bluuebunny/crossref_metadata_2025 huggingface dataset:
QTc intervals in acute myocardial infarction: First‐year prognostic implications
Authors: Helmers C. , Ahnve S. , Lundman T. , Rehnqvist N. , Sjögren A.
Published: February 2009

Corrected QT (QTc) intervals were measured retrospectively in 160 consecutive survivors of acute myocardial infarction under 66 years of age. Calculations were made the first 2 d in the coronary care unit (CCU), the first post‐CCU day, at discharge, and at 1–3, 6, and 12 months after discharge. All patients were in sinus rhythm and without bundle branch block at discharge from the hospital. Sixteen patients died during the first follow‐up year. Twenty patients suffered a reinfarction, five of whom died.

The highest QTc values were registered in the CCU and the lowest at the 1‐year control. Patients with subendocardial infarcts had longer QTc intervals than those with transmural infarcts, especially during the acute phase. Patients with inferior infarcts had shorter QTc intervals during the CCU period.

Those who reinfarcted or died a cardiac death (particularly when sudden) during the follow‐up year had longer QTc intervals during the post‐CCU phase. A multivariate analysis of risk factors revealed that the QTc interval at discharge was of significant independent value for predicting major cardiac events after discharge from the hospital. It is concluded that repeated measurements of QTc may be of value when assessing prognosis after acute myocardial infarction.
The effect of intravenous nitroglycerin on coronary blood flow and infarct size during myocardial infarction in conscious dogs
Authors: Fukuyama T. , Roberts R.
Published: February 2009

Nitroglycerin (TNG), based on electrocardiographic evidence, has been shown to reduce myocardial ischemia, but its effect on morphometrically and enzymatically estimated infarct size has not been defined. Accordingly, coronary occlusion was produced in 50 conscious dogs without LV failure. Twenty‐five received TNG (200–300 m̈g/min i.v. for 8 h) and the results compared with those in 25 untreated dogs. Coronary blood flow was measured with 141Ce, 85Sr, and 95Nb (9 m̈m) after occlusion before TNG, 30 min after TNG, and again at 8 h. Mean blood pressure decreased from 103 to 84 mmHg with TNG vs. 99 to 94 mmHg in controls (p<0.02). Average heart rates were similar [135±26 vs. 120±33 beats/min (SD)]. TNG Did not increase total transmural coronary flow in any region but increased subendocardial flow in the central ischemic areas by 45% (0.09 ml/min/g vs. 0.13 ml/min/g). Animals were sacrificed after 24 h. Infarct size estimated morphometrically (25± 1.5 vs. 26± 1.5 of LV weight) and from myocardial CK depletion (23±2 vs. 23±2) was similar for the two groups. Thus, despite increased subendocardial flow, prolonged i.v. TNG did not decrease infarct size even though a difference of 15% would have been detected with this sample size. TNG May relieve coronary spasm but does not appear to be beneficial with sustained coronary occlusion.
Myoglobin and creatine kinase rates of release during acute myocardial infarction
Authors: Sylvén J. C. H.
Published: February 2009

The release of cardiac enzymes as an index of infarct size (IS) development was studied in patients with acute myocardial infarction (AMI) treated at a coronary care unit. Serial determinations of serum myoglobin (MG) and creatine kinase (CK) were made on 34 consecutive patients with duration of symptoms less than 6 h at admission and with initial CK values below the upper reference limit. Computer‐calculated CK‐IS was determined on the basis of the log‐normal algorithm. This was compared to discretely calculated CK and MG release.

The correlation between computer‐ and discretely calculated cumulated CK release was 0.995 with a regression close to the line of equivalence.

Computer‐calculated CK rates of release showed a one‐peak development, while, when discretely calculated, mostly three or four peaks were observed, as found also for MG rates of release. The occurrence of MG and CK peaks was related as indicated by a correlation coefficient of 0.75. The initial CK rate of release was slower when computer‐calculated.

In the group studied, CK release began about 3 h post onset of symptoms, at which time 56% had an MG value above the upper reference limit. The CK and MG releases were finished about 31 and 36 h post onset of symptoms, respectively, with MG peaks at 6, 11, 19, and 22 h with corresponding CK peaks delayed 2, 3, 3, and 9 h. The first MG and CK peaks represented between 30 and 40% of the total release while the following three peaks represented between 20 and 30% each. Cumulative MG release was correlated to the time of AMI development. No such correlation was found for CK.

The results indicate that the development of AMI is a wavelike process not sufficiently described by the log‐normal algorithm, on the basis of which, however, an index of total release might be obtained.
Enzymatic analysis and collagen content in endomyocardial biopsy samples of patients with congestive cardiomyopathy of unknown etiology
Authors: Schultheiss H. P. , Bolte H. D. , Fischer S. , Cyran J.
Published: February 2009

Endomyocardial biopsy samples from patients suffering from congestive cardiomyopathy of unknown etiology (COCM) were analyzed for lactate dehydrogenase (LDH) isoenzyme distribution by microisoelectric focusing. In addition, the concentration of collagen in the biopsy samples was estimated by determination of hydroxyproline and proline. The results were correlated with the clinical and hemodynamic data of the patients.

Increased activities of total LDH and LDH5— the worse the hemodynamic parameters, the higher the concentration of LDH5— indicate an enhanced anaerobic glycolysis in the myocardium of COCM patients. The close correlation between the hemodynamic data and the LDH isoenzyme pattern suggests an association between severity of COCM and impairment of aerobic metabolism. The results of the alteration in the LDH isoenzyme pattern were not influenced by the collagen content in the myocardial biopsy samples.

Varying isoenzyme patterns in the different parts and wall layers of the normal heart show the necessity of analyzing biopsy samples only from comparable localizations.
Evaluation of diuretic therapy by impedance cardiography in acute myocardial infarction
Authors: Gabriel S. , Ekelund L. G. , OrÖ L.
Published: February 2009

Changes in transthoracic electrical impedance (TEI) were recorded in 20 patients with acute myocardial infarction before, during, and 60 min after intravenous administration of furosemide (Impugan®). The major change was an increase in TEI (Z0) (6.2%, p<0.001). The mean impedance stroke volume (n = 10) decreased by 7.8% (p<0.05) while the mean impedance cardiac output (n = 10) decreased by 6.3% (p>0.05). Heart rate and blood pressure remained unchanged. It was possible to differentiate between two types of TEI changes after furosemide. In 10 patients there was an early and rapid increase in Z0 (type A), while the rest of the patients showed a decreased or unchanged Z0 followed by a slow increase (type B). The line describing the mean Z0 change in type A was significantly higher than that of type B and fell outside ±2 SEM of the line describing the mean Z0 change found in five normal subjects (type C). The Z0 change in type B was similar to that in type C. It is assumed that Z0 change in type A may represent patients with an increased amount of extravascular fluid (heart failure), while the change in type B represents patients without heart failure. This assumption is based on the difference in dependency of TEI on extravascular volume versus intravascular volume changes. It is suggested that the impedance method may be used as a simple noninvasive method to assess the effect of diuretic therapy and may have the value of detecting extravascular thoracic fluids in acute myocardial infarction.
Comparative effects of intravenous dipyridamole and sublingual nitroglycerin on coronary hemodynamics and myocardial metabolism at rest and during atrial pacing in patients with coronary artery disease
Authors: Arrotti J. , Gunnar R. M. , Ward J. , Loeb H. S.
Published: February 2009

The effects of intravenous dipyridamole (20 mg) and sublingual nitroglycerin (0.6 mg) were compared at rest and during rapid atrial pacing in patients with significant coronary obstruction. Dipyridamole, which had no significant effect on resting systolic blood pressure, caused a significant increase in coronary sinus flow (CSF) and reduction of coronary vascular resistance (CVR) and arterial‐coronary sinus oxygen difference (AO2‐CSO2δ), whereas nitroglycerin reduced resting systolic pressure but had no significant effect on CSF, CVR, or AO2‐CSO2°. Although these effects of dipyridamole and nitroglycerin on resting systolic pressure, CSF, CVR, and AO2‐CSO2° were qualitatively similar during rapid atrial pacing, the onset of chest pain and ischemic ECG changes occurred at a lower heart rate following dipyridamole (136±5 beats/min) than following nitroglycerin (149±6 beats/min, p<0.01). However, maximal double product and myocardial oxygen consumption achieved during pacing were similar following both dipyridamole and nitroglycerin and were less than control pacing values. Coronary dilatation following dipyridamole appears to reduce tolerance to pacing‐induced ischemia probably by maldistribution of coronary flow away from ischemic myocardium. Nitroglycerin differs from dipyridamole by improving tolerance to pacing; however, this difference appears to be due to systemic vasodilator effects of nitroglycerin rather than to enhancement of flow to ischemic myocardium.
The resting cardiokymogram: Distribution of morphologies in normal patients and in patients with coronary heart disease
Authors: Tzivoni D. , Diamond G. A. , Vas R. , Silverberg R. A. , Forrester J. S.
Published: February 2009

The cardiokymograph, a relatively new noninvasive device capable of recording anterior left ventricular segmental wall motion, was used to evaluate the frequency and type of wall motion abnormalities in 25 normal patients and in 109 patients with ischemic heart disease. Of the 25 patients with normal coronary arteries and normal left ventriculograms, 24 had smooth systolic inward motion which morphologically resembles the normal pattern of systolic shortening as measured in experimental animals by various length gauges. In patients with angiographically established coronary artery disease but normal left ventriculograms and no previous myocardial infarction (MI), systolic outward motion was significantly more common than in normal patients. The most common systolic outward motion pattern seen in this group was partial outward motion characteristic of early stages of myocardial ischemia in experimental animals. In contrast, holosystolic outward motion, characteristic of severe ischemia in animals, was seen most commonly in patients with MI (72% anterior vs. 28% inferior). Thus, holosystolic outward motion was characteristic of MI especially when acute and involving the anterior wall, while partial systolic outward motion was the more common pattern in ischemic heart disease without MI, and systolic inward motion was the pattern most commonly seen in normals.
Controlled study of intravenous nitroglycerin treatment for two days in patients with recent myocardial infarction
Authors: Bussmann W.‐D. , Barthe G. , Klepzig H. , Kaltenbach M.
Published: February 2009

Hemodynamic measurements were obtained for 48 h in 46 patients with recent myocardial infarction. Patients were randomized to treatment with (n = 22) and without nitroglycerin (NTG) (n = 24). In patients with diastolic pulmonary arterial pressure (PAEDP) <20 mmHg (group I), NTG decreased PAEDP from 15 to 11 mmHg (n = 13); in the untreated control group PAEDP remained unchanged (n = 15). Cardiac output decreased in the NTG group from 5.4 to 5.0 1/min and in the control group from 4.7 to 4.4 1/min. Mean arterial pressure decreased in both groups, in the NTG group from 106 to 97 mmHg and in the control group from 102 to 94 mmHg.

In patients with left ventricular failure and PAEDP >20 mmHg (group II) the decrease in left ventricular filling pressure was significantly greater (25 to 17 mmHg, n = 9) than in the control group (24 to 20 mmHg, n = 9). Cardiac output increased during NTG treatment from 4.2 to 5.1 1/min. In the control group, however, cardiac output decreased from 4.2 to 3.6 1/min. Mean arterial pressure decreased from 103 to 95 mmHg in the NTG group and from 114 to 96 mmHg in the control group. Heart rate did not change significantly.

Thus, PAEDP decreased significantly in patients who received NTG treatment for 48 h compared to an untreated control group. Cardiac output increased in treated patients, especially those with left ventricular failure, but decreased in the control group. Mean arterial pressure decreased to the same degree in treated patients and in controls.
Pulmonary hypertension in systemic lupus erythematosus: Hemodynamics and effects of vasodilator therapy
Authors: Santini D. , Fox D. , Kloner R. A. , Konstam M. , Rude R. E. , Lorell B. H.
Published: February 2009

A case is reported of a 29‐year‐old woman with systemic lupus erythematosus (SLE) who developed clinical manifestations of pulmonary hypertension at a time when other manifestations of SLE were quiescent. She had a restrictive ventilatory defect but clear lung fields on chest x ray. Cardiac catheterization revealed severe pulmonary hypertension. Calculated pulmonary vascular resistance fell slightly after administration of oxygen and during infusion of vasodilators. Symptomatic improvement and a modest increase in right ventricular ejection fraction, as measured by radionuclide ventriculography, were noted following 1 week of oral hydralazine therapy. Clinically significant pulmonary hypertension is a rare complication of SLE and the increased pulmonary vascular resistance may not be entirely fixed. Cardiac catheterization and radionuclide ventriculography may be useful in assessing response to medical therapy.
Atrioventricular sequential pacing in cardiac amyloidosis: An acute doppler echocardiographic and catheterization hemodynamic study
Authors: Mathew Verghese , Chaliki Hari , Nismmura Rick A.
Published: February 2009

Background and hypothesis: Congestive heart failure due to cardiac amyloidosis is often refractory to conventional medical management and is associated with a high mortality rate. Recently, dual‐chamber pacemaker implantation has been proposed as a therapeutic option in the management of patients with certain forms of cardiomyopathy with persistent heart failure symptoms, despite optimal medical therapy. The present study evaluates the acute hemodynamic response to atrioventricular (AV) pacing in patients with cardiac amyloidosis who presented with refractory heart failure symptoms.

Methods: Three patients with medically refractory heart failure due to cardiac involvement of amyloidosis underwent a simultaneous cardiac catheterization/Doppler echocardiography study with acute AV sequential pacing at varying AV intervals.

Results: During pacing at various AV intervals, all patients showed an increase in their filling pressures and either no change or decline in their cardiac index.

Conclusion: The current study demonstrates an absence of acute hemodynamic benefit with AV sequential pacing in patients with amyloid heart disease and medically refractory heart failure symptoms.
Early presentation of dilated cardiomyopathy as a part of seroconversion illness in human immunodeficiency virus infection
Authors: Fath‐Ordoubadi F. , Van Der WATT M. J. , Noble M. I. M.
Published: February 2009

It has been debated whether dilated cardiomyopathy seen in patients with acquired immune deficiency syndrome is caused by the virus itself or by the combination of other factors such as presence of opportunistic pathogens and/or severe immunosuppression. This paper describes the first reported case of a patient with human immunodeficiency virus (HIV) infection presenting with dilated cardiomyopathy during his acute seroconversion illness. Presence of cardiac involvement at a very early stage of HIV infection with no evidence of opportunistic infections, or immunosuppression with high CD4 count indicates that HIV may itself be a cardiac pathogen. This case also illustrates the importance of testing for HIV infection as part of the assessment of any patient presenting with myocarditis or dilated cardiomyopathy.
Evaluation and treatment strategies in patients at high risk of sudden death post myocardial infarction
Authors: Underwood R. Dent , Sra Jasbir , Akhtar Masood
Published: February 2009

Over 50 percent of deaths in patients who survive an acute myocardial infarction are due to fatal ventricular tachyarrhythmias. Patients who survive an episode of sustained ventricular arrhythmia are at highest risk of recurrent cardiac arrest. Electrophysiologic studies have been found to be useful in guiding therapy and reducing mortality in these patients and in patients with syncope due to arrhythmic etiology. Evaluation and treatment of nonsustained ventricular tachycardia post infarction remains somewhat controversial. A recently published trial (MADIT), however, showed improved survival with an implanted defibrillator in patients with coronary disease and asymptomatic nonsustained ventricular tachycardia. Asymptomatic patients post infarction at high risk include those who have significant left ventricular dysfunction, late potentials, high‐grade ventricular ectopy, and abnormal heart rate variability. These tests individually, however, have a low positive predictive accuracy. This, combined with the fact that antiarrhythmic drugs are frequently not effective and can be proarrhythmic, leaves the best treatment for these patients uncertain. It is known, however, that beta‐adrenoreceptor blocking agents do reduce mortality after an acute myocardial infarction. Early studies have shown mixed results relating to sudden death and total mortality with amiodarone. To date, no other antiarrhythmic drug has shown benefit, while several have been shown to be harmful. Recent studies have also shown some beneficial effects of angiotensin‐converting enzyme inhibitors, carvedilol, a third‐generation beta‐blocking agent with vasodilator properties, and the angiotensin II receptor antagonist losartan. However, their precise role in reducing sudden death needs to be defined further.
Direct conversion of atrial flutter to sinus rhythm with low‐output, short‐duration transesophageal atrial pacing
Authors: Ajisaka Hidehiko , Hiraki Tatsuro , Ikeda Hisao , Kubara Ichiro , Yoshida Teruhisa , Ohga Masanobu , Imaizumi Tsutomu
Published: February 2009

Background and hypothesis: Transesophageal atrial pacing (TAP) is useful for terminating paroxysmal non‐selfterminating atrial flutter (RAF); however, high output pacing of long stimulus duration causes severe symptoms such as chest pain. The objective of this study was to investigate the effect of low‐output, short‐duration TAP on the conversion of PAF.

Methods: We applied low‐output (within 15 mA with a pulse duration of 10 ms), short‐duration (within 4 s) TAP in 31 patients (50±19 years) with PAF. Transesophageal pacing was delivered with 10 pulses of burst pacing at intervals that were 20 ms shorter than those of the flutter wave length. When the conversion was unsuccessful, we delivered 20 pulses of burst pacing.

Results: Sixteen patients (52%) were converted directly to sinus rhythm and 12 (38%) to atrial fibrillation. Transesophageal pacing was ineffective in 3 (10%) patients. The duration of atrial flutter, maximum flutter wave amplitude, effective pacing intervals, underlying heart diseases, and cardiac function were not different between patients who had direct conversion to sinus rhythm and those converted to atrial fibrillation. The patients who had direct conversion to sinus rhythm had longer flutter wave cycle lengths than those converted to atrial fibrillation (248 vs. 221 ms, p<0.005). No patient had complications and complained of any symptoms.

Conclusion: Low‐output, short‐duration TAP was useful to convert PAF directly to sinus rhythm without side effects.
Relationship between exercise hyperpnea, hemodynamics, and blood gases before and during glyceryl trinitrate infusion in patients with exercise‐induced elevation of pulmonary artery wedge pressure
Authors: Jørgensen Lars H. , Thaulow Erik , Refsum Harald E.
Published: February 2009

Background: The mechanisms underlying the excessive ventilatory response to exercise in patients with cardiac failure are still not fully understood.

Hypothesis: This study was undertaken to investigate the mechanisms behind exercise hyperpnea in patients with exercise‐induced left ventricular dysfunction.

Methods: In 18 patients, aged 57–82 years, all with atherosclerotic lumbar aorta aneurysm and pulmonary artery wedge pressure (PAWP) >25 mmHg during supine exercise, ventilation (V), central hemodynamics, and arterial and venous blood gases were examined during supine rest and exercise, before and during infusion of glyceryl trinitrate (GTN).

Results: Before GTN, exercise PAWP was 32.2 ± 6.1 mmHg and V/V O2 was 33.8 ± 7.7 1/1 (130% of predicted). With GTN, exercise PAWP was markedly reduced to 15.3 ± 3.8 mmHg (p < 0.001), whereas V/V O2 was only marginally reduced to 32.3 ± 3.0 1/1 (124% of predicted) (p<0.05). Exercise physiologic dead space (VD/VT) declined from 0.31 ± 0.16 to 0.26 ± 0.17 (p<0.05), while PaCO2 was reduced from 5.20 ± 0.31 to 5.10 ± 0.24 kPa (p < 0.05). PvO2 and cardiac output (CO), however, were unchanged, below normal.

Conclusion: The data show that exercise‐induced hyperpnea was not substantially reduced by rapid normalization of PAWP and could not be related to preservation of normal PaCO2 in the presence of high VD/VT. The persistence of exercise hyperpnea and reduced PvO2 after GTN is consistent with augmented ventilatory stimuli from hypoxia‐induced metabolic abnormalities in the skeletal muscles, or/and persistently reduced CO, due to changes in the integrated superior command of ventilation and circulation.
Quantitative evaluation of blood row distribution to exercising and resting skeletal muscles in patients with cardiac dysfunction using whole‐body thallium‐201 scintigraphy
Authors: Wada Osamu , Asanoi Hidetsugu , Miyagi Kyoko , Ishizaka Shinji , Kameyama Tomoki , Ishise Hisanari , Inoue Hiroshi , Seto Hikaru
Published: February 2009

Background and hypothesis: Decreased blood flow to working muscles makes an important contribution to exercise intolerance in patients with chronic heart failure. This study was undertaken to examine whether maldistribution of skeletal muscle blood flow is closely related to exercise intolerance in patients with cardiac dysfunction.

Methods: Whole‐body thallium scintigraphy was performed during one‐leg exercise in 11 patients with left ventricular (LV) dysfunction (LV ejection fraction <45%). Blood flow distribution to the exercising and resting legs was quantified by expressing regional thallium counts as a percentage of the whole‐body counts at rest, at the level of anaerobic threshold, and at peak exercise.

Results: At anaerobic threshold, the thallium activity of exercising muscle increased from 4.2 ± 0.7 to 14.0 ± 2.5% (p< 0.05) in the thigh and from 1.7 ± 0.3 to 4.1 ± 0.9% (p<0.05) in the calf, compared with the resting value. Consequently, the ratio of thallium activity between exercising and resting legs increased to 2.7 ± 0.7 (p<0.05) in the thigh and to 2.3 ± 0.7 (p < 0.05) in the calf. When plotted as a function of anaerobic threshold, thallium activity of the exercising thigh (r = 0.78, p<0.05) and the thallium ratio between exercising and resting thigh (r = 0.69, p<0.05) declined with the reduction of exercise tolerance. These correlations were not observed in calves.

Conclusion: Whole‐body thallium scintigraphy demonstrated a maldistribution of leg blood flow in patients with reduced aerobic exercise capacity, suggesting that this abnormality could play an important role in exercising intolerance in these patients.
Cardiac repolarization interval in end‐stage diabetic and nondiabetic renal disease
Authors: Kirvelä Maija , Toivonen Lauri , Lindgren Leena
Published: February 2009

Background and hypothesis: QT interval length is influenced by autonomic nervous activity. In patients with diabetic autonomic neuropathy, both prolongation and shortening of ventricular repolarization has been reported. We studied diabetic and nondiabetic uremic patients to assess the effects of autonomic neuropathy on QT interval length.

Methods: 24‐hour electrocardiogram recordings were performed in 12 diabetic and 11 nondiabetic renal transplantation patients, and in 12 control patients. Mean and corrected QT interval (QTc) during the 24‐h period and intervals at predetermined heart rates at day and night periods were determined. The degree of autonomic neuropathy was assessed with cardiovascular autonomic function tests and measurement of heart rate variability.

Results: In the diabetic group, severe autonomic neuropathy was present; in nondiabetic uremic patients, abnormalities were less severe. Mean QTc interval during 24 h was 444 ± 24,447 ± 21, and 442 ± 19 ms in the diabetic and nondiabetic uremic patients, and in the control groups, respectively, without any between‐group difference. QT and QTc interval length did not differ among the groups when measured at heart rates of 70, 80, 90, or 100 beats/min.

Conclusions: In patients with autonomic failure caused by diabetes and/or uremia, QT interval length cannot be used as a diagnostic indicator of cardiac autonomic neuropathy.
Which fasting triglyceride levels best reflect coronary risk? evidence from the turkish adult risk factor study
Authors: Onat Altan , Sansoy Vedat , Yildirim Beytullah
Published: February 2009

Background: Association between raised low‐density lipoprotein cholesterol (LDL‐C) levels and high risk for coronary heart disease (CHD) is well established and taken into account in guidelines on coronary prevention.

Hypothesis: The relationship between risk for coronary heart disease (CHD) and the levels of fasting plasma triglycerides was studied in the cohort of the Turkish Adult Risk Factor Study, a representative random sample of an adult population.

Methods: In 829 men and 907 women aged ≥ 27 years (mean 48.5 ± 11), plasma lipids and lipoproteins were measured by the enzymatic dry method in the postabsorptive state. A sample of values was validated in a reference laboratory. Apoliprotein (apo) A‐I and B were measured by the turbidimetric immunoassay using commercial kits in part of the cohort. Blood pressure and anthropometric measurements were made. Criteria for the diagnosis of CHD were based on history, cardiovascular examination, and Minnesota coding of resting electrocardiograms.Coronary heart disease was diagnosed in about 7% of the subjects. Participants were divided into four categories depending on their triglyceride levels: I = < 100 mg/dl (282 men, 400 women), II = 100–139 mg/dl (204 men, 228 women), III = 140–212 mg/dl (188 men, 180 women), and IV = ≥ 212 mg/dl (155 men, 99 women).

Results: After adjustment for age, high‐density lipoprotein (HDL) and low‐density lipoprotein (LDL) cholesterol, smoking, and body mass index by logistic regression analysis, and after assigning the CHD risk of 1 to Category I, the relative risk for men and women combined rose to 1.42 in Category III (p<0.045) while it diminished to 0.94 in Category IV (p = 0.79). In women, the odds ratio (OR) rose gradually up to 1.78 (p < 0.025) in Category III, only to decline in Category IV. The OR in men was slightly, insignificantly, and equally elevated in Categories III and IV. Patients with CHD in Category III were not distinguished from those in Category IV by the studied risk parameters. It was suggested that high risk for CHD—particularly in subjects with slightly elevated or normal cholesterol levels—is often not reflected by extreme increases of fasting triglycerides but best by modest elevations (140–212 mg/dl), which serve better as a marker of triglyceride‐rich lipoprotein particles. This knowledge may prove to be of value in population screening and individual risk assessment.
Screening for carotid artery disease before cardiac surgery: Is current clinical practice evidence based?
Authors: Archbold R. Andrew , Barakat Khalid , Magee Patrick , Curzen Nicholas
Published: February 2009

Background: There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature.

Hypothesis: The study aimed to establish that current typical practice for screening cardiac surgical patients for carotid artery disease is illogical according to the evidence in the world literature.

Methods: The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline‐derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997.

Results: Of 529 patients undergoing urgent cardiac surgery, 44 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis ≥ 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk.

Conclusions: Only 8% of patients undergoing urgent cardiac surgery in a 1‐year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that are specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.
Electrocardiographic criteria for predicting total occlusion of the proximal left anterior descending coronary artery in anterior wall acute myocardial infarction
Authors: Kosuge Masami , Kimura Kazuo , Ishikawa Toshiyuki , Endo Tsutomu , Shigemasa Tomohiko , Sugiyama Mitsugi , Tochikubo Osamu , Umemura Satoshi
Published: February 2009

Background: Patients with occlusion of the left anterior descending coronary artery (LAD) proximal to both the first septal branch and the first diagonal branch may benefit most from early reperfusion therapy due to extensive area at risk.

Hypothesis: The aim of the study was to examine whether 12‐lead electrocardiograms (ECGs) in the acute phase of acute myocardial infarction (AMI) could identify total occlusion of the LAD proximal to both the first septal and the first diagonal branch.

Methods: A 12‐lead electrocardiogram was recorded on admission in 128 patients with anterior AMI within 12h from symptom onset. Patients were divided into three groups according to the culprit lesion: 33 patients had total occlusion of the LAD proximal to both the first septal perforator and the first diagonal branch (Group P), in 51 it was proximal to either the first septal perforator or the first diagonal branch (Group D‐a), and in 44 it was distal to both the first septal perforator and the first diagonal branch (Group D‐b).

Results: Sensitivity and specificity of a greater degree of ST‐segment depression in lead III than that of ST‐segment elevation in lead aVL were 85 and 95%, respectively, which was better than the results derived by all other ECG criteria (p< 0.001).

Conclusions: We conclude that a greater degree of ST‐segment depression in lead III than that of ST‐segment elevation in lead aVL is a useful predictor of proximal LAD occlusion in patients with anterior AMI.
Silent ischemic interval on exercise test is a predictor of response to drug therapy: A randomized crossover trial of metoprolol versus diltiazem in stable angina
Authors: Dwivedi Sudhanshu Kumar , Saran Ram Kirti , Mittal Sanjay , Gupta Ripen , Narain Varun Shankar , Puri Vijay Kumar
Published: February 2009

Background and hypothesis: There is no method available to predict the relative antianginal efficacy of beta blockers and calcium‐channel antagonists. The present study was undertaken to assess the role of silent ischemic interval (SII) on exercise treadmill test (ETT) as a predictor of response to therapy with metoprolol and diltiazem in patients with stable angina.

Methods: Thirty‐four patients with stable angina were divided into two groups depending upon the presence or absence of an SII gap of at least 1 min between onset of ST depression and appearance of angina on ETT. Metoprolol (50–100 mg twice daily) and diltiazem (60–120 mg three times daily) were randomly assigned for 6 weeks to patients in each group, and then patients were crossed over for further 6 weeks after a washout period of 2 weeks. Antianginal efficacy was assessed by clinical and exercise parameters.

Results: In patients with SII, the clinical responder rate was better with metoprolol than with diltiazem (90 vs. 60%, respectively), and on ETT, metoprolol produced significant improvement in the total exercise time (p<0.01), time to 1 mm ST depression (p < 0.01), time to angina (p < 0.01), and a significant decrease in peak rate‐pressure product (p<0.001), whereas diltiazem had no significant effect on exercise parameters. However, in patients without SII, metoprolol and diltiazem had a similar clinical responder rate (57%), and both produced a significant increase in total exercise time (p < 0.01), time to 1 mm ST depression (p < 0.01), and time to angina (p < 0.01). In addition, metoprolol had a significant effect on peak rate‐pressure product (p < 0.001).

Conclusion: Silent ischemic interval on ETT can be a predictor of response to antianginal therapy in stable angina, as patients with SII respond better to metoprolol and those without SII respond equally to both metoprolol and diltiazem.
Length of stay and procedure utilization are the major determinants of hospital charges for heart failure
Authors: Philbin Edward F. , Mccullough Peter A. , Dec G William , Disalvo Thomas G.
Published: February 2009

Background: Most of the 10 billion dollars spent annually on heart failure (HF) management in this country is attributed to hospital charges. There are widespread efforts to decrease the costs of treating this disorder, both by preventing hospital admissions and reducing lengths of stay (LOS).

Methods: Administrative information on all 1995 New York State hospital discharges assigned ICD‐9‐CM codes indicative of HF in the principal diagnosis position were obtained. Bivariate and multivariate statistical analyses were utilized to determine those patient‐ and hospital‐specific characteristics which had the greatest influence on hospital charges.

Results: In all, 43,157 patients were identified. Mean hospital charges were $11,507 ± 15,995 and mean hospital LOS was 9.6 ± 14.5 days. With multivariate analyses, the most significant independent predictors of higher hospital charges were longer LOS, admission to a teaching hospital, treatment in an intensive care unit, and the utilization of cardiac surgery, permanent pacemakers, and mechanical ventilation. Age, gender, race, comorbidity score, and medical insurance, as well as treatment by a cardiologist and death during the index hospitalization were not among the most significant predictors.

Conclusions: We conclude that LOS and procedure utilization are the major determinants of hospital charges for an acute episode of inpatient HF care. Reducing LOS and other initiatives to restructure hospital‐based HF care may reduce total health care costs for HF.
Heart rate‐lowering and ‐regulating effects of once‐daily sustained‐release diltiazem
Authors: Boden William E. , Vray Muriel , Eschwege Evelyne , Lauret Delphine , Scheldewaert Rudy
Published: February 2009

Background: Epidemiologic evidence suggests that an elevated heart rate (HR) is an adverse and independent prognostic factor in arterial hypertension and other cardiovascular diseases. Although diltiazem is characterized as an HR‐lowering calcium antagonist, no studies have quantified the magnitude of HR changes in patients with angina or hypertension.

Hypothesis: The study was undertaken to explore the magnitude of proportional HR reduction at varying levels of resting HR with the sustained‐release formulation of diltiazem (SR diltiazem) at the usual clinical doses of 200 or 300 mg once daily.

Methods: This meta‐analysis was conducted on six comparative double‐blind studies including 771 patients with angina or hypertension in which SR diltiazem 200–300 mg once daily was compared either with placebo or with other agents known not to influence HR (angiotensin‐converting enzyme inhibitors, diuretics). Sustained‐release diltiazem decreases elevated baseline HR, with an increasing effect at higher initial rates.

Results: Multiple comparisons by baseline HR category showed a significant difference between both groups for baseline HR of 74–84 beats/min and ≥ 85 beats/min (p = 0.001). Sustained‐release diltiazem had no significant HR‐decreasing effect on baseline HR ≤ 74 beats/min but appears to have a genuine regulating effect on HR: it reduces tachycardia without inducing excessive bradycardia. These findings are in contrast to those with dihydropyridine calcium antagonists, which tend to increase HR and have been associated with an adverse outcome in acute cardiovascular conditions. At the same time, there is evidence to suggest that HR‐lowering calcium‐channel blockers decrease cardiovascular event rates following myocardial infarction.

Conclusion: When calcium antagonists are indicated for use in patients with angina or hypertension, an HR‐lowering agent, that is, diltiazem rather than dihydropyridine, should be recommended.
Can cocaine abuse exacerbate the cardiac toxicity of human immunodeficiency virus?
Authors: Soodini Geetha , Morgan James P.
Published: February 2009

Both cocaine use and human immunodeficiency virus (HIV) infection alone have been associated with an increased incidence of cardiac dysfunction. Concomitant exposure to cocaine and HIV infection may exacerbate the cardiac toxicity of either agent alone, a hypothesis that is examined in this review article. A possible unifying hypothesis based on enhancement of adrenergic stimulation is proposed.
Early prediction of 30‐day mortality after q‐wave myocardial infarction by echocardiographic assessment of left ventricular function— a pilot investigation
Authors: Smock Andrew L. , Larson Brad , Brown Chris , Conti C. Richard
Published: February 2009

Background: The GUSTO angiographic substudy demonstrated that left ventricular function measured 90 min after thrombolytic therapy was given had important prognostic implications at 30 days in patients with an acute myocardial infarction (MI).

Hypothesis: Thirty‐day prognosis after Q‐wave MI can be determined by early echocardiographic assessment of left ventricular function.

Methods: Using transthoracic echocardiography, semiquantitative ejection fraction and wall motion score index was assessed prospectively in 201 consecutive patients within 24 h following Q‐wave MI. Independent experts blinded to the patient's status performed the echocardiographic assessment. All patients received standard medical care as dictated by the attending cardiologist.

Results: Of the 201 patients, 24 (11.9%) died within 30 days, with 70% of the deaths occurring within 10 days after the infarction. Three deaths occurred in the 120 patients with an ejection fraction ≥ 45% (2.5% mortality rate). In contrast, 21 deaths occurred among the 81 patients with an ejection fraction < 45% (25.9% mortality rate) p = 0.0003. Two of the three patients who died in the high ejection fraction group died as a result of intracerebral hemorrhage from thrombolytic therapy. Ejection fraction was lower in nonsurvivors (32.3 ± 10.3 vs. 46.3 ± 13%) than in survivors, p < 0.0002. Wall motion score index (WMSI) of < 1.4 was associated with a 2.9% 30‐day mortality (two deaths in 76 patients); WMSI of ≥ 1.4 was associated with a 17.6% 30‐day mortality (22 deaths in 125 patients), p = 0.0007. Average WMSI was higher in the nonsurvivors (1.95 ± 0.5) than in survivors (1.52 ± 0.45), p = 0.00001.

Conclusions: Echocardiographic assessment of left ventricular function during the first 24 h after an acute Q‐wave MI can be performed in all patients regardless of stability. High‐risk patients are identified early in the hospital course, with relative ease, at no risk and at an acceptable cost. An ejection fraction < 45% or WMSI ≥ 1.4 identifies patients who are at a high risk of dying within 30 days. These are the patients who may benefit most from aggressive medical therapy and early angiography to assess coronary pathology.
Rescue use of abciximab improves regional left ventricular function after early incomplete reperfusion in acute myocardial infarction
Authors: Cho Goo‐Yeong , Lee Cheol Whan , Hong Myeong‐Ki , Kang Duk‐Hyun , Song Jae‐Kwan , Kim Jae‐Joong , Park Seong‐Wook , Park Seung‐Jung
Published: February 2009

Background: Abciximab was shown to have important beneficial effects beyond the maintenance of epicardial coronary artery patency. However, it remains uncertain whether abciximab may lead to a better functional outcome in patients with acute myocardial infarction (AMI) and with incomplete reperfusion after primary angioplasty (PA).

Hypothesis: The study aimed to evaluate whether rescue use of abciximab may lead to a better functional outcome in such patients.

Methods: The study included 25 patients with first AMI who met the following criteria: (1) total occlusion of the infarct‐related artery, (2) PA within 12 h of symptom onset, (3) postprocedural diameter stenosis < 30%, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2. Echocardiographic examination was performed before and on Days 7 and 30 after PA. The study population was divided into two groups: Group 1 (usual care, n = 13) and Group 2 (rescue use of abciximab, n = 12). Baseline characteristics were similar between the two groups.

Results: Peak level of creatine kinase was higher in Group 1 than in Group 2 (5,800 ± 2,700 vs. 3,800 ± 2,000 U/l, p < 0.05). At 1 month follow‐up, infarct zone wall motion score index (2.71 ± 0.26 vs. 2.05 ± 0.63, p < 0.01) and left ventricular (LV) volume indices were smaller in Group 2 than in Group 1, whereas LV ejection fraction was higher in Group 2 than in Group 1 (52.1 ± 7.8 vs. 42.1 ± 6.4, p < 0.01). At 1‐month, abciximab was the only independent predictor of wall motion recovery index by multiple regression analysis.

Conclusions: Rescue use of abciximab may reduce the infarct size in patients with AMI and TIMI grade 2 flow after PA, which may improve the recovery of regional LV function.
Myocardial bridging of the left anterior descending coronary artery in acute inferior wall myocardial infarction
Authors: Yano Kohei , Yoshino Hideaki , Taniuchi Masato , Kachi Eisei , Shimizu Hisashi , Watanuki Atsushi , Ishikawa Kyozo
Published: February 2009

Background: We observed marked myocardial bridging of the left anterior descending coronary artery (LAD) in the acute stages of inferior wall myocardial infarction (MI) in a group of patients who developed shock despite successful reperfusion of the infarct‐related lesion (IRL).

Hypothesis: The purpose of this study was to elucidate the clinical significance of myocardial bridging in patients with inferior wall MI and shock.

Methods: The study group consisted of 53 patients with single‐vessel disease of the right coronary artery, who underwent coronary angiography for acute inferior wall MI. Clinical characteristics, coronary angiographic findings, and left ventricular function during the chronic phase were compared between the patients who developed shock (the shock group) and those who did not (the non‐shock group). In addition, a multiple logistic analysis was performed to identify independent predictors of shock in patients with acute inferior wall MI.

Results: Reperfusion of the IRL was obtained in all 53 patients. The incidence of myocardial bridging of the LAD, the incidence of right ventricular MI, the peak creatine phospho‐kinase (CPK‐MB), the pulmonary capillary wedge pressure, and the prevalence of pulmonary congestion seen on chest roentgenogram were significantly higher in the shock group than in the non‐shock group. Myocardial bridging (p = 0.0018), right ventricular MI (p = 0.0374), and peak CPK‐MB (p = 0.0189) were identified as independent predictors of shock in acute inferior wall MI.

Conclusion: This study suggests that myocardial bridging plays a role in left ventricular function in the acute stage of inferior wall MI.
Efficacy of balloon valvuloplasty in patients with critical aortic stenosis and cardiogenic shock—the role of shock duration
Authors: Buchwald Arnd B. , Meyer Thomas , Scholz Karlheinz , Unterberg Christina , Schorn Bernd
Published: February 2009

Background: Because of limited long‐term success, aortic balloon valvuloplasty is considered to be a palliative procedure, including patients at excessive risk for standard therapy—aortic valve replacement—that is, those in cardiogenic shock.

Hypothesis: The study was undertaken to evaluate the outcome of balloon valvuloplasty for critical aortic stenosis complicated by cardiogenic shock.

Methods: Over a 10‐year‐period, we followed 14 patients (age 74 ± 11 years, range 50–91) presenting in cardiogenic shock and critical aortic stenosis, who underwent valvuloplasty, together with 19 patients with critical aortic stenosis requiring urgent major noncardiac surgery.

Results: In patients in shock, calculated aortic valve area could be increased successfully by at least 0.3 cm2, from 0.38 ± 0.09 to 0.81 ± 0.12 cm2, with an insignificant increase in cardiac index from 1.89 ± 0.33 to 2.01 ± 0.41 1/min *m2. In‐hospital mortality was 71% (10 patients). Two patients underwent valve replacement within 16 days and survived after 1 year, as did two patients refusing surgery. By multivariate logistic regression analysis, only an interval between onset of shock symptoms and valvuloplasty of > 48 h was significantly associated with fatal outcome (p < 0.01). In those patients requiring noncardiac surgery, this was possible after valvuloplasty in 95% who survived 1 year after hospital discharge. One patient in this group died of pulmonary embolism the day after the procedure.

Conclusion: These data support the concept of causal treatment in patients with cardiogenic shock, as well as in the setting of cardiogenic shock and critical aortic stenosis, at the earliest possible convenience.