelor is an intravenous antagonist of the P2Y12 receptor characterized by rapid, potent, predictable, and reversible platelet inhibition. However, cangrelor was not superior to clopidogrel in reducing the incidence of ischemic events in the cangrelor versus standard therapy to achieve optimal management of platelet inhibition (CHAMPION) trials. A prospectively designed platelet function substudy was performed in a selected cohort of patients to provide insight into the pharmacodynamic effects of cangrelor, particularly in regard to whether cangrelor therapy may interfere with the inhibitory effects of clopidogrel. This pre-defined substudy was conducted in a subset of patients from the CHAMPION-PCI trial (n = 230) comparing cangrelor with 600 mg of clopidogrel administered before percutaneous coronary intervention (PCI) and from the CHAMPION-PLATFORM trial (n = 4) comparing cangrelor at the time of PCI and 600 mg clopidogrel given after the PCI. Pharmacodynamic measures included P2Y12 reaction units (PRU) assessed by VerifyNow P2Y12 testing (primary endpoint marker), platelet aggregation by light transmittance aggregometry following 5 and 20 μmol/L adenosine diphosphate stimuli, and markers of platelet activation determined by flow cytometry. The primary endpoint was the percentage of patients who achieved <20 % change in PRU between baseline and >10 h after PCI. The main trial was stopped early limiting enrollment in the platelet substudy. A total of 167 patients had valid pharmacodynamic assessments for the primary endpoint. The percent of individuals achieving <20 % change in PRU between baseline and >10 h after PCI was higher with cangrelor + clopidogrel (32/84, 38.1 %) compared with placebo + clopidogrel (21/83, 25.3 %), but this was not statistically significant (difference:12.79 %, 95 % CI: −1.18 %, 26.77 %;p = 0.076). All pharmacodynamic markers as well as the prevalence of patients with high on-treatment platelet reactivity were significantly lower in patients treated with cangrelor. A rapid platelet inhibitory effect was achieved during cangrelor infusion and a rapid offset of action after treatment discontinuation. This CHAMPION platelet function substudy represents the largest pharmacodynamic experience with cangrelor, demonstrating its potent P2Y12 receptor inhibitory effects, and rapid onset/offset of action. Although there was no significant pharmacodynamic interaction when transitioning to clopidogrel therapy, further studies are warranted given that enrollment in this study was limited due to premature interruption of the main trial. Content Type Journal ArticlePages 1-12DOI 10.1007/s11239-012-0737-3Authors Dominick J. Angiolillo, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USADavid J. Schneider, University of Vermont, Burlington, VT, USADeepak L. Bhatt, VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA, USAWilliam J. French, Harbor–UCLA Medical Center, Torrance, CA, USAMatthew J. Price, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA, USAJorge F. Saucedo, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USATamaz Shaburishvili, Diagnostic Services Clinic, Tbilisi, GA, USAKurt Huber, 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, AustriaJayne Prats, The Medicines Company, Parsippany, NJ, USATiepu Liu, The Medicines Company, Parsippany, NJ, USARobert A. Harrington, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USARichard C. Becker, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Pre PCI hospital antithrombotic therapy for ST elevation ... Abstract Strong evidence exists in favor of rapid transfer of a patient suffering an ST-elevation myocardial infarction (STEMI) to the nearest hospital with primary percutaneous coronary intervention (PCI) capability, assuming the time from first medical contact to balloon inflation can be achieved in less than 90 min. In many areas, PCI hospitals have successfully collaborated with regional non-PCI hospitals to provide primary PCI for STEMI; however, significant variations exist in how these programs are executed. For example, the pre PCI hospital administration of antithrombotic agents by emergency medical personnel can include aspirin, clopidogrel, unfractionated heparin, low molecular weight heparin, partial or full dose fibrinolytics or combinations thereof. There is little consensus on the optimal cocktail, dose and route of administration. Standardizing the pre PCI antithrombotic regimen across hospital systems may be one approach to improve timely administration of these therapies, and potentially improve STEMI outcomes. Content Type Journal ArticlePages 1-11DOI 10.1007/s11239-012-0744-4Authors S. Michael Gharacholou, Division of Cardiovascular Medicine, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792, USABrenda J. Larson, Division of Cardiovascular Medicine, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792, USAChristian C. Zuver, Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USARyan J. Wubben, Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USAGiorgio Gimelli, Division of Cardiovascular Medicine, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792, USAAmish N. Raval, Division of Cardiovascular Medicine, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792, USA Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- The frequency of factor V Leiden and prothrombin G20210A ... Abstract Factor V Leiden and prothrombin G20210A are the two most prevalent causes of inherited thrombophilia. The prevalence of these mutations varies widely in healthy Caucasian population. The aim of our study was to determine the frequency of factor V Leiden and prothrombin G20210A mutations in Slovak and Roma ethnic group from Eastern Slovakia. We analyzed 540 asymptomatic individuals (269 individuals of Slovak ethnicity and 271 individuals of Roma ethnicity) by real-time PCR method. The detected allele frequencies were 2.97 versus 6.64 % for factor V Leiden (p = 0.0049), and 0.74 versus 0.92 % for prothrombin mutation (p = 0.7463) in Slovak and Roma population, respectively. The Roma ethnic group had significantly higher prevalence of factor V Leiden mutation when compared to Slovak ethnic group. The allele frequency of factor V Leiden in ethnic Romanies from Eastern Slovakia was one of the highest in Europe. Our results confirm an uneven geographical and ethnic distribution of factor V Leiden. Content Type Journal ArticlePages 1-4DOI 10.1007/s11239-012-0736-4Authors Alexandra Bôžiková, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaDana Gabriková, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaAdriana Sovičová, Department of Biology, Faculty of Humanities and Natural Sciences, University of Prešov, Prešov, SlovakiaRegina Behulová, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaSoňa Mačeková, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaIveta Boroňová, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaEva Petrejčíková, Department of Biology, Faculty of Humanities and Natural Sciences, University of Prešov, Prešov, SlovakiaMiroslav Soták, Department of Biology, Faculty of Humanities and Natural Sciences, University of Prešov, Prešov, SlovakiaJarmila Bernasovská, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, SlovakiaIvan Bernasovský, Excellence Centre of Animal and Human Ecology, Faculty of Humanities and Natural Sciences, University of Prešov, 17 Novembra 1, 08116 Prešov, Slovakia Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- A case of IVC filter thrombosis A case of IVC filter thrombosis Content Type Journal ArticlePages 1-2DOI 10.1007/s11239-012-0735-5Authors Kamil Muhyieddeen, Department of Internal Medicine, The Methodist Hospital, 6565 Fannin Street, SM 677, Houston, TX 77030, USAWei Chung Chen, Department of Internal Medicine, The Methodist Hospital, 6565 Fannin Street, SM 677, Houston, TX 77030, USAJoseph Varon, University of Texas Health Science Center, Houston, USA Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Efficacy of rituximab in acute refractory or chronic rela... Abstract Idiopathic thrombotic thrombocytopenic purpura (TTP) occurs primarily due to the formation of autoantibody against ADAMTS13, a specific von Willebrand factor-cleaving protease, resulting in low ADAMTS13 activity and subsequent accumulation of large vWF multimers, platelet aggregation and thrombus formation in the microvasculature of tissues. Limited clinical data suggest that the administration of anti-CD20 antibody (rituximab) may be useful in treating acute refractory or chronic relapsing idiopathic TTP. We carried out a systematic review with pooled data analysis using individual patient data to evaluate the efficacy of rituximab in these settings. Fifteen case series and 16 case reports comprising 100 patients were eligible for the study. Median age was 39 years. Male constituted 31 % and female 69 %. Complete remission was seen in 98 %, non-response in 2 % and relapse after complete remission in 9 %. For patients with complete remission, median follow-up was 13 months. Median platelet recovery from the first dose of rituximab was 14 days. ADAMTS13 inhibitor positivity and severe ADAMTS13 deficiency were highly predictive of the response to rituximab, implying that these can be useful markers in predicting response to rituximab in acute refractory or chronic relapsing idiopathic TTP. Content Type Journal ArticlePages 1-13DOI 10.1007/s11239-012-0723-9Authors Nay M. Tun, Division of Hematology and Oncology, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11220, USAGina M. Villani, Division of Hematology and Oncology, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11220, USA Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Neighborhood deprivation and hospitalization for venous t... Abstract Arterial cardiovascular disease and neighborhood deprivation are associated. However, no study has determined whether neighborhood deprivation is associated with venous thromboembolism (VTE). We aimed to determine whether there is an association between neighborhood deprivation and hospitalization for VTE, and whether effects vary across sociodemographic groups. The entire Swedish population aged 25–74 was followed from January 1, 2000 until hospitalization for VTE, death, emigration, or the end of the study period (December 31, 2008). Data were analyzed by multilevel logistic regression, with individual-level characteristics (age, marital status, family income, educational attainment, immigration status, urban/rural status, mobility, and comorbidity) at the first level and level of neighborhood deprivation at the second level. Neighborhood deprivation was significantly associated with VTE hospitalization rate in both men (OR = 1.09) and women (OR = 1.38). In the full model, which took account of individual-level socioeconomic characteristics and comorbidities, the odds of VTE remained significant only in women (OR = 1.12, 95 % CI 1.06–1.20) in the most deprived neighborhoods. Neighborhood characteristics affect odds of hospitalization for VTE, particularly in women. Thus, neighborhood deprivation is a common risk factor for both arterial cardiovascular disease and VTE. This study adds to knowledge of the negative effects of neighborhood deprivation on cardiovascular health. Content Type Journal ArticlePages 1-9DOI 10.1007/s11239-012-0728-4Authors Bengt Zöller, Center for Primary Health Care Research, Skåne University Hospital, Lund University/Region Skåne, CRC Building 28, Floor 11, Entrance 72, 205 02 Malmö, SwedenXinjun Li, Center for Primary Health Care Research, Skåne University Hospital, Lund University/Region Skåne, CRC Building 28, Floor 11, Entrance 72, 205 02 Malmö, SwedenJan Sundquist, Center for Primary Health Care Research, Skåne University Hospital, Lund University/Region Skåne, CRC Building 28, Floor 11, Entrance 72, 205 02 Malmö, SwedenKristina Sundquist, Center for Primary Health Care Research, Skåne University Hospital, Lund University/Region Skåne, CRC Building 28, Floor 11, Entrance 72, 205 02 Malmö, Sweden Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
- Three case reports of inherited antithrombin deficiency i... Abstract Antithrombin is a plasma protein critical to the regulation of coagulation. It plays a pivotal anticoagulant role by preventing the activation of procoagulant proteinases. Inherited and (or) acquired deficiency of AT is an established risk factor for venous thromboembolism. Sequencing analysis of SERPINC1 gene of three families revealed that Family I had double novel missense mutations (c.134G > A&c.342T > G), Family II had a nonsense mutation (c.770G > A) while Family III had a frameshift mutation (c.800-803del). In addition, all of them had a large number of carriers in their families what was very rare in China. Content Type Journal ArticlePages 1-7DOI 10.1007/s11239-012-0733-7Authors Haoyu Deng, Department of Vascular Surgery, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of ChinaWei Shen, Department of Clinical Laboratory, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of ChinaYi Gu, Department of Clinical Laboratory, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of ChinaXiong Ma, Department of Gastroenterology, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of ChinaJiwei Zhang, Department of Vascular Surgery, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of ChinaLan Zhang, Department of Vascular Surgery, Shanghai JiaoTong University School of Medicine Renji Hospital, Shanghai, 200127 People’s Republic of China Journal Journal of Thrombosis and ThrombolysisOnline ISSN 1573-742XPrint ISSN 0929-5305
Diabetes Journal
- Comment on: Marquez et al. Low-Frequency Variants in HMGA...
- {beta}-Cell-Specific Gene Repression: A Mechanism to Prot...
- Paradigm Shift or Shifting Paradigm for Type 1 Diabetes
- PGC-1{alpha}: The Missing Ingredient for Mesenchymal Stem...
- Challenges of Linking Early-Life Conditions and Disease S...
- Do Acute Exercise and Diet Reveal the Molecular Basis for...
- Selective Insulin Receptor Modulators (SIRM): A New Class...
- GLP-1-Based Therapies and the Exocrine Pancreas: More Lig...
- GLP-1 Receptor Agonist Effects on Normal and Neoplastic P...
- Mitochondria, Diabetes, and Alzheimer's Disease
Journal of Cardiovascular Nursing
- PCNA: Preventive Cardiovascular Nurses Association No abstract available
- Cardiovascular Health Promotion and Risk Reduction in Chi... No abstract available
- Patient Preferences for the Delivery of Disease Managemen... Background and Research Objective: Chronic heart failure (CHF) management programs (CHF-MPs) are applied in different ways including via face-to-face settings. However, we know little about consumer preferences when applying CHF-MPs via a patient’s home or specialist hospital clinic. The aim of this pilot study was to explore CHF-MP characteristics that are considered desirable by patients with CHF. Subject and Methods: Semistructured interviews with a purposive sample of 12 CHF patients. Results: Participants had a mean age of 61 (SD, 17) years, 3 were female, and the majority was of white background. Most were assessed as either functional New York Heart Association class III (n = 3) or IV (n = 6). Home- and clinic-based CHF-MPs were preferred by 5 and 7 participants, respectively. Key themes around patient preferences related to practical aspects of program delivery and social and peer support, as well as health-related benefits that translate to traditional outcomes in program evaluations. Participants identified transport, cost, and ill health as barriers to attending a clinic-based program. However, they also highlighted benefits (eg, the ability to share experiences with other patients) that may be difficult to provide with a home-based service unless specifically organized. Conclusions: These preliminary data suggest that patients value aspects of a program beyond those directly related to health outcomes. They also recognize a need for flexibility in program delivery, with potential preferences for home- or clinic-based programs depending largely on individual patient circumstances. More definitive studies are required to explore how best to cater for individual preferences while optimizing health outcomes.
- Factors Associated With Medication Adherence in Hypertens... Background: Rates of medication adherence are low among hypertensive blacks despite numerous interventions to increase their adherence. Purpose: The aim of the study was to conduct a systematic review of the literature to understand the factors associated with medication adherence in hypertensive blacks. Methods: A systematic computer search of qualitative and quantitative studies that examined factors associated with medication adherence in hypertensive blacks from 1966 to 2010 was performed. Studies were excluded if medication adherence was not either the primary or secondary outcome variable. Results: Studies (n = 18) were cross-sectional or qualitative, measured adherence via self-report, and conducted in low-income blacks. Factors that were associated with medication adherence were self-efficacy, depression, patient-provider communication, and healthcare system related. Conclusions: Findings from existing studies should be interpreted with caution because of their methodological limitations. Longitudinal studies with heterogeneous samples of hypertensive blacks are imperative so that targeted interventions can be developed for this vulnerable population. Clinical Implications: Even though there are methodological limitations associated with existing studies, clinicians may want to consider some of the factors that were associated with medication adherence in this systematic review as they provide care for hypertensive blacks. Given that self-efficacy and patient-provider communication are modifiable factors, they can be the focus of interventions to increase medication adherence. Finally, clinicians may want to screen their hypertensive patients for depression and treat, if necessary.
- Intensive Care Nurses’ Perspectives of Family-Centered ... Background: Family-centered care (FCC) has been cited as important to patient care; however, little is known about nurses’ perspectives toward FCC. Family presence during resuscitation (FPDR) is an example of the implementation of FCC; however, nurses do not necessarily agree with FPDR, especially those from non-Western countries. It is also unknown whether there is an association between FPDR and FCC. Objectives: The objective of the study was to determine (a) the attitudes of nurses toward FCC and FPDR and (b) whether there is an association between FCC and FPDR. Subjects and Methods: A convenience sample of 96 Israeli intensive care unit and cardiovascular registered nurses completed 5 questionnaires: a demographic data questionnaire, Nursing Activities for Communication With Families–Revised, Barriers to Providing Family-Centered Care–Revised (Barriers), Nurses’ Experiences of Family-Witnessed Resuscitation, and Attitudes to Family Presence During Resuscitation. Descriptive statistics and Pearson correlations were conducted. Results: The item mean values for the Nursing Activities for Communication With Families–Revised and the Barriers scales were only 3.7 of 5 and a moderate 2.4 of 4, respectively. Only 19 of the sample (20%) had experienced FPDR, of which 17 reported a negative as opposed to a positive experience. Overall, nurses objected to FPDR (mean item score = 1.8 of 5). No statistically significant relationship was found between FCC and FPDR. A significant negative correlation was found between the Barriers scale and FPDR (r = −0.36, P = .0001). Conclusion: Although FCC has moderate support, objection still remains to FPDR. Family presence during resuscitation has been used as an example of FCC, but at least in certain populations, this example might not be applicable. Increased education and policy changes should be encouraged to promote FCC and FPDR.
- Decisive Situations Affecting Partners’ Support to Cont... Background and Research Objective: Effective treatment of obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) can reduce morbidity and mortality, but adherence rates are low. The partner has an important role in supporting the patient, but this role may be adversely affected by difficulties during the early phase of the CPAP initiation. The aim of this study was to explore and describe decisive situations affecting partners’ support to patients with OSAS and how the partners manage these situations during the initial phase of CPAP treatment. Subjects and Methods: A qualitative descriptive design using critical incident technique was used. A total of 542 decisive situations affecting partners’ support and 222 situations describing managing were collected by means of interviews with 25 strategically selected partners of patients with CPAP treated OSAS. Results: Adverse effects, limited effect, practical and psychosocial problems, limited presence, and inappropriate initiation emerged as negative influences on the partners’ support. A well-functioning treatment, improvements, high motivation, and receiving support from others were identified as positive influences on the partners’ support. The partner managed the situations by letting the patient handle the CPAP treatment by himself/herself, by handling the treatment together with the patient, or taking over the handling of CPAP treatment. Conclusion: Increased knowledge about the different situations that affect the partners’ support negatively or positively and how these situations are managed by partners can be used in educational situations involving both patients and partners during CPAP initiation.
- A Narrative Study of Women’s Early Symptom Experience o... Background and Research Objective: Delayed arrival at the emergency department after the onset of ischemic stroke symptoms is an important reason for low tissue plasminogen activator administration rates. There is evidence that women arrive at the hospital later than do men, but little is known about women’s experiences in the period between symptom onset and hospital arrival. The purpose of this naturalistic investigation using narrative methodology was to gain understanding of women’s early symptom experience of ischemic stroke. Subjects and Methods: The sample consisted of 9 women aged 24 to 86 years with an ischemic stroke within 1 year of diagnosis. Data were collected using in-depth interviews in which participants were asked to tell the story of their stroke from the moment they noticed the symptoms until they arrived at the hospital. Data were analyzed using sequential methods of narrative analysis. Results and Conclusions: The participants experienced stroke onset as the inability to carry out their accustomed activities in usual ways and as a process occurring over time rather than a discrete event. There was a tendency to objectify the body. Two participants considered stroke as a possible cause for their symptoms, and the other women attributed symptoms to everyday bodily experiences and/or other health conditions. Most participants did not perceive themselves at risk for stroke, although all but 1 woman had risk factors. For some women, stroke onset was different from their previous ideas about this event, and this was especially the case if a woman had prodromal symptoms. Decision making during early stroke flowed from women’s evaluation of symptoms and the meaning of symptoms, and meaning was informed by a woman’s life situation. The findings from this study may yield variables for future studies of cognitive, emotional, and behavioral predictors of hospital arrival time. There is a need for research on women’s prodromal symptoms.
- Self-efficacy and Barriers to Healthy Diet in Cardiac Reh... Background and Research Objective: Participation in cardiac rehabilitation (CR) can result in positive outcomes for patients, but this population comprises only up to 20% of the total cardiac population. Thus, it is also necessary to examine the determinants of lifestyle behaviors in cardiac patients who do not attend CR programs. Studies have focused largely on physical health and outcomes of exercise participation, with less attention to dietary habits and the psychological determinants of behavior change. The purpose of this descriptive comparative study was to examine the differences in self-efficacy for and barriers to healthy dietary intake between CR participants and nonparticipants at 6 and 12 weeks after hospital discharge. Participants and Methods: A prospective longitudinal design was used. The sample consisted of 51 adults who (1) were diagnosed with/recovering from an acute cardiac event, treatment, or intervention; (2) received phase I CR; and (3) were physically able to participate in phase II CR. Participants were primarily male, elderly, married, and white; had more than a high school education; and had incomes more than $30 000. Analysis of covariance was used to determine differences over time in self-efficacy and barriers to healthy dietary intake between groups. Results and Conclusions: Although time 1 findings between groups were not significant, CR participants reported higher self-efficacy for healthy dietary intake than did nonparticipants. At time 2, CR participants also reported greater self-efficacy (F3,40 = 13.69, P ≤ .0001), indicating more confidence they could commit to a healthy diet. A significant difference was found in barriers to healthy dietary intake (t = 2.13, P = .04) at time 1, with CR participants reporting fewer barriers. At time 2, CR participants reported fewer barriers to healthy dietary intake (F3,39 = 18.19, P < .0001), indicating a more positive perception. Findings improve understanding of factors influencing adoption of healthy diet behaviors and are useful for designing interventions to assist individuals in sustaining secondary preventive efforts over time.
- Sleep Duration, Snoring Habits, and Cardiovascular Diseas... Background: Lack of sleep has been associated with an increased risk for cardiovascular disease (CVD) and all-cause mortality, but the mechanisms are not fully understood. Prior research has often been conducted in select populations and has not consistently adjusted for confounders, especially psychosocial factors. Objective: The aims of this study were to assess the association between sleep habits and established risk factors for CVD and to evaluate potential interactions by race and gender. Methods: Participants were part of a CVD screening and educational outreach program in New York City. Free-living men older than 40 years and women older than 50 years (n = 371, mean age = 60 years, 57% women, 60% racial/ethnic minorities) were systematically assessed for CVD risk (including traditional, lifestyle, and psychosocial risk factors) and completed a standardized questionnaire regarding sleep habits (including sleep duration and snoring). Lipids were analyzed by validated finger-stick technology. Stress at work and at home was assessed using a validated screening tool from the INTERHEART study. Associations between participants’ sleep habits and CVD risk factors/demographic factors were assessed using multivariable logistic regression. Results: The proportion of participants who reported sleeping less than 6 hours per night on average was 28%, and 52% of participants reported snoring. Sleeping less than 6 hours per night was significantly (P < .05) associated with female gender, being single, increased stress at home, increased financial stress, and low-density lipoprotein cholesterol (LDL-C) level. Gender modified the association between sleep duration and LDL-C level (P = .04): Sleeping less than 6 hours per night was significantly associated with reduced LDL-C level among women and increased LDL-C level among men. Snoring was significantly associated with low high-density lipoprotein cholesterol (HDL-C) level (<40 mg/dL for men/<50 mg/dL for women), being married, increased stress at work and at home, less than 30 minutes of exercise per day, less than 5 servings of fruits and vegetables per day, and being overweight/obese (body mass index ≥25 kg/m2). The association between snoring and low HDL-C level remained significant in logistic regression models adjusted for demographic confounders (odds ratio, 1.83; 95% confidence interval, 1.06–3.19) but not after adjustment for body mass index greater than 25 kg/m2. Conclusions: Sleeping less than 6 hours per night was associated with several traditional and psychosocial CVD risk factors, and snoring was associated with low HDL-C level, likely mediated through overweight/obesity. These data may have significance for health care providers to identify individuals who may be at increased CVD risk based on sleep habits.
- Transcatheter Aortic Valve Implantation Outcomes: Implica... Aortic stenosis is a common valvular pathological finding in older adults. Currently, aortic valve replacement is the gold-standard treatment for severe symptomatic aortic stenosis. However, patients with advanced age and multiple comorbidities carry a significant operative risk. Transcatheter aortic valve implantation (TAVI) was developed with the goal of offering a less invasive alternative to symptomatic high-risk patients with aortic stenosis. Since the first successful TAVI procedure in 2002, TAVI has been used as a treatment option for patients at very high or prohibitive surgical risk in clinical feasibility trials, registries, and in ongoing randomized controlled trials. There are 2 transcatheter valves in widespread clinical application, with several others in different stages of development. This article provides an overview of TAVI outcomes including insertion options, procedural outcomes, morbidity, valve durability, short- to medium-term survival, and quality of life to guide nursing care interventions. Enhancing nurses’ knowledge of the risks, benefits, and potential complications of TAVI will empower nurses in their role as patient advocates and educators and improve patient outcomes. Gaps in the current TAVI research literature are identified.
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